Factors affecting the provision of high-quality postnatal care services in Zanzibar: a qualitative study.

BACKGROUND: In Sub-Saharan Africa, the postnatal period is associated with high mortality and accounts for a substantial proportion of maternal deaths. Although postnatal care has been identified as critical in reducing maternal mortality, the quality of care provided is often inadequate. Tanzania and Zanzibar have not made sufficient progress towards achieving the Sustainable Development Goals on maternal health, and there is limited knowledge about the utilization and quality of postnatal follow-up. The aim of this study was therefore to explore factors affecting the provision of high-quality postnatal care services in the urban area of Zanzibar. METHODS: Five focus group discussions were performed in Swahili with 25 healthcare providers from primary healthcare units in urban Zanzibar. Interviews were audio-recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis with an inductive approach. RESULTS: Factors affecting provision of high-quality postpartum care services could be divided into three generic categories. Difficulty achieving high attendance comprised three subcategories: long waiting times, low awareness among women, and out-of-pocket payment. Lack of basic resources also comprised three subcategories: shortage of healthcare providers, lack of adequate space, and inadequate medical equipment. Insufficient care routines comprised two subcategories: lack of guidelines and deficient chain of information. CONCLUSIONS: The present findings suggest that the women's perceptions of postnatal care do not align with the intended purpose of routine postnatal care. Instead, the postnatal period primarily leads to visits to health facilities only when urgent care is required, and there is a lack of awareness about the importance of postnatal care. Moreover, limited resources, including equipment, staff, and space, as well as long waiting times, hinder the delivery of high-quality care and contribute to a negative reputation of postnatal care services. To effectively reach all women and improve postnatal care, it is necessary to increase basic resources, modify health education approaches, and enhance the flow of information between different levels of care using context-specific strategies.

Barriers to using postpartum family planning among women in Zanzibar, Tanzania.

BACKGROUND: Effective family planning is associated with substantial benefits, including reductions in maternal and neonatal mortality due to the avoidance of unintended pregnancies, and contributions to spacing, timing, and limiting births. However, in Zanzibar, Tanzania, the utilization of modern contraceptive methods is low. This study therefore aimed to identify barriers to using postpartum family planning among women in Zanzibar. METHODS: Five focus group discussions were conducted with 24 women who gave birth in the maternity unit at a reference hospital in Zanzibar during the first quarter of 2022. The discussions took place in Swahili, were performed with the assistance of an interview guide, and were audio recorded, transcribed in Swahili, and translated to English. Data were analysed with qualitative content analysis using an inductive approach. RESULTS: Barriers to using postpartum family planning in Zanzibar could be summarized in three generic categories. Inadequate knowledge about postpartum family planning is expressed in the subcategories: inadequate knowledge about contraceptive methods and their mode of action, insufficient quality of family planning services, and belief in traditional and natural medicine for family planning. Perceived risks of modern contraceptive methods are described in the subcategories: fear of being harmed, and fear of irregular bleeding. Limited power in one's own decision about contraceptive use consist of the subcategories: the need to involve the husband, and opposition and lack of interest from the husband. CONCLUSIONS: The participants' current knowledge of postpartum family planning was insufficient to either overcome the fear of side-effects or to understand which side-effects were real and likely to happen. The woman's power in her own decision-making around her sexual reproductive rights is of critical importance. Given the barriers identified in this study, the findings call for increased knowledge about family planning methods and their mode of action, and involvement of the husband throughout pregnancy, childbirth, and the postpartum period in postpartum family planning education and counselling, in Zanzibar and in similar settings.

Lost and lonely: a qualitative study of women's experiences of no embryo transfer owing to non-fertilization or poor embryo quality.

