Exploring women’s views on factors influencing the quality of maternal care among women of reproductive age in Burkina Faso: a fuzzy cognitive mapping study

Exploring women’s views on factors influencing the quality of maternal care among women of reproductive age in Burkina Faso: a fuzzy cognitive mapping study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring women’s views on factors influencing the quality of maternal care among women of reproductive age in Burkina Faso: a fuzzy cognitive mapping study Sarah Cooper, Alice Bila, Kadidiatou Kadio, Haoua Nadège BILA, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7199612/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Assessing the quality of maternal care as perceived by patients remains a challenge. Integrating community perspectives is an important but underused approach for identifying indicators to measure the quality of maternal healthcare services. Objective This qualitative study employed fuzzy cognitive mapping (FCM) to explore women’s perceptions of maternal care quality in Burkina Faso. Methods This study used a qualitative participatory method called FCM to describe and visualize women’s views on maternal care quality. Women identified and weighted factors influencing their experiences with reproductive care. A total of eight FCM sessions were conducted in rural and urban areas. Data was analyzed using thematic analysis to categorize influencing factors and determine their relative importance. Results A total of 32 women (aged 15–49 years) participated in eight mapping sessions, identifying 21 key categories influencing maternal care quality through 111 interconnections. Significant factors included inadequate medical equipment, availability of healthcare providers, hygiene standards, continuity of care, and provider-patient interactions. Additional insights highlighted the importance of personal experiences and psychological support in shaping perceptions. Conclusion The maps offer a visual language to present and discuss women’s perspectives on maternal care quality, integrating their experiences to inform research and decision-making. Quality of care maternal care qualitative research participatory methods Burkina Faso Figures Figure 1 Figure 2 Figure 3 Introduction Maternal mortality remains a significant global health issue. In 2020, almost 95% of maternal deaths occurred in low- and middle-income countries (LMICs), where 287,000 women died during pregnancy and childbirth [ 1 ]. The Sustainable Development Goals (SDGs), established by the United Nations in 2015, aimed to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [ 2 ]. However, by 2020, this ratio had only slightly decreased from 227 to 223 maternal deaths per 100,000 live births [ 3 ], and 72% of those occurred in sub-Saharan Africa [ 3 ]. To reduce maternal mortality rates, sub-Saharan African countries have implemented interventions aimed at improving access to reproductive healthcare [ 4 ], including newly built health facilities with maternity services, performance-based incentives for healthcare staff, user fee exemptions, and maternity waiting homes (lodging near medical facilities for women approaching delivery) [ 4 – 7 ]. Underscoring persistent regional disparities, skilled birth attendance in sub-Saharan Africa increased from 57% in 2015 to 73% in 2023, even as global rates increased from 80–86% over the same period [ 2 , 8 ]. Despite improvements in access indicators, reduced financial barriers, and increased births attended by skilled providers, utilization indicators (including antenatal care visits and facility-based deliveries) reveal that maternal morbidity and mortality rates have not shown similar progress [ 9 – 11 ]. This persistent gap highlights the limitations of these interventions in achieving their intended outcomes. The suboptimal quality of maternal health services is often cited as a key reason for persistent gaps in improving maternal health outcomes. While reducing financial access barriers in LMICs, including providing care at no cost to patients, has increased healthcare utilization, the effect of these measures on quality of care remains unclear [ 12 , 13 ]. A systematic scoping review in sub-Saharan Africa revealed that in 8 out of 13 studies, pregnant women perceived care quality as poor under free maternal healthcare policies, although this perception might not be directly linked to the policies themselves [ 4 ], and evidence regarding how no-cost care affects quality is inconsistent. Some studies have linked fee removal to challenges like insufficient supplies and medications, increased workload for healthcare staff, poor infrastructure, and decreased morale among providers; others have reported improvements in service reliability, enhanced antenatal care education, better support at reception for prenatal services, and improved screening of vital signs [ 11 , 14 – 18 ]. According to the Lancet Commission on High-Quality Health Systems in 2018 and other studies, improving healthcare access and use is insufficient, and poor quality of maternal care remains a critical barrier to reducing mortality in LMICs [ 12 , 13 , 19 ]. Important questions then arise: What do we mean by “quality of maternal care,” and how do we measure it? Traditionally, it has been measured using a set of standardized indicators articulated in an overall framework. The most commonly cited of these in the last 50 years is the Donabedian model [ 20 ], which categorizes quality into three dimensions: structure, process, and outcome [ 21 ]. The WHO Quality of Care Framework for Maternal and Newborn Health, developed in 2015, integrates the Donabedian model's dimensions of structure, process, and outcome with six key attributes from the US Department of Health and Human Services Institute of Medicine (IOM) framework: safety, effectiveness, timeliness, efficiency, equity, and