http://doi.org/10.33698/NRF0138 – Reena Jairus, Indarjit Walia
Abstract : ‘Maternal cards’ in the community health care setup are a principal source of information in which the documentation of maternal care is an essential part. Maternal Care covers the antenatal and postnatal care of women with pregnancy, problems during pregnancy, care during puerperium and family planning. Antenatal care is one of the “four pillars” of safe motherhood, as formulated by the Maternal Health and Safe Motherhood Program, Division of Family Health of the World Health Organization. Home visits by community- based health workers can help to reduce neonatal mortality by ensuring identification of pregnant women, and by ensuring optimal maternal health through both antenatal and postnatal care visits to their homes. The information for the mothers, their age, education and the health status and the care provided by the Female Multipurpose Health Workers and nursing students to the mothers is documented on the maternal cards in the family folders. The audit is the major tool to evaluate the quality of care. It was felt that there is need for the evaluation of documented care and a tool is required hence an Audit tool is developed to audit the documented care. There are 81 items to evaluate care of mothers. Content validity was checked by giving the tool to experts, construct validity by application of Principal component analysis and reliability by Cronbach’s alpha. The value of Cronbach’s alpha was .95 which showed that tool is reliable. The developed tool shall evaluate the family folders maintained by health workers and nursing students. This tool will help in improving the quality of documentation.
Key words :
Audit tool, Maternal care in the community.
Correspondence at : Reena Jairus
Assistant Nursing Superintendent CMCH, Ludhiana
Introduction
Mothers are important components of family as the health of children depends upon the health of the mother so the mothers are to be provided the best care right from the adolescent period. Mothers need timely access to skilled care during pregnancy, child birth, and postpar tum period. Immediate and effective care during and after labor can make a significant difference between the life and death of both the mother and the new born as the complications are unpredictable and rapidly become life threatening. Timeliness or degree to which care is provided at the most beneficial or necessary time is a key component of quality health care along with effectiveness.1,2
A maternal health record shows the extent of the health problems’, needs and other factors that affect mothers’ health. What has been done for the mothers is documented in the maternal cards and further what is to be done is also written. It also indicates the plans for future visits in order to meet the needs. Record serves as a guide for evaluation of care provided by the workers. When records are made they help to continue the care and also help to identify the high risk mothers.3 Audit is a kind of review and is a major tool used to evaluate the quality of care.4 An audit is the systemic review of records for the purpose of evaluation of the documentation. Nursing audit is the assessment of quality of nursing care and uses the record as an aid in evaluating the quality care. It is useful to identify areas of strength and weakness for further planning. A nursing audit is two types. First, a retrospective audit which refers to an in depth assessment of the quality after the provision of the care and the record is the source of data. The second is the concurrent audit which refers to evaluation when client is still getting care.5
The records are the primary source for getting the information related to the mothers. These are the legal records and the evidence of the basis on which decisions were made.6 To see the quality of care and the documentation auditing is required in the community to improve the care. C B Jorvell developed an audit instrument that measures the extent to which patient records describe important aspects of nursing care.7
Improving documentation is an urgent issue. Poor documentation is an indication that further investigation is needed to judge whether or not the given care is less than optimal. Evaluating the care through documentation improves the care as well as the documentation. Looking into the need for evaluation of the care of mothers, the investigator felt the need to develop an audit tool.
With the ongoing emphasis in resource management cost control, efficiency in client care, quality improvement and accountability, the health workers are required to provide care and do effective documentation at the same time.3 Maternal health records are the means of providing information about health of mothers. These records are practical and indispensable aid to the health personnel for giving best possible proper care to mothers. The health worker before she goes to the family will read the record and get knowledge about their health and she will not be treated as a stranger because this will help her to create good personal rapport.8
Objective
The objective of the present study was to develop an audit tool for documented care for mothers by the health workers and the nursing students.
