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Objectives: The objective of the study was to identify where delays occur when women present for antenatal care in four Nigerian referral hospitals, and to make recommendations on ways to reduce delays in the course of provision of antenatal care in the hospitals. Design: Prospective observational study. Setting: Four Nigerian (1 tertiary and 3 secondary) Hospitals. Participants: Women who presented for antenatal care. Interventions: A process mapping. The National Health Service (NHS) Institute Quality and Service Improvement Tool was used for the assessment. Main outcome measures: The time women spent in waiting and receiving antenatal care in various departments of the hospitals. Results: Waiting and total times spent varied significantly within and between the hospitals surveyed. Mean waiting and total times spent were longest in the outpatients’ departments and shortest in the Pharmacy Departments. Total time spent was an average of 237.6 minutes. χ2= 21.074; p= 0.0001. Conclusion: There was substantial delay in time spent to receive care by women seeking routine antenatal health services in the four secondary and tertiary care hospitals. We recommend managers in health facilities include the reduction of waiting times in the strategic plans for improving the quality of antenatal care in the hospitals. This should include the use of innovative payment systems that excludes payment at time of service delivery, adoption of a fast-track system such as pre-packing of frequently used commodities and the use of new tech informational materials for the provision of health education. Funding: The Alliance for Health Policy and Systems Research, World Health Organization, Geneva; Protocol ID A65869.
The study used process mapping to follow women when they first entered the hospitals, as they traversed each department of the hospital to access antenatal care. The patients were identified randomly as they entered the maternity units of the hospitals. Four referral hospitals (one tertiary and three secondary facilities) were selected from three out of six geo-political zones of Nigeria. Administratively, Nigeria has 36 states and a Federal Capital Territory (Abuja). These states are further categorized into six zones: North-central, Northeast, Northwest, Southeast, South-south, and Southwest. Each of the zones is predominantly made of people of similar culture. In the Northwest, a tertiary health facility, Aminu Kano Teaching Hospital (AKTH) in Kano, Kano State was selected. The secondary care facilities were General Hospital GHA), Ijaye, Abeokuta in the Southwest; General Hospital (GHM), Minna, Niger State and Karshi General Hospital (KGHA), Abuja in the North-central. Each hospital offers antenatal and delivery care as part of comprehensive provision of maternal health services. The antenatal clinics are held in designated parts of the hospitals and are administered by the Departments of Obstetrics and Gynaecology of the hospitals. Each Department has full complements of residents in training, consultant staff and midwives that offer full time services. However, the antenatal clinics are mainly run by residents under the supervision of clinical Consultants. The Consultants attend to complicated clinical cases, who are oftentimes then admitted for more intensive care in the antenatal wards of the hospitals. As part of the provision of antenatal care, women presenting for the first time in the antenatal clinics report at registration desks that are situated in the antenatal clinics. Thereafter, they are assigned to specific consultant teams (Consultant and residents) and given dates to consult the teams. However, the specific times of the dates given for visit are often not identified in the appointments and so patients attending clinical appointments have to take turns to wait until they see doctors in the consulting teams. After the consultations, women are then requested to visit the laboratory departments (for laboratory investigations), radiology departments (for ultrasound or X-rays) or pharmacy departments (for prescribed drugs) to receive recommended services in other parts of the hospitals. Oftentimes, the costs of such services are paid at the individual service delivery points, rather than at a central location. Furthermore, none of the facilities had computerized records, dedicated pharmacy for antenatal clinics or and pack system for antenatal drugs. A major concern in the four hospitals is poor staffing of the antenatal clinics with few doctors allocated to attend to patients in the hospitals. Our formative research estimated patients to doctor ratios in the hospitals to range from 330 per doctor per year in Abuja, to 924 in Kano, 2740 in Abeokuta to 1,976 in Minna. The NHS Institute Quality and Service Improvement Tool was used by the research teams, working with a midwife and a doctor from each of the hospitals. Each patient was identified at the point of entry by a project staff in each of the hospitals. The purpose, objectives and methods of the study were explained to them in detail. Only those who agreed to participate and who could read their wrist watches and record the findings accurately were included in the study. Also excluded were women who were coming to the hospitals to register for antenatal care for the first time. These women were often seen by record officers on their first visits and were then given appointments on days to see their consultant teams. Since they were not expected to complete all clinical processes on their first visits, they were not included in the study. The patients were given a form (Form A3, also called client flow form) to record the times they entered and left each service delivery unit (Records, Out-patient, Pharmacy and Laboratory departments), to enable the calculation of the total time they spent in receiving care in various departments of the hospital. The women were taught to record the waiting times (i.e. times they spent waiting to see the service provider), and the contact time (i.e. times they spent with the service provider). Upon completion and exit from the hospitals, the patients were requested to deposit the completed forms at the same desk they obtained them. The forms were then examined and the clients interviewed by the project staff to ensure accuracy in the documentation of waiting times and contact times. The number of women included in the sample in each hospital was determined by the number of consenting women in the hospital, who successfully and correctly completed the timing at the service delivery points, The data analysis was done centrally. The analysis was conducted semi-quantitatively. Data were entered into the computer using the SPSS Pc+ software. The mean duration of time reportedly spent by the patients from arrival at each department in the facility to exit was calculated. Waiting time was measured as time of arrival in the Department to time when service started. Women who did not complete the forms correctly were excluded from the analysis. Due to the asymmetric nature of the data, non-parametric statistics, Kruskal-Wallis H test was used to compare the means across the facilities and departments. An independent t-test was also conducted to determine if there is a statistically significant difference in the mean duration of time spent between patients who were visiting for initial treatment and those who came for follow-up. The significance level was set at 0.05. Ethical approval for the study was obtained from the World Health Organization and the National Health Research Ethics Committee (NHREC) of Nigeria – number NHREC/01/01/2007 – 16/07/2014, renewed with NHREC 01/01/20017-12/12/2015b.
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