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Stemming the tide: A study of technical and perceived quality of care and their associations with maternal health determinants

Swedo, Elizabeth (2012)
Master's Thesis (196 pages)
Committee Chair / Thesis Adviser: Stephenson, Robert
Committee Members:
Research Fields: Health Sciences, Public Health; Health Sciences, Obstetrics and Gynecology; Health Sciences, Epidemiology
Partnering Agencies: International Non-governmental organization (e.g., CARE, Inc.)
Keywords: maternal health, utilization, quality of care, antenatal care, Mali, developing country
Program: Rollins School of Public Health, Hubert Department of Global Health
Permanent url:


Background: The impoverished West African nation of Mali has one of the worst maternal mortality rates in the world - 830 maternal deaths per 100,000 live births. Many of these deaths have been attributed to poor utilization of maternal health services. Little research has been done to investigate how quality of care - both technical and perceived - influences women's decision to seek maternal care.

Objective: This study utilizes measures of both technical and perceived quality of care and household data to analyze associations between quality of care and maternal healthcare uptake.

Study participants were women who had given birth within the previous twelve months. Additionally, health facility audits were conducted in all CS-COM facilities in Bandiagara and Bankass, two regions of Mopti, Mali. Data from health facility audits and the household survey were linked and analyzed using bivariate analysis and logistic regression. Outcomes included skilled delivery in a healthcare facility, receipt of four antenatal care (ANC) visits, receipt of one ANC visit during the first trimester, and receipt of the WHO minimum standard of ANC.

Bivariate analysis of household data revealed that parity, education, cohabitation with one's mother-in-law, and employment outside the home were significant factors for maternal health service uptake. Among perceived quality of care domains, maternal health service utilization was associated with perceived physical accessibility, satisfaction with quality of service offered at CS-COM, perceived equipment functionality, and safety of delivery at CS-COM. Technical measurements of CS-COMs revealed sub-optimal signal function capabilities, avoidable maternal and neonatal deaths, absent or broken equipment, frequent medication stockouts, and a paucity of retrained staff; however, only equipment and medication stockouts were significantly associated with maternal health service uptake.

The results of this study suggest that women's perceived quality of care at their local healthcare institution influences their choice to utilize maternal health services. Efforts to improve maternal health services must include provisions for better technical quality of care and outreach to the community to improve perceived quality of care.

Table of Contents


Characterizing maternal mortality worldwide 5

Maternal mortality in Mali 12

Determinants of maternal mortality 18

Global uptake of maternal health services 32

Determinants of maternal healthcare uptake in sub-Saharan Africa 45

Quality of care: a quest towards definition 55

Quality in maternity care 63

Distinguishing technical quality of care & patient satisfaction 70

Healthcare quality and its influence on uptake 77

Measuring quality in maternity care 80

The current state of research in maternal quality of care in sub-Saharan Africa 93

Improving maternal healthcare quality 107

Gaps in the literature 113




Results: a closer look 158

The results in context 165

Limitations 167

Policy and program implications 168

Conclusion 170



application/pdf Dissertation/Thesis 196 pages (4.7 MB) [Access copy of Dissertation/Thesis]
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