Kerala, a South Indian state known internationally for its health achievements has achieved MMR of 66 (SRS 2010-12) against the MDG target of 109 by 2015 [7]. Considering that the population in Kerala have the advantage of early and nearly universal antenatal coverage (99.8%) [8] the potential for improving the quality of care is considerable.

Approaches to improving quality of care should be based on regular quality assessment and operational research activities. There is little evidence on the content and quality of antenatal care in these settings. The only accessible study on quality of antenatal care in Kerala was done in tertiary level maternity hospitals in Thiruvananthapuram [9]. Hence it was decided to conduct a study on the quality of antenatal care provided through the public health sector of Kozhikode district in North Kerala.

Most studies deal with quality either according to technocratic perspective of health care professionals or from the lay perspective of clients. In this study, both client perspective and technocratic perspective were looked into.

1. To evaluate the quality of process of antenatal care both interpersonal aspects and technical aspects as observed by the investigator at various levels in the public health sector of Kozhikode district in North Kerala, India.
2. To find out the perception of the antenatal women attending the antenatal clinic regarding the antenatal care provided to them.

Study Design: Cross sectional study.

Study setting: Health care institutions providing maternal and child health care functioning at various levels in the public health sector namely Primary Health Centres (PHC), Block Level Primary Health Centres (BPHC), Community Health Centres (CHC) and Taluk Hospitals (TH) of Kozhikode district in North Kerala, India. Subcentres and tertiary level institutions like Medical College and Woman & Child Hospital were excluded due to feasibility issues. A list of PHCs, BPHCs, CHCs and THs was collected from the District Level Statistical Wing Data, District Medical Office, Kozhikode and arbitrarily 30% of institutions [11] were selected from each stratum [10].

A total of 27 institutions i.e. 30% institutions from each stratum were included in the study that is 20 PHCs, 3 BPHCs, 3 CHCs and 1 TH. Antenatal clinics were conducted on a weekly basis in these selected institutions, majority (81.5%) on Thursdays. Remaining (18.5%) were conducted on Wednesdays along with the immunization clinic which they attributed to the low case load on Thursdays.

Round the clock delivery services were available only in 2 out of the 27 selected institutions, namely one BPHC and one TH, where doctors conducted the antenatal clinics along with the JPHN. The median antenatal attendance in the antenatal clinic in these institutions on the day of observation was 7 (range 1 – 32) with an attendance of 1-21 in PHCs, 5-12 in BPHCs, 8- 15 in CHCs and 32 in the TH studied.

Assessment of Process of care: On the day of assessment by investigator, a total of 199 antenatal women attended the antenatal clinic in these 27 selected institutions. As two antenatal women did not give consent, 197 were observed while they were being provided antenatal care by the health care provider (observed quality). About half (52.8%) were visiting the institutions for antenatal care for the first time. Hence 93 antenatal women were included for exit interview. 72.1% of those exit interviewed had come for their second visit. 39.8% (37) of the antenatal women interviewed were primigravida, 30 (32.2%) were second gravida and 26 (28%) third gravida or above. 61 (65.6%) interviewed were in their second trimester of pregnancy and 16 (17.2%) each in their first and third trimesters of pregnancy.

Results regarding various attributes under interpersonal aspects and technical aspects have been depicted in Table 1. The mean percentage scores for the various attributes under process of care for the different levels of health care facility are given in Table 2. Table 3 depicts the proportion of women who received good quality antenatal care as per the observer.

Client perspective of antenatal care: (Table 1) Overall quality of care from the client’s perspective was good except in few aspects. Except for maintaining privacy all aspects of interpersonal relations was reported by 90% or more women. Advice regarding family planning (17.2%) and breast feeding (25.8%) were given to a quarter or less.

(37.6%) was reported by a quarter or less.