Methodology
Present study used the methodological approach. The study was conducted in one of the nongovernmental hospital of Panjab where it has three health centers and they are providing services to the rural and urban population. The health centers where the study was conducted the Health Care is provided by the Female Multipurpose Health Workers and nursing students through home visits. The nursing students are posted for their field experience in these centers and they work under supervision. Center is providing care for mothers, children and for general population. These centers work under the department of social and preventive medicine. All the records, reports and registers belong to community medicine department but they are maintained by Female Multipurpose Health Workers and nursing students posted in the areas. The reports and records, which are generally used by these centers, are sent to the SPM department on monthly, quarterly and yearly basis.
Family folder is maintained for each family which gives description about socioeconomic status of the family which further describes about type of house, animal kept, sanitation and water supply, mechanical profession and economical status. It also describes about the house no., area, family folder no., workers name, religion, description about all the family members, family planning status and immunization status whether it is complete or partial. The folders are enclosed with many other cards like eligible couples’ cards, maternity cards, preschool cards and individual cards etc.
The total family folders in the one Urban Family Welfare center were 3189, in the other urban health center the total family folders were 2080 and whereas in the Rural health center the total family folders were 2100. Audit tool is developed by literature review, identifying items, discussion with peers and determining items. There was generation of item pool and their organization; suggestions were incorporated about the format of tool. The tool can record all the above information for five eligible couples and five mothers. The tool is divided into two parts.
Part-I was to record the identification as house no, folder no, area, name of the head of the family, date of making the folder, total family members, family income, religion, type of family, year of making the folder.
Part II is further divided into five parts and 196 items. The par ts are related to preparation of eligible couple card, assessment and care of antenatal mothers, information related to abortions, assessment and care of mother during delivery and post natal period. Content validity of the tool was done in four rounds by peers, five rounds among exper ts from the field of nursing and community medicine. Further, five times the tool was field tested for feasibility, content validity and the consumption of time.
Cronbach’s alpha was applied to check reliability of the audit tool after its field test on 100 maternal records.. This resulted in deletion of 100 items from different components of maternal care and retention of reliable 96 items.
Thereafter the audit tool was field tested on 2000 sample records. On the data collected, once again the Cronback’s alpha was applied and principal component analysis was done. This resulted in deletion of 15 more items from maternal care. Total 81 items are left in final Audit tool. The reliability of the tool is found to be .995 which shows that all items of this tool are consistent and show undimentionality. Factor analysis of tool after Varimax rotation method indicated that total seven factors.
Results
For construct validity of the tool factor analysis is applied which divides the tool in to seven parts according to the factors generated through factor analysis. These parts were as preparation of eligible couple card, antenatal mother, abortion, and post natal mother. The items of the tool are organized under the same heads as they were prepared after analysis. Other 15 items which were related to identification on folders, intra natal mother and few items related to postnatal mother were deleted but they are also important and can be included in the tool.
Time of preparation of Maternal Card retained maximum items 1-3 in Factor 1 which reflect preparation of eligible couple card and documentation of antenatal visits as shown in table 1.
Table-1: Factors using Principal component Analysis of items related to gestational period when Maternal Card prepared
| Items | Factors | ||||
| 1 | 2 | 3 | 4 | 5 | |
| 1. Eligible couple card made
2. LMP |
0.338 |
0.876 |
0.650 | ||
| 3. Maternity Card made at
a. 16 wks of pregnancy |
0.571 |
0.709 |
|||
| b. 20 weeks | 0.669 | 0.638 | |||
| c. 32 weeks | 0.706 | ||||
| d. 36 weeks | 0.669 | 0.415 | |||
After Factor analysis the maximum items related to assessment and care of antenatal mothers retained under factor 1 and 2 (Table-2 and 3). These items measures the documentation related to construct of antenatal mother.
