The use of antenatal services in health centres of Fès Morocco

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Journal of Obstetrics and Gynaecology

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The use of antenatal services in health centres of Fès, Morocco

M. Couillet, Z. Serhier, N. Tachfouti, K. Elrhazi, C. Nejjari & F. Perez

To cite this article: M. Couillet, Z. Serhier, N. Tachfouti, K. Elrhazi, C. Nejjari & F. Perez (2007) The use of antenatal services in health centres of Fès, Morocco, Journal of Obstetrics and Gynaecology, 27:7, 688-694

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The use of antenatal services in health centres of Fe ` s, Morocco

M. COUILLET

¹

, Z. SERHIER

²

, N. TACHFOUTI

²

, K. ELRHAZI

²

, C. NEJJARI

²

& F. PEREZ

¹

1Institut de Sante´ Publique, d’Epide´miologie et de De´veloppement (ISPED), Universite´ Victor Segalen, Bordeaux, France and

2Laboratoire d’Epide´miologie, Sante´ Publique, Faculte´ de Me´decine et de Pharmacie, Fe`s, Morocco

Summary

Morocco has reported important achievements in coverage for mother and child healthcare services. Nevertheless, client-use and quality of antenatal care (ANC) services need to be improved. The aim was to identify factors related to the use of ANC services through a cross-sectional survey among women attending an urban maternity hospital in Fe`s. We describe quality of ANC services assessed in six health centres through pre-established national checklists. Of 240 women interviewed in postnatal wards, 23% had not undertaken any ANC consultation during their last pregnancy. The main characteristics of women not using ANC services were being multiparous (OR: 2.7; CI: 1.5 – 4, 8) and having no formal schooling (OR: 3.7;

CI: 2.2 – 6.4). These women stated three main reasons: (1) did not find it necessary (46.9%); (2) health centre too far away (14%); (3) dissatisfied about the quality of care (12%). Evaluation of the quality of care showed a shortage of personnel and basic supplies and malfunctions were identified at various levels. In the region of Fe`s, there is a need to strengthen ANC and overall maternal health activities through community mobilisation and information and education. We recommend that the WHO ANC protocol (less ANC visits with emphasis on quality) be pilot tested in Morocco.

Keywords

Antenatal care, determinants, Fe`s, quality of care, Morocco

Introduction

More than 70% of women worldwide carry out only one antenatal care (ANC) visit with a health professional during their pregnancy (WHO/UNICEF 2003). Important disparities exist between developed countries where 98% of women use ANC services and resource-poor settings, where the rate is nearly 68% (Zanconato et al. 2006). ANC services play an important role in the prevention of maternal and neonatal mortality. One of their aims is to identify obstetrical complications and when needed, refer patients to a higher care level with adapted infrastructure (such as a district or regional hospital) (Prual et al. 2000). Health risks related to pregnancy in developing countries have been well documented. In Zambia, Murray et al. (2001) reported that nearly 40% of 2,892 pregnant women from ANC clinics, serving for gynaecological triage, in this urban setting, needed a transfer to a university hospital due to complications during pregnancy (Murray et al. 2001). One-third of pregnant women in six countries of West Africa presented a complication related to their pregnancy: of these, 3% of cases needed hospitalisation (de Bernis et al. 2000).

Through ANC services, women can be sensitised to use public or private health services for their delivery. The World Health Organization (WHO) and UNICEF have shown significant correlation between having had at least one ANC during pregnancy and having delivered with the assistance by qualified health professional in developing countries (WHO 2005). ANC services constitute a first essential link to the management of pregnancy and an entry

point to the general health system, improving access to complementary services such as maternal-child care, family planning and postnatal care (WHO 2005).

Since the late 1980s, the Ministry of Health, Morocco (MOHM) has made important efforts in setting up the Pregnancy and Childbirth Monitoring Programme based on the ‘Safe Motherhood’ public health strategy promoted during the International Conference of Nairobi in 1987.