All 93 who were exit interviewed reported easy accessibility by road to the health facility. Only half reported home visit by health worker. Only 54 out of the 93 (58.1%) had received a Mother and Child Protection card. One reason noted for this low value was that the women availed services from PHCs in both her mother village as well as her husband’s village. The JPHN in one PHC will assume that the card to be issued by JPHN of the other PHC. The JPHN reported that all women will get the card eventually though there is time lag.

The time spent by the health care provider for each antenatal woman varied significantly between different levels of health care facility (Chi square 84.132; p value <0.001). More than half (61%) of the antenatal women observed in the PHCs spent less than 5 minutes with the health care provider, though the attendance in the clinics in PHCs ranged between 1 and 21on the day of observation. The situation was better in the BPHCs, CHCs and TH where the health care providers spent between 5 – 15 minutes with the antenatal women.

Waiting to meet the health care provider: In the study, 74.2% antenatal women reported that they had to wait less than 15 minutes to meet health care provider and only 24 (25.8%) had to wait more than 15 minutes.

More than three fourth (88.17%) were satisfied with the time they spent with their health care provider though most spent only 5 – 15 minutes.

A similar proportion (86.02%) was satisfied with the freedom they perceived in discussing their fears and anxiety. One-quarter (25.8%) were dissatisfied with the advice received regarding nutrition as they were not provided this health education.

Half of the women interviewed were dissatisfied with the advice received regarding rest and exercise during pregnancy and warning signals and complications. Less than three quarters were advised about their next visit.

Observed conduct of clinic: The ANC clinics officially started at 9am and closed at 1pm. Service delivery usually did not start on time either due to the late arrival of the health worker or due to the fact that they did not expect any pregnant women to come that early. Health workers encouraged pregnant women to arrive early in the morning as the antenatal women generally came towards noon, probably after morning chores at home have settled. There were instances when the JPHN did not attend to women who made her ANC visit on a day not scheduled for antenatal clinic and told her to come back on the correct day.

An informal history taking was usually conducted but not properly structured or complete; usually in the presence of other women. Most of the women had their blood pressure measured, weight checked and tetanus toxoid vaccination.

However, genital examination, abdominal examination including manual palpation of the foetus, measurement of the fundal height, the fundal lie and listening to the foetal heart, foetal heart rate and recording of body temperature, pulse rate and respiration rate were not performed for most of the antenatal women at the primary or secondary level facilities where the antenatal clinic was conducted by the JPHNs.

The JPHNs said that they did not perform most of the examination as per guidelines because of the perceived patients' preferences. Their clients were on regular antenatal check-ups from a gynaecologist and did not want to be examined by them. Moreover, the only expectation from the health facility was the prophylactic tetanus vaccination and IFA tablets.

It is seen here that most of the attributes under Interpersonal Aspects were performed better in the primary levels like the PHC, BPHC and CHC than in the TH. This may be due the fact that JPHN conducts the clinic at the primary level and have a better rapport with the antenatal woman. The difference in case load for the JPHN and gynaecologist may be another factor.

With regards to Technical Aspects of process of care, the percentage of speculum examination was low (1%) and this may be due to two factors: one that antenatal women of all trimesters were included in the study, whereas this examination is done in only the third trimester women and the other reason may be that JPHN was the health care provider in 92% institutions.

The same reasons may hold good for the finding that abdominal examination was performed in only 23%. In this study, health education regarding HIV / STD was not provided in any of the observed cases. This was because the JPHN assumed that this information is to be provided by the counsellor in the ICTC when the antenatal goes for screening.

Only 49% of the 197 antenatal women observed were given Iron and Folic acid tablets (IFA). The health workers as well as the antenatal women perceived the available IFA tablets to be of poor quality and hence the JPHNs were reluctant to give. Only 81% were observed being administered Tetanus vaccination; this may be because services delivered by the health care provider only on the day of visit by the investigator were considered; whilst the subject may have received the injection during her previous visits.