Table-2 : Factor Analysis of record maintained on maternal assessment by Principal Component Analysis
| 1 | 2 | |
| 1. Age | 0.656 | 0.678 |
| 2. Gravida | 0.711 | 0.607 |
| 3. Para | 0.761 | 0.536 |
| 4. No. of Living children | 0.659 | 0.637 |
| 5. LMP | 0.634 | 0.711 |
| 6. EDD | 0.643 | 0.696 |
| 7. Weight | 0.811 | 0.490 |
| 8. Height | 0.875 | 0.412 |
| 9. Blood Pressure | 0.837 | 0.458 |
| 10. Blood GP | 0.867 | 0.418 |
| 11. Hemoglobin once in each trimester | 0.865 | 0.420 |
| 12. Urine Sugar | 0.880 | 0.408 |
| 13. Urine Albumin | 0.879 | 0.409 |
| 14. Edema | 0.918 | 0.361 |
| 15. Minor Ailment: | 0.923 | 0.355 |
| a. Backache | 0.920 | 0.358 |
| b. Heart Burn | 0.921 | 0.357 |
| c. Constipation | 0.923 | 0.355 |
| d. Hemorrhoids | 0.921 | 0.356 |
| 16. High Risk | 0.921 | 0.356 |
| 17. Fetal Palpations | 0.904 | 0.381 |
| 18. FHR | 0.889 | 0.400 |
| 19. Referral on need | 0.921 | 0.356 |
Items Factors
Table-3 : Factor Analysis of care of mother by Principal Component Analysis
- Management of minor ailment 920 0.358
- Immunization
- 1st Dose of TT 741 0.577
- 2nd Dose of TT 767 0.539
c . Booster TT 0.890 0.387
- Administration of Iron & Folic Acid 854 0.435
- Instructions about
- Diet 0.802 0.502
- Routine Checkup 827 0.467
- Immunization 814 0.490
- Not to Travel 923 0.354
- Not to life heavy weight 923 0.354
- Not to wear high heel 923 0.354
- Exercise 0.921 0.356
- Rest 0.834 0.464
- Preparation for delivery 923 0.355
- Preparation for Breast Feeding 923 0.355
- Care of the New Born 918 0.359
Table 4 shows the items retained after factor analysis for quality of documentation are under factor 1 and 2 and reflect the quality maintained by the female health workers and nursing students during documenting the care of antenatal mothers.
Table-4 : Factor analysis for the quality of documentation for antenatal mother
| Items | Factors | ||
| 1 | 2 | ||
| 1. Registration before 16 weeks of pregnancy | 0.633 | 0.728 | |
| 2. Every visit with a pre specified objective | 0.923 | 0.355 | |
| 3. Women given 3 antenatal visit | 0.761 | 0.462 | |
| 4. Evaluation of Care | 0.919 | 0.358 | |
| 5. Visits made in time | 0.653 | 0.694 | |
| 6. Referral of high risk | 0.921 | 0.355 | |
| 7. Health education | 0.781 | 0.524 | |
| 8. Follow up | 0.790 | 0.514 |
In Table 5 after factor analysis the maximum items retained under factor 1 and 2 which are related to the care during Abortion maintained in the records.
Table-5 : Factor Analysis for the record of information and care related to Abortion by Principal Component Analysis
| 1 | 2 | |
| 1. Abortion | 0.342 | 0.923 |
| 2. Date | 0.343 | 0.924 |
| 3. Month | 0.343 | 0.924 |
| 4. Year | 0.344 | 0.927 |
| 5. Time | 0.355 | 0.927 |
| 6. Period of gestation | 0.348 | 0.927 |
| 7. Number of Abortion | 0.353 | 0.928 |
| 8. Induced | 0.344 | 0.927 |
| 9. Spontaneous | 0.345 | 0.926 |
| 10. Hospital | 0.349 | 0.930 |
| 11. Home | 0.349 | 0.927 |
| 12. Trained Dai | 0.348 | 0.927 |
| 13. Bleeding | 0.354 | 0.928 |
| 14. Sepsis | 0.354 | 0.928 |
| 15. Shock | 0.354 | 0.928 |
| 16. Referral on need | 0.354 | 0.928 |
| 17. Follow up | 0.354 | 0.928 |
Items Factors
The thir teen items related to quality of documentation maintained by the female health workers and nursing students for the
care during abortion are retained under the factors 1 and 2 as shown in table 6.