The operational aim of this programme is to reach the highest coverage possible of ANC services and assisted delivery (De Brouwere 1996). This programme recommends that all pregnant women should use an ANC service in a health centre at least three times during their pregnancy.

Here, ANC services are free of charge (Direction de la Sante´

1987). Despite the improvement reported during the last few years, national ANC coverage remains insufficient in Morocco. In 2004, only 69% of pregnant women consulted a health professional at least once during their last pregnancy (Direction de la Sante´ 2004).

The Fe`s-Boulemane region of Morocco has one of the most important maternal mortality prevalence rates in the country, with an ANC coverage of 60% in 2004 (Direction de la Sante´ 2004). Although ANC coverage has improved in the principal city of the area, Fe`s, from 40% of women attending at least one ANC in 1997 to 60% in 2004, there is still a need to increase ANC coverage (Direction de la Sante´

2004).

To investigate this, it is compulsory to understand the barriers with which women are confronted in their approach to the use ANC services. Indeed, in certain situations where

Correspondence: F. Perez, ISPED, Case 11, Universite´ Victor Segalen, Bordeaux 2, 146 Rue Leo Saignat, 33076 Bordeaux Cedex, France.

E-mail: freddy.perez@isped.u-bordeaux2.fr

ISSN 0144-3615 print/ISSN 1364-6893 onlineÓ2007 Informa UK Ltd.

DOI: 10.1080/01443610701629080

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health services are accessible, the quality of care can discourage women to use them. In Nigeria, Uzochukwu et al. (2004) showed that 89% of a representative sample of pregnant women from 405 households were willing to pay for health services if they were quality services (Uzochukwu et al. 2004).

In Morocco, previous studies evaluating the quality of ANC services showed deficiencies in the quality of the information being provided to pregnant women, inefficient follow-up systems for pregnant women, as well as gaps in the training and supervision of health workers (Direction de la Sante´ 1994). The objective of this study was to identify the determinants to the use of ANC services among women who had delivered in a public reference maternity unit and to evaluate the ANC quality in six health centres of Fe`s. The aim was to establish recommendations in order to improve the ANC coverage.

Methodology

A cross-sectional survey was carried out among women who had delivered, in the public maternity unit of Al Ghassani at the end of 2005. This maternity unit was selected due to its important delivery coverage in the city of Fe`s (440% of all childbirths). In order to obtain a meaningful sample, sample size was calculated based on the prevalence of ANC coverage in Fe`s (60% in 2004), with a precision of 10% and an alpha type one error of 5%.

Based on this, 240 women from a total of 472 who had delivered in the maternity unit during the last month were selected by consecutive sampling. Interviewers were to follow the numbering of the post-delivery rooms and all women present at that time were contacted. Criteria selection were: (1) being in the Al Ghassani maternity service and having delivered during the preceding 1 or 2 days and (2) agreeing to take part in the survey.

Each of the interviewers who took part in the survey (10 medical students, four midwife students and two residents) were informed of the aims of the study and trained on survey techniques and sampling. The instrument used was a questionnaire applied individually and anonymously, collected orally (translated from French into Arabic) for an estimated duration of 20 min. The questionnaire was composed of several parts: sociodemographic data, obstetrical history, use of ANC services and satisfaction with services during the last pregnancy. For specific questions requiring precise information on the women’s obstetrical history, the interviewer collected data through the patient’s medical record.

The tool was pre-tested in the same maternity unit among 36 women 3 months before to the actual survey. In parallel, a quality evaluation of ANC services was carried out in a stratified sample of health centres of the same city. Fe`s has 32 health centres distributed throughout the city, based on standardised administrative mapping. Three types of stra- tum were used: rural, suburban and urban (each divided into four groups based on the social disparities). Each second health centre appearing in the alphabetical order list was selected. Six health centres were thus retained.

In order to evaluate the quality of care among the health centres selected, a selection of indicators was applied based on recently published experiences (Boller et al. 2003).