Certain aspects like weight measurement during ANC and advice regarding nutrition, rest, sleep and exercise during pregnancy were comparable to the findings in a similar study done in Thiruvananthapuram; but most aspects were found to be poor in our study like blood pressure checking, haemoglobin measurement, blood grouping, urine examinations other than Urine pregnancy testing, blood examination for HIV /HBsAg/ VDRL and health education regarding breast feeding [9].

Blood pressure measurement was received by a greater proportion in Nepal (82.5%) and Pakistan (86.4%) [14,15]. With regards to blood examination lesser proportion received the service in Nepal (45.3%) and Pakistan (60.8%) [14,15].

Overall quality of care from the client’s perspective was good in all aspects of interpersonal relations except for few aspects like maintaining privacy.

In the study conducted by Rani M et al in India, poor interpersonal quality was reported by illiterate women and women from southern states reported better interpersonal quality when compared to those from northern states [19]. Less than a quarter (12.9%) were explained about labour and 33.3% regarding warning signals and complications during pregnancy. Greater proportion (81.6%) were explained regarding complications in the study conducted in Pakistan [15].

Observed antenatal care vs. client’s perspective: There is an evident disparity between the observed antenatal care process and the care as perceived by the woman as depicted in Table 1. When 98% respondents felt the health care provider was polite to them, it was observed that only 90% were polite.

This may be a subjective difference in what is considered polite. Though in only 27% either a screen was used or door closed during consultation, twice the percentage (54%) responded that either a screen was used or door was closed.

Similar wide disparities between the observations made and client perception were evident in enquiry of previous medical / obstetric conditions (58% vs. 80%); explanation of the procedure or investigation going to be performed (24% vs. 64.5%); explanation regarding present condition and prognosis (7% vs. 57%); explanation regarding diet, rest and exercise (38% vs. 59%); breast feeding and breast care (1% vs. 25.8%); family planning (4% vs. 17%); labour (0.5% vs. 13%); warning signals and complications (3% vs. 21.5%).

The disparity noted in relation to health promotion of HIV (0% vs. 20.4%) may because this information is provided by the ICTC counsellor, so we did not observe but the antenatal received the health education. A similar disparity has been discussed in the study done in Nepal were 54% reported going to ICTC but only 33% were observed [14]. Disparities were also noted in blood pressure measurement (70% vs. 85%) and examination of eyes (7% vs. 25%).

There may be various explanations for this disparity between observed care and client’s perspective of care provided.

Moreover as the perceptions of the antenatal women were assessed through an exit interview in the same institution, some of the perceptions of care delivery may not have been properly expressed.

Process of antenatal care in totality was not satisfactory and needs improvement in all aspects at all levels. None of the studied institutions had a satisfactory score. Only a quarter provided satisfactory care in terms of interpersonal aspects and diagnostic aspects. The quality was poorest at the CHC level.

History taking needs improvement at all levels as only less than a per cent provided good quality care in this aspect. Only one per cent scored well in Physical examination aspect and in Provision of health education. There is a need to improve the quality of health education provided at all levels especially at higher levels like CHC, TH. Treatment aspect was adequate at the TH level, but very low at primary levels like PHC, BPHC and CHC.

The client provider interaction time was lower than the WHO recommendations though the average attendance was only 7. Most of the antenatal women came for availing only immunization facility. A disparity was noted between the observed and perceived duration of consultation.

Perceived quality was satisfactory though there was wide disparity between observed antenatal care and client perspective of care provided. Only half the women interviewed reported home visit by health worker and a similar percentage reported receiving Mother and Child Protection card.

The government sector was utilized by majority for Tetanus immunization; whereas both government and private sectors were equally utilized for obtaining Iron tablets. The quality of iron tablets in the government sector was perceived to be of poor quality by both the health workers and antenatal women. All antenatal women were planning to deliver in a health facility. Majority were planning to deliver in a tertiary set up and 17% in private sector.

Overall none were dissatisfied with the care they received. More than three fourth were satisfied with the health facility and other structural facilities available; with the time they spent with their health care provider;