people-centeredness [ 22 ]. This comprehensive approach states that the quality of maternal and newborn health reflects the health system (structure) which allows access to quality care and interlinked dimensions of provision and experience of care (process), which are in turn linked to better individual and facility-level outcomes. These two frameworks, frequently used to assess the quality of maternal care, rely on a large set of comparable indicators often described as “objective” and include diverse measures like the proportion of births attended by skilled personnel and whether blood pressure and weight are recorded during antenatal care visits. While these indicators are important, the frameworks have been criticized for failing to capture the subjective perceptions held by women, which are also an important measure of quality of maternal care [ 19 , 22 , 23 ]. More comprehensive models of maternal health have thus been developed to include women’s perceptions about the extent to which maternal healthcare services meet their needs and expectations [ 24 , 25 ]. Literature has increasingly confirmed the association between women’s perceptions of healthcare quality and their health-seeking practices [ 26 – 28 ]. However, there is growing criticism of the tools used to quantify these perceptions [ 12 ]. Few studies engage communities or integrate women’s perspectives into quantitative measures to improve the quality of maternal care. In Burkina Faso, we employed fuzzy cognitive mapping (FCM), a participatory qualitative research tool, to explore and organize how women of reproductive age perceive the quality of maternal health services. This approach, within the framework of a larger mixed-methods study, aims to identify the key concepts and factors that shape women's perceptions of the quality of maternal care in Burkina Faso. Methods Setting Burkina Faso is a landlocked Sahelian country with a population of ~20 million [29], of which two thirds reside in rural areas [30]. It has one of the highest fertility rates in the world (4.7 births per woman) and half of the population is under 15 years old [31]. The proportion of women receiving prenatal care from a qualified provider has significantly increased from 60% in 1993 to 74% in 2003, 96% in 2010, and 98% in 2021 [32]. The most recent Demographic and Health Survey reported that nearly all births in 2021 (96%) were attended by skilled health personnel [32]. In July 2016, Burkina Faso implemented a national policy that eliminated clinic fees for pregnant and postpartum women and children under five years of age [33]. The policy covers comprehensive prenatal and postnatal care, delivery, emergency obstetric care and evacuation, and cesarean sections [34]. Four years later, user fees for family planning services (i.e., contraception) were also removed [35]. These policies have improved access to maternal healthcare in all public health facilities [33]. Design This study is the qualitative phase of a larger exploratory sequential mixed methods project to integrate women’s perceptions into quantitative measures of the quality of maternal care in Burkina Faso. The findings presented in this manuscript will inform the development of a compositive quantitative index: a culturally relevant and context-specific tool to measure quality of maternal care [36, 37]. This study was conducted in the rural health district of Leo and in the capital city of Ouagadougou, ( Figure 1 ). Data collection was completed between June and July of 2023. FIGURE 1 INSERT HERE Study participants and recruitment Sampling was convenient: Participants were recruited during visits to health facilities or by phone, with the help of healthcare workers or the Burkinabe Association for Family Welfare [38]. Recruitment was stratified according to age (15–30 vs. 31–49 years old) and maternal status (pregnant vs. postnatal), as in purposive sampling. Eight FCM sessions were conducted: 4 in the rural district of Leo and 4 in the capital of Ouagadougou. The sessions were stratified by maternal status to account for power differentials and variability of experience [39]. Instrument and procedure: Fuzzy Cognitive Mapping We used FCM to generate visual maps of collective perspectives on the quality of maternal health care [40]. This method is widely employed for stakeholder engagement, as it integrates diverse perspectives into composite frameworks to inform decision-making [41, 42]. FCM is increasingly used in different cultural contexts to explore determinants of health from stakeholders' perspectives [42]. During group mapping session, women of reproductive aged 15 to 49 were asked to identify factors associated with more quality of maternal care and how those factors relate to each other. Each factor was represented as a node linked to other factors (nodes) by edges (arrows) [39], generating a map. Participants assigned weights to the arrows to indicate the perceived causal strength of each link, denoting the influences of different factors on one another. Each mapping session was facilitated by two women: one experienced qualitative researcher who was the facilitator (AB) and one research assistant who was the note taker (HNB), in Mooré or French according to the participant’s preference. The facilitators initiated the discussions and drew the map on a large sheet of paper with sticky notes representing nodes following participant directions. Each participant also completed a brief demographic questionnaire. Facilitators guided participants in creating maps using an adapted standard protocol for FCM (for more details, please refer to [39]). Participants identified and discussed factors influencing the quality of prenatal, delivery, and postnatal care. Group consensus from participants in real time determined: 1) which factors appeared on the map; 2) direct and indirect links (arrows); and 3) arrow weights