STUDY QUESTION: What are the experiences of women undergoing IVF who could not receive an embryo transfer because of failed fertilization or poor embryo development? SUMMARY ANSWER: No embryo transfer because of failed embryo development is associated with considerable emotional suffering and the need for an early appointment with a physician to obtain information on what went wrong and new alternatives. WHAT IS KNOWN ALREADY: The psychological and emotional impact of IVF treatments as experienced by IVF patients is well known, particularly following the failure to achieve pregnancy. STUDY DESIGN SIZE DURATION: A qualitative study running from January 2018 to April 2019 was carried out at one public and one private IVF clinic. The invitation to participate was sent to women within 1 month after the cycle failed. PARTICIPANTS/MATERIALS SETTING METHODS: The women undergoing IVF were diverse in terms of cause of infertility, age, number of previous cycles, country of birth and educational level. Nineteen of the 41 invited women who had experienced no embryo transfer because of non-fertilization or poor embryo development took part in a semi-structured interview. Data were analysed by thematic content analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The master theme was identified as: 'Lost and lonely' organized in two main themes 'Experience of the event' and 'Perception of needs from healthcare providers'. Considerable emotional suffering was recognized after no embryo transfer. The need for support was expressed as to be offered an early appointment with a physician for information about what went wrong, looking at new alternatives and, for many women, providing information about counselling. LIMITATIONS REASONS FOR CAUTION: Only women participated, not partners. Of the women invited, 46% participated. Several declined to participate because of high levels of emotional stress. WIDER IMPLICATIONS OF THE FINDINGS: Patients undergoing IVF and not achieving embryo transfer due to poor embryo development are a vulnerable group. They need early feedback concerning reasons for failure and future alternatives. They also require psychological support. This ought to be offered by IVF clinics. STUDY FUNDING/COMPETING INTERESTS: The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (ALFGBG-70940). It was also financed by the Local Research and Development Board for Gothenburg and Södra Bohuslän (VGFOUGSB-866771) and by Hjalmar Svensson's research foundation (HJSV-2017012). None of the authors declares any conflicts of interest. LARGE SCALE DATA: N/A.

In vitro fertilization healthcare professionals generally underestimate patients' satisfaction with quality of care.

INTRODUCTION: Previous studies have mainly compared professionals' and patients' ratings of the importance of different care aspects, finding poor agreement between the groups concerning patient-centered quality of care. There is still little known about professionals' knowledge of how patients experience the quality of care they receive during in vitro fertilization (IVF) treatments. The aim of this study was to investigate how IVF healthcare professionals estimate patients' experience of patient-centered quality of care and if certain factors influenced the IVF professionals' perceptions and IVF patients' experience of quality of care. MATERIAL AND METHODS: All 16 IVF public and private clinics in Sweden participated in this cross-sectional study. A total of 268 IVF healthcare professionals and 3298 patients (women and men) undergoing IVF treatment between January and May 2015 participated by answering the validated questionnaire "Quality from the patients' perspective of in vitro fertilization treatment" (QPP-IVF). RESULTS: Healthcare professionals significantly underestimated patients' satisfaction with the patient-centered quality of care they received in all aspects measured. Both patients and professionals rated the most deficient factors to be "responsibility/continuity", "participation" and "availability". Healthcare professionals and patients belonging to private clinics evaluated patient-centered care as significantly better than professionals and patients at public clinics in almost all aspects measured. CONCLUSION: The results of this study will increase the professionals' understanding of the patients' experiences during IVF treatment and provide additional knowledge when identifying areas to prioritize to improve quality of care.

Patient-centred quality of care in an IVF programme evaluated by men and women.

STUDY QUESTION: Do men and women value the same aspects of quality of care during IVF treatment when measuring rates of importance by the validated instrument, quality from the patient's perspective of in vitro fertilization (QPP-IVF)? SUMMARY ANSWER: Women valued most aspects of care as significantly more important than their partner although men and women evaluated the importance of the different care factors in a similar pattern. WHAT IS KNOWN ALREADY: A few validated tools measuring patient-centred quality of care during IVF have been developed. Few studies of gender differences concerning experiences of patient-centred quality of care have been reported in the literature to date. STUDY DESIGN, SIZE AND DURATION: A two-centre study was conducted between September 2011 and May 2012. Heterosexual couples (n = 497) undergoing IVF were invited to complete a questionnaire before receiving the result of the pregnancy test. PARTICIPANTS/MATERIALS, SETTING, METHODS: In all, 363 women and 292 men evaluated quality of care by answering the QPP-IVF questionnaire. The measurements consisted of two kinds of evaluations: the rating of the importance of various aspects of treatment (subjective importance) and the rating of perceived quality of care (perceived reality). Comparisons between men and women on importance ratings and perceived reality ratings were performed both on factor (subscale) and single item levels by intra-couple analyses and corrected for age. A stepwise multiple logistic regression analysis was performed in order to select baseline variables independently predicting evaluation at factor level. MAIN RESULTS AND THE ROLE OF CHANCE: The response rate was 67.5%, with 363 women (74.2%) and 292 men (60.6%) completing the study. Both the woman and man responded in 251 couples. Women rated the different care aspects as significantly more important than their partner in all factors except the factor, 'Responsibility/continuity'. Both genders gave the factors, 'Medical care' and 'Information after treatment', the highest scores. At item level women rated the majority of items as significantly more important than men. Perceived reality for the majority of factors and items was similarly rated by men and women in the couples. For women, receiving embryo transfer, short duration of infertility, IVF as a method and number of previous cycles were independently correlated to the highest score of importance of certain factors. LIMITATIONS, REASON FOR CAUTION: The lower response rate of men compared with women (60.6 versus 74.2%, respectively) might have influenced the results through selection bias. Only patients who had adequate fluency in the Swedish language participated. WIDER IMPLICATIONS OF THE FINDINGS: This study is an important contribution in comparing the needs of men and women undergoing IVF treatments. The QPP-IVF instrument is a suitable instrument for revealing important care aspects identified by both men and women and a useful tool for stimulating patient-centred quality improvements within and between clinics. STUDY FUNDING/COMPETING INTEREST: The study was supported by the LUA/ALF agreement at Sahlgrenska University Hospital, Gothenburg, Sweden, and by Hjalmar Svensson's Research Foundation. None of the authors declared any conflict of interests.