In this study, we used structure and process indicators (Table I). In reference to the package of ANC services, based on the recommendations of WHO and the MOHM

(Table II), a binary list of 24 basic medical acts was established to evaluate the performance of health workers (nurses and midwifes) during six ANC consultations in each of the six selected health centres (Table III). Quality data collection was completed by applying a MOHM national checklist on the availability of ANC material and supplies and interviewing health staff by using a structured guide. Questionnaire content included information on: (a) the reference and counter reference between the health centres and public maternities (Direction de la Sante´

1994); (b) mechanisms allowing to identify pregnancies at risk (Koffi et al. 2004); (c) the existence and use of health information and education support material (Acharya and Cleland 2000); (d) how supervision is undertaken (Direc- tion de la Sante´ 1994) and (e) the number of health workers providing ANC services in each health centre (Acharya and Cleland 2000).

Data analysis

Quantitative variables were analysed using Epi Info 2002.

The women interviewed were classified in two groups: (1) women having used at least three ANC consultations

Table I. Indicators used to evaluate quality of care Indicators of structure

Number of health workers

Availability of basic material and supplies Indicators regarding the organisation of services

The reference and counter-information system

Existence of collaboration systems between health centres Supervision of health centres

Indicators linked to the offer of care

Health worker’s procedures and techniques practices Patient’s satisfaction

Table II. ANC basic service (n¼36) Basic service

Blood pressure measurement Weight and height measure Examination of the uterine level Tetanus toxoid immunisation Vaginal examination

Complementary exams recommended Syphilis

Toxoplasmosis Blood grouping Echography

Table III. ANC observation grid in health centres (n¼8) Personnel reception and kindness

Antecedents interview

Obstetrical complete examination Eyes, legs, breast examination Blood pressure measurements Pregnancy risk evaluation

Information education and communication activities provided (including the importance of assisted childbirth)

Antenatal services in Fe`s, Morocco 689

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(minimum number recommended by the MOHM) and (2) women having used less than three consultations. Descrip- tive analysis of variables was carried out on the basis of means and corresponding percentages. Differences between groups were calculated by usingw²or Fishers’ exact tests. Univariable and multivariable analyses were carried out to determine the relationship between the sociodemographic characteristics of the women (age, education level, parity, distance of residence with a health centre) and use of ANC services during the woman’s last pregnancy.

Ethical considerations

Authorisation to conduct the study was sought from the Ministry of Health of Morocco and the ethical committee of the Faculty of Medicine of Fe`s, Morocco. Verbal informed consent was obtained from study participants after explaining to them what the study involved. Con- fidentiality was ensured to all participants.

Results

A total of 240 women identified in postpartum maternity services were interviewed; no refusals were reported.

Sociodemographic data

The median age was 26 with an interquartile range from 23 to 31 years. Of the total number of women interviewed, 60% were multiparous, 97.5% were married, 86% were not carrying out any paid activity, 47.5% had never attended school, and 79% of the households had an income lower than the average national income (2,000 Dirhams¼US$229). Nearly half of the women (46%) lived in the rural zones of Fe`s (Table IV). In this sample, the percentage of women having carried out at least one ANC visit was 77% with a median of 4.5 consultations per woman. Nevertheless, it is important to note that 23% of women never consulted a health worker during their pregnancy. The majority of women (129/184; 72%) who undertook at least one ANC did so through a public health centre. Other women, consulted at a private health centre (22.4%) or at the main maternity unit of the city (6%).

Women who had not undertaken any ANC visit at all, stated three main reasons: (1) did not find it necessary (47%); (2) found the health centre too far away from the residence (14%) and (3) dissatisfied with the quality of care from the health worker (12%).

Determinants of the use of ANC services

Univariate analysis of the use of ANC services and its determinants showed a significantly positive relationship between distance to a health centre (55 km), being primiparous and being schooled (Table V). Use of ANC services was not significantly asserted with the age of women, the income of the household and living in an urban setting. In the final multivariate logistic regression model, primiparas were more likely to have the total number of ANC visits recommended (OR¼2.9; 95% CI: 1.5 – 5.4;

p¼0.01). The probability of using ANC services was still significantly higher among women resident at least 5 km from the health centre than those living more than 5 km (OR¼3.0; 95% CI: 1.4 – 6.8; p¼0.02). Finally, women having received a minimum of formal education were more

likely to undertake at least three ANC visits (OR¼3.3;

95% CI: 1.8 – 6.0;p¼0.01) (Table V).