from 1 (weakest) to 5 (strongest) to indicate the strength (positive or negative) of the relationships between factors. Once participants deemed the map complete, it was photographed ( Figure 2 ). FIGURE 2 INSERT HERE Participants were next presented with a list of factors commonly recognized in maternal care literature as measures of quality ( Supplementary Material: Table 1) . After being prompted with this list of factors, the participants decided whether to incorporate these elements and their weighted relationships into the map. A photograph of the updated map was taken. The FCM sessions were audio-recorded, translated, and transcribed verbatim by a local researcher in French. The maps were digitized from the photos in freeware yEd. Fuzzy Cognitive Mapping Analysis The lead author, along with another qualitative researcher (MCG), standardized node names across all maps to unify terms with similar meanings. For example, factors such as "advice on nutrition and pregnancy by healthcare workers," "nutrition advice from healthcare workers," and "lack of advice (no nutrition advice after cesarean)" were standardized to "healthcare workers’ advice on nutrition." Positive or negative connotations of factors were adjusted accordingly, including reversing the signs of their relationships if necessary. This iterative standardization process incorporated input from the note-taker (HNB) and the facilitator (AB). The standardized maps were converted into individual adjacency matrices, with rows and columns representing factors and cell values reflecting normalized relationship weights (+/-0–1). Using CIETmap 2.2 [43] fuzzy transitive closure (TC) was applied to estimate the maximum direct and indirect influence of each factor. The average weights from TC matrices were then calculated to define factor-level relationships [44]. Through qualitative thematic analysis, these factors were grouped into categories, validated by the research team, and used to create a category-level map [45, 46]. Category relationships weights were calculated by aggregating mean weights of factor-level relationships and normalizing these values by dividing by the maximum absolute of all sums to a range between -1 and +1. An adjacency matrix is a mathematical representation of the relationships between categories, where each cell indicates the presence and strength of a connection between two categories ( Supplementary Materials: Table 2). This matrix was used to digitize the final full category map and to identify the relationships with the strongest impact on the quality of maternal care. Indegree and outdegree centrality measures (key influencing categories) were used to analyze the category map [40]. Outdegree centrality (sums of weights of absolute values of outgoing arrows) reflected categories exerting the most influence on the main outcome, while indegree centrality (sums of weights of incoming arrows) highlighted categories most impacted by others. Qualitative Thematic Analysis Audio transcriptions from mapping sessions were analyzed using inductive and deductive thematic analysis to validate and refine categories identified in the physical maps [47]. Deductive coding incorporated predefined factors from the FCM aalysis, while inductive coding allowed new themes to emerge. Coding, conducted primarily by the lead author using QSR NVivo version 10, identified patterns, similarities, and differences across sessions according to the categories defined in the FCM analysis [45]. After preliminary analysis, the intermediate results and digitization of the maps were validated during three peer debriefing sessions between authors in Canada and in Burkina Faso. The digitization of maps was triangulated with the transcriptions and field notes recorded during data collection. Ethical considerations All participants provided informed written consent. The study was approved by the Comité d’éthique de la recherche en sciences de la santé at University of Montreal (Certificate #CERSES-2022-1809) and by the Comité d’éthique pour la Recherche en Santé in Burkina Faso (Deliberation #2023-03-051). Participants were compensated for transportation and provided with a meal at the end of each session. Results A total of 32 women aged 15–49 years old participated in 8 mapping sessions. Table 1 presents the characteristics of study participants. Thirty women had given birth at least once before (21 in a primary health facility, 8 in a medical center with a surgical maternity unit, and one in a larger regional hospital, for the last pregnancy). Seventeen women were pregnant at the time, including two women with no previous pregnancies. TABLE 1 INSERT HERE 3.1 Factors influencing quality of maternal care The main analysis presented here focuses on the factors, categories, and themes identified during the initial mapping sessions—prior to any literature-based prompting—since this approach allows us to capture the participants’ unmediated experiences and perspectives. The literature-based prompting, which is presented later in the results, serves to explore additional factors that may not have emerged spontaneously but may be relevant. Before the prompt, the eight maps had an average number of 21 categories (range 17–25) and 44 relationships after TC, with 75 unique concepts ( Table 2) . Factors were condensed into 21 categories interacting through 111 relationships (see Supplementary Material: Figure 1 ). TABLE 2 INSERT HERE The five most influential categories on quality of maternal care were, in order with the biggest: Unavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care (ANC), childbirth, and postpartum care (C11); Medical care for pregnant women and newborns before, during, and after childbirth (C13); Hygiene and health standards in an establishment (C15); Availability of human resources (healthcare workers and centers) (C08); and Inappropriate behaviors and