Overt versus covert observations on health care providers' care and communication during antenatal care visits in Lao PDR

Background: Antenatal care contributes to health delivery for mother and child by identifying potential problems early and providing advice to mothers. The quality of antenatal care in Laos remains inadequate. This study aims to assess the quality of the public antenatal care service in a real life setting and to investigate differences in results between overt and covert observation as ways to identify where interventions are most needed. Methods: This health-facility based, cross-sectional observation study compared overt and covert observation to identify strong and weak points during antenatal visits. Four trained nurses and midwives assessed performance using a World Health Organization checklist. For covert observation, research assistants posed as relatives of pregnant women attending an antenatal care session. Results: One hundred and fifty-four pregnant women were analyzed. Overall performance was poor for both overt and covert observation, but the scores for most items were lower when observation was covert. Provision of health promotion was insufficient. Less than one quarter of cases were advised to eat a variety of food during pregnancy, and none of the health providers provided counseling. Communication skills, behavior and attitude of health providers were highly inadequate. Less than a quarter of pregnant women were treated with kindness and respect. Less than 10% of available information materials were used during ANC session. Overall mean (standard deviation) time-spent for each ANC session was 15.3 (4.4) minutes. Conclusion: Using covert rather than only overt observation to identify where the antenatal care needs to be improved added detailed information on where improvement is needed. The level of performance was already inadequate when health workers knew they were being observed but it declined even further on most items when they were unaware of the observation. These findings can guide efforts to improve the quality of ANC services in Laos.