Quality of care

Evaluation of the indicators of structure showed a shortage of personnel and basic material and supplies, such as:

urinary analyses reagents, lamp and thermometer. Inter- views carried out among health workers allowed to obtain information on the organisation of the ANC services in the health centres. Malfunctions were identified at various levels. References and counter-references between health centres, laboratories, public maternity units, as well as with other health centres showed an ineffective coordination between these structures and the continuum of care of pregnant women. No functional collaboration system between the healthcare team carrying out ANC services in the various health structures was identified.

Only two of the six centres had set up a specific screening system to detect women with at-risk pregnancies. Five health centres had set up an internal monthly supervision system and three health centres had received an external supervision by central health authorities of the Ministry of Health in the last year.

Observations carried out in the 36 ANC services of the 36 selected health centres concluded that, of the 24 medical and paramedical procedures evaluated, only five Table IV. Sociodemographic characteristics of women (n¼240), Fe`s 2005

Characteristics n (%)

Age

525 110 45.8

25 – 30 68 28.3

31 – 35 33 13.8

435 29 12.1

Residence

Urban 130 54.2

Rural 110 45.8

Household income*

2000^{Dirhams^{ 175 78.8

42000 47 21.2

Parity

0 97 40.4

1 60 25

2 38 15.8

43 45 18.8

Marital status

Married 234 98

Not married^x 6 2

Health centre distance

51 km 120 50

1 – 5 76 31.6

5 – 10 20 8.3

410 km 24 10

Education level

None 115 47.9

Koranic (only) 7 2.9

Primary 60 25

Secondary 58 24.2

*20 missing answers (n¼220). ^{Minimum national salary as of 2006 based on government regulations¼2000 Dirhams (Dh).

{US$1¼8.77 Dh.^xIncluding singles and widows.

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were carried at all centres. These procedures included among others, blood pressure measurement, weight and height of the patient, evaluation of risk factors linked to the on-going pregnancy, administration of the anti-tetanus vaccination and preventive treatment of anaemia. Many deficiencies were highlighted regarding the application of the basic national ANC protocol. Examination of con- junctiva and legs was undertaken for only 39% of women and only 8% of women had received a breast examination.

Information education and communication activities (IEC) recommended during each ANC consultation was not carried out for all patients. Only 33% of women interviewed obtained general information on pregnancy and delivery, 36% received information on their on-going pregnancy and 11% women received an explanation on the importance of having an assisted delivery.

Of the 181 women who responded to questions regarding satisfaction of the health services received, 57%

stated they were satisfied overall with the ANC services received. It is the access to the health centre which is a problem for 29.3% of women. Women’s satisfaction was compared according to the type of consultation being private or public (Table VI). There were significant differences between the two types of health services concerning the satisfaction for access to a health facility and cleanliness of the material in the health centre. Indeed, women are three times more satisfied with the access to the service in the private sector vs the public sector as well as with how clean the rooms are in the private structures (p¼0.03). The group of women were questioned on their global satisfaction of the services provided in health centres. Of a total of 167 women who answered this

question, 74% were satisfied and very satisfied (56, 9% and 17, 1%, respectively) with the services usually provided in the health centres they use. Nevertheless, 84% of the women who had consulted a private health structure were satisfied compared with only 49% who used public health centres (p¼0.005). The group of women who declared they were unsatisfied with the services provided in public health centres highlighted two main reasons: difficult to access the health centres (53%) and the confidence they had in the health workers (49%).

Discussion

The use of ANC services is determined by the needs, the demand and the offer of healthcare during a pregnancy.

This study aimed to determine the factors which influence the use of ANC services among women who delivered in a public maternity unit in urban Morocco. It allowed collecting information on the use of ANC services and women’s satisfaction linked to these services.

