Aligning Perceptions of Maternal Health Care Quality with Reality: An Interview with Zeina Siam

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By: Mathilda Regan,

Zeina Siam is a doctoral candidate in the Department of Global Health and Population at the Harvard TH Chan School of Public Health. The Maternal Health Task Force interviewed her about her recent publication on maternal health care quality.

Zeina Siam, a doctoral candidate in the Department of Global Health and Population at the Harvard TH Chan School of Public Health

Can you tell me a little about your background and how you became interested in the quality of maternal health care?

I have always been passionate about studying disease patterns and developing evidence-based policies to advance women’s health at the population level. I specialized in breast cancer epidemiology for my Masters. I particularly studied risk factors predicting breast cancer survival among women in the USA.

After graduation, I moved to the Middle East, and worked at the health systems division of the World Health Organization. My assignment at WHO drew my attention to the suboptimal quality of care women receive for the most basic of health services– the services pertaining to child rearing and delivery.

For instance, institutional births in the Palestinian Territories are almost universal, yet maternal mortality is well above rates in developed countries, an indicator that the quality of care may need improvement. Given these indicators, I worked on a few initiatives in the Palestinian Territories targeting quality of care, including the WHO patient-safety and baby-friendly initiatives. I could see during this work the large gains to maternal health that could be harvested with the right policies and strategies targeting quality of care. With that, quality of care for maternal health became a major area of interest for me. I am hoping to pursue my interest further to enhance healthcare services that women need during their life cycle, including but not limited to, maternal services, and breast cancer screening, diagnosis and treatment.

You just published a paper in BMJ Open about how women’s perceptions of maternal health care quality in different facilities in Nairobi align with actual quality. What inspired you to research this topic?

This is absolutely one of the most exciting research projects I have worked on in the past few years, and I want to start by acknowledging all my colleagues and mentors who have contributed to this study.

This study examined an economic theory that has been well established in the literature but has not been fully explored in developing contexts. The theory is information asymmetry. Basically, the theory states that people are unable to discern which facilities and/or providers offer the best quality care before utilizing the service. Our aim was to see if this theory applied to maternal health in the informal settlements of Nairobi, Kenya. In these settlements, quality of care varies substantially across facilities and the referral system is suboptimal. With that, information asymmetry is likely to be present and to possibly influence women’s behaviors.

We were particularly interested in getting insight about whether women can accurately perceive the relative technical quality levels of facilities within their choice sets, and whether accurately perceiving facilities’ relative quality levels predicts the quality levels at women’s final facilities of choice.

How did you quantify information asymmetry and quality of care?

We surveyed women during pregnancy regarding their perceptions of the quality of all facilities they were considering for delivery. After delivery, we obtained information about their final facilities of choice. Women’s perceptions of quality were based their rankings of the facilities they were considering with regards to perceived abilities to handle emergencies and complications.

Delivery facilities were assigned a quality index score based on a direct assessment of performance of emergency “signal functions”, skilled provider availability, medical equipment, and drug stocks.

“Accurate perceptions” was a binary variable for whether a woman’s ranking of facilities based on her quality perception equaled the index ranking.

Can you tell us a little about your findings?

We found that 2 out of every 5 women in our sample were unable to correctly perceive relative abilities of facilities in their choice sets to delivery technical quality of care. Our study thus shows, that in the context of the informal settlements with Nairobi Kenya, information asymmetry is substantially existent. This is not surprising because obstetric and newborn complications can be relatively rare, and the relative technical skills available at maternity facilities may be hard for a woman to observe or judge beforehand, without a referral system through which they would be directed to better quality facilities or some form of objective information about facility quality levels made available to them. The other major interesting finding that we found is that women who were able to correctly determine what facilities offer the best quality care were more likely to deliver in top quality facilities.

What are the policy implications of this work?

Our study suggests that providing information to pregnant women about the quality of available maternity facilities may be a promising approach to steering women toward higher quality options. As quality improvements require a multi-pronged approach from the consumer side and the provider side, I personally see this as a potential short-term policy option that should be explored in complementarity  with initiatives to improve quality of care at the facility level in the study context.

What research questions are you looking at now?

We are now proceeding to examine what other facility attributes women consider in addition to quality, such as cleanliness, respectful care, and knowing someone in the facility. We are trying to understand how these factors contribute to their decision-making process about which facilities they consider and ultimately utilize.

Is there anything else you would like to add?

Quality of care is really an extremely important area of work today. In the past, global efforts have focused on access to care, and we have witnessed tremendous improvements in maternal health. However, recent evidence from insightful new work and research, shows that without an added focus on quality of care, we may be soon hitting ceiling with these achievements.

On the other hand, improving quality of care is no easy feat. It requires efforts on multiple levels, including demand-side, as we looked at in this paper, and supply-side. Enhancing quality also requires looking at how a given country’s context is shaping people’s needs and how the health system has evolved to meet those needs. Hopefully this research project will be complemented by other research efforts on quality of care in sub-Saharan Africa and beyond at such an exciting time for global health!