Women’s acceptability of maternal health services between 2008/09 and 2020/21 and its impact on maternal mortality in a health sub-district of Johannesburg, South Africa

Abstract

The practical implications of healthcare acceptability are increasingly recognised across the wide spectrum of health sciences to guide the planning and implementation of service delivery. Yet, acceptability of healthcare remains a controversial concept without a common definition and a shared conceptual framework within health professionals. Notwithstanding the current debate in defining and conceptualising healthcare acceptability, growing evidence supports acceptability of healthcare as a multi-construct and moving away from a unitary construct concept. Moreover, it is becoming increasingly evident that acceptability of healthcare is one of the dimensions of access to healthcare rather than a standalone theory. The study used different methods to propose a consensual definition and framework of healthcare acceptability in general by drawing on existing literature. It then specifically focused on measurement of maternal healthcare acceptability and generated a data-driven hypothesis between the later and the MMR using data from a sub-health district of Johannesburg in South Africa. This research project produced six manuscripts in an attempt to fill the gaps identified in literature on this topic. The first manuscript drew from existing literature and applied thematic content analysis to propose a more practical definition and a workable conceptual framework of healthcare acceptability. In the second manuscript, the researcher invited different experts in the field to provide their inputs on the proposed definition and conceptual framework. After two rounds of Delphi process, experts achieved a consensual definition of healthcare acceptability as “a multi-construct concept describing the nonlinear cumulative combination in parts or in whole of experienced or anticipated specific healthcare from the relevant patients/participants, communities, providers/researchers or healthcare systems' managers and policy makers' perspectives in a given context". They also proposed a shared healthcare acceptability conceptual framework. Agreed definition and framework of healthcare acceptability were reviewed and validated by a group of experts to be applicable to a wide range of healthcare disciplines. The third manuscript aimed to explore the depth and breadth of evidence on healthcare acceptability through the lens of patients and healthcare providers in HIV, TB and maternal healthcare services. The fourth manuscript narrowed the scope to consider practical implications of maternal healthcare acceptability from the mothers’ perspective. Both the third and fourth manuscripts consisted of registered reports as scoping reviews and have been included in the university initiative to mentor undergraduate students in evidence synthesis that the researcher was taking part. The fifth manuscript presented a practical tool to define and measure the maternal healthcare acceptability in a selected South African health sub-district. The manuscript applied factor analysis to calculate maternal healthcare indices. Three factors were retained to predict three indices namely provider, healthcare and community corresponding to maternal healthcare acceptability constructs. Structural equation model showed good fit with a comparative fit index (CFI) of 0.97 displaying good reliability and validity. Hypothesis testing confirmed that components and their corresponding constructs were related (p < 0.01). The manuscript recommended simple arithmetic analysis as an alternative method to assess acceptability of maternal healthcare. The sixth manuscript described the trends of maternal healthcare acceptability in relation to maternal mortality between 2008/09 and 2020/21 at a selected teaching hospital in South Africa. Maternal healthcare acceptability indices were calculated using simple arithmetic equation. The maternal mortality ratio (MMR) was estimated using the number of maternal deaths per 100 000 live births during the related periods. The manuscript revealed a slight decline in provider acceptability falling from 66% to 63% between 2008/09 and 2020/21. Healthcare acceptability increased from 49% to 62% and community acceptability increased from 66% to 90%. The MMR fell by 20% (from 207.26 to 193.51) over the same period. Therefore, an inverse relationship between the maternal healthcare acceptability indices and MMR was a data-supported hypothesis generated from the sixth manuscript’s findings. This research offered new insights into defining, conceptualising and measuring acceptability of maternal healthcare. It attempted to demonstrate general practical implications and applications across the wide range of healthcare disciplines. Drawing on general definition of healthcare acceptability proposed by experts on this topic, this study suggested a specific definition of maternal healthcare and it was the first of its kind to describe the trends of maternal healthcare acceptability in relation to maternal mortality. The Experts’ participation provided significant contribution to build a consensus on definition and conceptual framework of healthcare acceptability. However, participating experts were from relatively few countries to confirm universal adoption of proposed definition and conceptual framework of healthcare acceptability. This research has complemented existing evidence on the concept of healthcare acceptability and equipped health professionals to apply and assess this concept with greater confidence. However, there were some limitations including the failure to retain or reject the generated hypothesis due to COVID-19 pandemic and subsequent amendments made to narrow down the study sites which affected the data quality to run regression analysis. Therefore, further studies are recommended to shed more light on this topic including testing the generated hypothesis and determining its magnitude