This sample is reasonably representative of the users of ANC and maternity public health services. An important proportion of the women interviewed (40%) in this maternity unit did not carry out the three ANC visits recommended by the MOHM. Similar results have been reported from other developing countries, such as in the district of Kausani in Nigeria, where 88% of pregnant women did not use ANC services (Adamu and Salihu 2002). Another study in India compared the use of several maternity health services and concluded that the overall ANC cover was 64.2% in an urban reference centre.

Women had more frequently used other services rather Table V. Determining factors of the use of antenatal consultations by pregnant women in Fe´s, 2006 (n¼240), univariate and multivariate analysis

Determinants

ANC53 n¼98 (40.8%)

ANC3

n¼142 (59.2%)

Total

n¼240 Crude (univariate)

Multivariate final model ANC consultations53*

n % n % n % OR [IC 95%] pvalue^{ OR [IC 95%] pvalue

Age 0.30

525 43 (39.0) 67 (61.0) 110 (46.0)

26 – 30 25 (37.0) 43 (63.0) 68 (28.0)

31 – 35 17 (51.5) 16 (45.7) 33 (13.7)

435 13 (45.0) 16 (55.0) 29 (12.0)

Household income 1.7 [0.8 – 3.5] 0.43

52,000 Dirhams^{ 33 (46.0) 39 (54.0) 175 (78.8) 2,000 and more Dirhams^x 75 (43.0) 100 (57.0) 47 (21.2)

Parity 2.7 [1.5 – 4.8] 50.01 2.9 [1.5 – 5.4] 0.01

Multiparous 72 (50.3) 71 (49.7) 143 (60.0)

Primiparous 26 (27.0) 71 (73.0) 97 (40.0)

Residence 0.6 [0.3 – 1.02] 0.06

Rural 52 (47.3) 58 (52.7) 110 (45.8)

Urban 46 (35.0) 84 (65.0) 130 (54.2)

Education 3.7 [2.2 – 6.4] 50.01 3.3 [1.8 – 6.0] 0.01

Not schooled 65 (57.0) 49 (43.0) 114 (47.5)

Schooled^{ 33 (26.0) 93 (74.0) 126 (52.5)

Distance to a health centre 2.3 [1.2 – 4.6] 50.01 3.0 [1.4 – 6.7] 0.02

5 km 26 (58.0) 18 (42.0) 44 (18.3)

55 km 72 (37.0) 124 (63.0) 196 (82.0) ANC, antenatal care; km¼kilometers.

{Mann Whitney for continuous variables andw²test for qualitative variables;^{20 missing answers (n¼220);^x1US$¼8.77 dirham;^{Coranic education included; *Compared with3 antenatal care consultations.

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than ANC services (Banerjee 2003). The sample is not representative however of all women of reproductive age in Fe`s. In order to obtain a representative sample, it would have been necessary to target all delivered women: at home, in a private clinic or in a maternity unit or public hospital. Due to time and logistical constraints, it was impossible to carry out such a survey. Despite this limitation, our sample was composed by heterogeneous profiles of women which made it possible to look for determinants of the use of ANC services, with a significant association between the use of ANC services and the area where women lived (urban/rural), the distance between the residence and the nearest health centre and the level of education.

A number of studies in developing countries have shown the importance of sociocultural determinants linked to the use of ANC services. In contrast to other reports (Adamu and Salihu 2002; Pebley and Rodrı´guez 1996), this study did not show a significant association between the use of ANC services and the household’s income. It is possible that the information we collected did not completely capture the income capacity of the women interviewed, which requires a more detailed household survey. A specific econometric study on the subject could give more information on this topic.

The multivariable analysis made it possible to identify the profile of women who need targeted actions, so as to be informed and sensitised in order to use at least once and/or the complete set of ANC services during their pregnancy, as recommended by national Moroccan maternal health policy. Based on the results of this survey, it should be recommended that healthcare workers carry out particular attention to pregnant women living more than 5 km away from a health centre, women who are multiparous, and pregnant women who have not received any formal education. Strategies must be put in place in order to target actions towards these women (WHO 2002), assum- ing these data are routinely collected.

