Factors affecting quality of maternal care during childbirth : a qualitative exploratory study in public and private maternity care centers of Karachi, Pakistan

Maternal mortality is an alarming indicator of human development. In the majority of developing countries, the reproductive-aged women are highly affected by death rates related to pregnancy and childbirth. It is estimated that each year around 529,000 women dies worldwide due to harmful consequences of childbirth. Also, according to progress report of Millennium Development Goal, Pakistan was expected to reduce the maternal mortality rate by three-quarters till 2015, however, due to insufficient progress, it has remained off track on all the maternal care indicators. Hence, timely interventions and adequate provision of treatment can reduce the persistently high trends of maternal mortality. Moreover, the most effective approach to catalyze this issue is the provision of skilled and high-quality maternity care at health care facilities. Thus, this study aimed to explore facilitating and impeding factors that influence the provision of quality care during childbirth at maternity care centers of Karachi, Pakistan. Methodology: The qualitative exploratory study design was used to explore the phenomena of interest. The study was conducted during July till September, 2016 at a public and private secondary level maternity health facilities of Karachi, Pakistan i.e. Sobhraj maternity care center and Aga Khan maternity center, Garden. The in-depth interviews from mothers, health care providers and health facility administrators were conducted using semi-structured interview guides. The purposive sampling technique was employed for the selection\u27of participants for the in-depth interviews. The standard data recording, transcription, and coding methods were conducted and framework method using content analysis approach for data analysis was used. Also, document review of the essential documents was conducted in both public and private maternity care facilities. The document review identified several gaps and helped in triangulating the data with that of the qualitative findings. Findings: This research study identified several constraining and facilitating factors during childbirth in healthcare facilities that impacts on quality of intrapartum care. These factors are explored by integrating them with health system pillars. The main drivers identified in the private maternity -----4 6 care center were skilled and efficient workforce, availability of guidelines, equipment and supplies, leadership and governance and service delivery. However, in the public maternity care center, service delivery and health care financing were the vital facilitating factors found. The barriers identified in the private maternity care center were mainly regarding the financing and physical infrastructure of the health facility. Conversely, there were multiple barriers related to leadership and governance, unhygienic environment, unavailability of equipment and supplies and absence of safe delivery guidelines identified in public maternity care center. Conclusions, Systems, and Policy Level Implications: To conclude, quality maternity care during a facility-based delivery can contribute in minimizing high maternal illness in developing countries. The findings obtained from this study suggested several potential implications such as development of health workforce, establishing quality standards in maternity care facilities, creating culture of safety etc. to minimize gaps in quality of care delivered in maternity care centers. This study will also aid policymakers and health systems stakeholders to initiate effective strategies to identify and mitigate the reasons for the provision of low quality of maternity care during facility-based deliveries. This will eventually strengthen health sector of Pakistan in improving maternal care services, provision of essential supplies and drugs necessary for delivery and availability of vital guidelines and skilled health workforce in maternity healthcare facilities