Table-6 : Factor Analysis for quality of documentation for Abortion by Principal Component Analysis.
| 1 | 2 | |
| 1. Visit in time | 0.351 | 0.928 |
| 2. Place of abortion | 0.351 | 0.928 |
| 3. Reason for the abortion | 0.356 | 0.927 |
| 4. Condition at the time of visit | 0.357 | 0.926 |
| 5. Physical condition of mother | 0.357 | 0.926 |
| 6. Psychological condition | 0.357 | 0.926 |
| 7. Condition of home environment | 0.357 | 0.926 |
| 8. Economic condition | 0.357 | 0.926 |
| 9. Self care | 0.357 | 0.26 |
| 10. Abstinence | 0.357 | 0.926 |
| 11. Contraception | 0.357 | 0.926 |
| 12. Medical checkup | 0.357 | 0.926 |
| 13. Follow up | 0.355 | 0.924 |
Items Factors
Table 7 shows five items related to postnatal mother for the conduct of delivery. On the basis of factor analysis 81 items retained in the audit tool.
Table-7 : Factor analysis of items recorded on information related to conduct of delivery by Principal Component Analysis
| Items | Factors | |||
| 1 | 2 | 3 | ||
| 1. Delivery conducted at Hospital | 0.925 | |||
| 2. Home | 0.919 | |||
| 3. Nursing home | 0.932 | |||
| 4. Date of delivery | 0.363 | 0.866 | ||
| 5. Designation of the person conducted delivery | 0.371 | 0.851 | ||
Discussion
The aim of present study was to develop an audit tool for care of mothers. The care is documented related to mothers during pregnancy, intranatal period, for abortion and post natal period. Audit tool is developed to audit care for mothers.
The internal consistency and reliability of the tool was measured by Cronbach’s alpha. The estimated Cronbach’s alpha >0.70 is considered statistically significant and indicates a substantial internal consistency of scale in simple items. High Cronbach’s alpha of 0.995 highlights a homogeneity of all its items and all items measured the underlying construct of mother. This was supported with the study where Socio-Economic Status Scale was developed and cronbach’s alpha was 0.81.10 The widely-accepted social science cut-off is that alpha should be .70 or higher for a set of items to be considered a scale, but some use .75 or .80 while others are as lenient as .60.11 To check the eligibility data for factor analysis minimum sample size should be total no of items multiplied by 10 and for the present study there 96 items and the sample size was 2000 so the data was eligible for factor analysis.9
Principal component Factor analysis was used to compute the construct validity. Total seven factors were identified. This was compared with a study where the tool was developed and for Birth preparedness and total 10 factors were identified.12 First factor retained maximum number of items which reflect “Assessment and Care of Antenatal Mother”. Factor 2 retained items which reflect “Assessment and Care of Abortion”. Factor 3 retained 4 items which reflect “Postnatal care”. Factor 4 retained only 2 items which reflect “Eligible Couple card made”. Item 4, which was ‘folder no’ has value <.3 which was deleted. If this was deleted it did not lose the information as on the first page of the audit ‘Folder no’ is to be written. Factor 5 retained 1 item. Factor 6 retained item no: 6 and 7 which had value <3 and were related to “Eligible couple card made” deleted. Factor 7 retained 1 item ‘HIV’ which was discarded because as a useful factor it should have at least 3 items loading significantly on that component.
The item of ‘HIV’ which was under the eligible couple card made and was deleted because it was not very useful item as it was not documented in the folders and may be because of the social stigma people do not tell about it or the nursing students and the health workers are not asking about it. A valid and reliable tool developed to evaluate the quality of nursing care and documentation of nursing care provided to mother and the tool can also be used to compare the quality of documentation of two institutes. The tool can be used by the teachers and administrators in order to evaluate the care provided to mother by nursing students and health workers.
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