In this survey, we found that multiparous women underestimate the importance of ANC, even more so, if they did not have complications during their last pregnancy. These results corroborate a report by Trinh and Rubin (2006), who found that women with more previous pregnancies may be more confident and do not recognise the possible risks of a pregnancy because of their uncomplicated past experience (Trinh and Rubin 2006).

It is advisable thus to strengthen IEC activities, including clear messages regarding the possible risks women could encounter if they do not have regular ANC visits during the entire pregnancy period. Educational level had been proven in our study to be a determinant of the use of ANC

services. This correlates with results reported by Cleland (1988) who showed that women who had a minimum of formal education, at the same time have better financial incomes and a more important autonomy in the decision- making within the household (Cleland 1988). In Morocco, this question does not only concern health issues but has to do with the overall social conditions of women. The use of health services is determined by social and cultural factors as has been shown by a national health survey, where nearly 50% of women interviewed from a representative sample of women of reproductive age, considered they needed consent and where obligated to be accompanied by someone to attend a health centre (Direction de la Statistiques 1998) It is thus important to extend and reinforce partnerships among different stakeholders at health centre and community level to support education and access to health information for all women in particular and the community in general.

Public health research has highlighted that the quality of health services in general could be a barrier for their use. In resource-poor settings, as in developed countries, there is a considerable difference between the standards recommended and the services provided to the population (Hayne 1993). An important number of studies looking at the use of ANC services have not integrated the quality of care as a determinant. An example is the case of Fujita et al.

(2005), who highlights the lack of evaluation of the quality of care as a limitation to his research (Fujita et al. 2005).

Although positive associations have been found between the level of quality of care procured and the use of ANC services, it is important to study the role and effectiveness (in term of quality) of ANC services in the Safe Mother- hood Programme (Sangho et al. 2004). The data collected on the quality of ANC services in this study shows many deficiencies which need to be improved within the Morocco Safe Motherhood Program. Deficiencies appear at several levels: (1) lack of human and material resources, (2) dysfunction in the administrative organisation and (3) difficulties in the quality of the offer and provision of care (IEC, obstetrical exam and patient satisfaction).

As in other studies (Sangho et al. 2004), the use of ANC services was determined by the perception they had of the risks linked to pregnancy. This study highlights the importance of improving health information and education at the ANC setting. Only half of the women interviewed (54.1%) received IEC regarding their pregnancy and delivery. Indeed, women who had not carried out any ANC visit, stated that they did not feel the need to consult a health professional during their pregnancy. Barnejee (2003), in India, also observed that even when ANC services were available, the use of the services was very low Table VI. Satisfaction of women on selected antenatal care issues according to the attendance of private and public health services (n¼167), Fe´s, 2005

Item declared being satisfied Publicn¼129 (%) Privaten¼38 (%) OR 95% Confidence interva1 pvalue

Opening schedules 112 (86.8) 36 (94.7) 2.73 [0.5 – 18] 0.17

Access to the health centre 88 (68.2) 33 (86.8) 3.01 [1.0 – 9.7] 0.02

Confidentiality 120 (93) 36 (94.7) 1.11 [0.1 – 6.5] 0.7

Tidiness or maintenance of the centre 115 (89.1) 38 (100) – – 0.03

Use clean material/supplies 114 (88.4) 36 (97.3) 4.7 [0.6 – 37.0] 0.1

Trust in health worker 111 (86) 38 (100) – – 0.01

Health worker listens 109 (84.5) 37 (97.7) 6.78 [0.88 – 52.0] 0.03

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(Banerjee 2003). This lack of information on the importance of ANC can be explained partially by the fact that ANC consultations are relatively of short duration. Studies evaluating the performance of health workers confirm that a consultation of short duration does not always allow the establishment of a correct diagnosis or to properly inform the patient of the clinical outcomes for which she has come (Calnan 1988). Several observations made in this study help us to understand why women cannot receive a longer consultation period, among them: crowded waiting and consultation rooms as well as a lack of health workers.