Quality of care in an IVF programme from a patient's perspective: development of a validated instrument.

STUDY QUESTION: Is it possible to develop a trustworthy instrument to evaluate the patient's perspective on fertility care and to document fully all methodological steps, including validation? SUMMARY ANSWER: A validated instrument has been developed for both women and men undergoing assisted reproduction to monitor the quality of care on a regular basis, similar to live birth rates and other effectiveness data. WHAT IS KNOWN ALREADY?: Within fertility care, several instruments have been developed, but many have significant methodological problems and few have been validated. Most instruments focus exclusively on women and no questionnaires have been directed at women and men separately. STUDY DESIGN, SIZE AND DURATION: The questionnaire specific to IVF treatments (QPP-IVF) is based on the theoretical foundation of the validated general instrument, quality of care from patients perspective (QPP), for both women and men. The QPP-IVF was developed and validated by quantitative methods. A two-centre study ran between September 2011 and May 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: In all, 655 women and men participated. The measurements consisted of two kinds of evaluations: the rating of perceived reality of care and the rating of the subjective importance of various aspects of treatment. The questionnaire consisted of 43 items for women and 42 items for men. An exploratory factor analysis was performed for women for all items of subjective importance. Eigenvalue, explained variance and factor loading are given for each factor. Internal consistency of subscales was assessed by Cronbach's alpha, item discriminant validity and percentage scaling success. For external validity, a correlation with fertility quality of life (FertiQoL) was performed and for reliability, a test-retest analysis was carried out. Sensitivity analyses were performed by known-group analyses. All significance tests were two sided and conducted at the 5% significance level. MAIN RESULTS AND THE ROLE OF CHANCE: The QPP-IVF instrument, divided into four dimensions, seemed a valid and reliable way of measuring the quality of care from a patient's perspective, for both women and men. The item-scaling test confirmed 10 underlying factors, with scaling success in all subscales and Cronbach's alpha >0.70 for women in almost all subscales. It was somewhat lower for men but still acceptable. The external validity was acceptable, with significant correlation between QPP-IVF and FertiQoL. The test-retest analysis confirmed that QPP-IVF was a stable instrument, with intra-class correlation coefficients from 0.74 to 0.89 for women. Sensitivity analyses indicated a sensitive instrument. LIMITATIONS, REASON FOR CAUTION: The response rate to the questionnaire was 67.5%. Although considered acceptable in questionnaire studies, this response level might introduce a certain risk of selection bias. The questionnaire was developed and validated only in Sweden. WIDER IMPLICATIONS OF THE FINDINGS: The QPP-IVF may be of use for purposes of quality improvement and national comparisons. Future studies should focus on establishing the QPP-IVF as a valuable instrument for measuring the quality of care outside Sweden. STUDY FUNDING/COMPETING INTEREST: The study was supported by the LUA/ALF agreement at Sahlgrenska University Hospital, Gothenburg, Sweden and by Hjalmar Svensson's Research Foundation. None of the authors declared any conflict of interests.