Sangho et al. (2004) in Mali recommend providing more information to pregnant women, in particular on the importance of the continuity of care during pregnancy (Sangho et al. 2004). IEC campaigns on mother and child as well as on reproduction health should be undertaken at community level. In addition, settings such as schools are strategic places in order to target the future pregnant woman.

Observations of ANC services in six of the 32 health centres of Fe`s based on a standard checklist showed that only five out of 24 selected procedures were completely carried out. Among the procedures evaluated were: measurement of the blood pressure and weight, the identifica- tion of risk factors during pregnancy, breast examination, administration of the anti-tetanus vaccine and delivery of medication to prevent anaemia. It seems that the practices and procedures that need to be undertaken in ANC services by the health staff have become ‘routine’. which could be one of the reasons why the complete ANC protocol is not being provided to pregnant women during the ANC consultation. It could have been that the presence of an evaluator during the ANC consultation might have biased the results (making the health worker perform better then usual) but as results show important deficiencies, this provides an over-, rather than an under-estimate.

It is critical that all women who come for ANC receive a complete service based on standardised protocols, which include a complete obstetric examination, explanation of laboratory results, information and education on basic health issues linked to pregnancy, delivery and child care.

In this sense, the WHO has compared a standardised ANC protocol, which recommends a minimum of four ANC consultations during a pregnancy with a new model with a less number of consultations but prioritising quality of care.

The new model obtained a better cost-effectiveness ratio (in particular for the management of urinary infections, pre-eclampsias, postpartum anaemia), without a significant difference among women’s satisfaction between one model and the other (Carroli et al. 2001). This ANC model thus recommends that health personnel propose pregnant women with the maximum of services that they can take advantage of with each contact to a health centre and guidance to establish an antenatal and delivery health plan (Carroli et al. 2001). The first results of the introduction of this scheme in resource-poor settings at a limited scale show that women’s satisfaction was linked to the time spent with the provider (Carroli et al. 2001). Based on the need to improve healthcare at the ANC setting in Morocco and especially its quality, there is a need to apply such a model.

Healthcare services are supposed to respond to the requirements of patients (Aldana and Al Sabir 2001).

Studies have indicated the importance of patient satisfaction as an enhancing factor to the efficacy of medical care (Calnan 1988; Aldana & Al Sabir 2001). The results of our study revealed that 57% of women were satisfied and 17%

were very satisfied with the services being provided in the ANC setting. Despite these overall positive conclusions, it is important to take these results with caution. This group has a low educational level and certainly had a limited amount of information concerning healthcare to be able to compare with a minimum expected basic package of services. As so, there is a risk that satisfaction was overestimated. The dissatisfaction of women (26%) was expressed mainly by the difficulties of access and poor communication with health staff. In South Africa, a study on the perception of ANC services showed that the interaction between women coming to ANC services and the health staff were poor and women expected to be inadequately received by the midwife (Abrahams et al.

2001). It is important to underline pregnant women’s dissatisfaction regarding the relation with health staff. In our study, one out of two women expressed their worry regarding their relation and contact with health personnel.

Results also revealed that women who had used private health services were more satisfied than those having consulted in public health centres. This can be related to the observation that in public services, health workers lack medical equipment and supplies and considered them- selves to be under paid.

Development of local health policies in favour of the improvement of ANC services in the health centres of Fe`s is needed. They do necessary need to be innovative but built upon a sound diagnosis taking into account health workers and end-users’ perspectives. The results of this survey could be used as a guide for health decision makers and actors in Morocco and elsewhere where there is a need to improve the coverage and quality of ANC services.

Acknowledgements

We thank all the women who agreed to participate in this survey, as well as the Epidemiology and Public Health laboratory teams of Faculty of Medicine and Pharmacy of Fe`s and at the Institute of Epidemiology, Public Health and Development (ISPED) of the University Victor Segalen University, Bordeaux 2, France for their suggestions and advice and finally, the maternal health services of the Al Ghassani maternity unit for their support.

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