communication of healthcare workers (towards women) (C06) (Figure 3) . Table 3 lists the category weights on quality of maternal care and their related weighted importance on a scale of -1 to +1. The weights account for both the direct and indirect pathways through which the categories influence the quality of maternal care. FIGURE 3 INSERT HERE TABLE 3 INSERT HERE Unavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care (ANC), childbirth, and postpartum care The unavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care (ANC), childbirth, and postpartum care (C11) had the highest negative influence on quality of maternal care according to our participants ( Table 3 ). This category included nine factors such as lack of seating, delivery tables, rooms, and medical equipment/supplies. In session 7, women mentioned health centers having only one delivery bed available, even when multiple women were giving birth simultaneously. As one participant from session 7 highlighted, “The delivery table is also missing; we only have one delivery table; there are 3 beds in the postpartum recovery room. But there can be 5 women giving birth at the same time, so some women end up giving birth on the floor and have to lie down on the floor with their baby.” [Session 7] The lack of sufficient seating in waiting rooms during ANC visits was a recurring worry. “[Lack of sufficient seating in the waiting room] is an important concept for quality of care. If there were no seats here, women would have to stand up, and that's not good for their health or the baby's health.” [Session 8] Medical care for pregnant women and newborns before, during, and after childbirth Medical care for pregnant women and newborns before, during, and after childbirth (C13) has the second strongest influence on quality of maternal care. This category has a positive relation and consists of five factors ( Table 2 ): Early initiation of ANC visits, regular ANC follow-up visits, follow-up of women by healthcare workers during pregnancy and childbirth, care for the baby after childbirth, and care for the women after childbirth.Participants described regular ANC follow-up visits as the most influential factor, closely related to other aspects, such as medical procedures, prescriptions, mosquito nets, and healthcare provider advice to patients. “What is important for pregnant women [and quality of maternal care] is regular prenatal check-ups; if you do not attend regularly, you cannot get the products to take regularly; but if the check-ups are regular, you also take the medications and your delivery will be easier.” [Session 7] Hygiene and health standards in an establishment Hygiene and health standards in an establishment had the third strongest influence on the quality of maternal care. This category consists of four factors ( Table 2 ): cleanliness of places (courtyard-delivery room, ANC, maternity ward), cleanliness of toilets, presence of mosquitos in the rooms, and excessive presence of bats. Cleanliness of toilets was one of the more influential factors in seven out of eight maps. From the participants’ perspectives, poor hygiene can lead to the spread of diseases. “The cleanliness of the premises, and especially the toilets, is very important because if the toilets are not clean, you can catch diseases since many people use them; you can easily contract diseases that cause itching in the genital area of women (sexually transmitted diseases).” [Session 1] Other categories influencing quality of maternal care The availability of human resources (healthcare workers and centers) (C08) ranked fourth as positively influencing the quality of maternal care. This category included availability of healthcare workers during childbirth, availability of depot pharmacists, sufficient number of healthcare workers, sufficient number of healthcare workers, and the presence of healthcare workers during transfer (Table 2) . Conversely, inappropriate behaviors and communications of healthcare workers (towards women) (C06) , ranked fifth in importance, negatively influenced quality ( Table 3 ). Specifically, verbal abuse by healthcare workers, lack of confidentiality, bad attitude, bad healthcare worker-patient relationship, and difficulty in phone communication were linked to a decrease in the quality of maternal care. The discourse in Session 6 among young postnatal women highlighted several factors related to verbal abuse, attitude, and communication skills of healthcare workers and the importance of these factors in the overall experience of care. One participant expressed frustration with the lack of clear communication from healthcare workers: “Participant 1: If you arrive and you don’t understand something, instead of explaining it to you, they’ll start talking badly to you, so you too go where you can have peace of mind Participant 2: It’s true; getting good care isn’t just about the products, already if the relationships isn’t good with the person who’s going to look after you, it's not good; you'll go back to being discouraged; that doesn't help you heal. Some health workers don't try to understand. It's because we're listened […] that we come [here] for consultation.” [Session 6] One category, quality of reception at healthcare center (C17) , consisting of a single factor, had a weight of 0.63, making it the most important factor of quality of maternal care at the individual factor level. This factor was a dominant theme across nearly all mapping sessions, with transcriptions revealing frequent references to its importance. According to participants, the initial reception received at healthcare centers strongly influenced women’s perceptions of quality of maternal care and influenced their decisions to seek services. The behavior of midwives—whether welcoming and supportive or not—can either encourage or deter women from attending consultations. As articulated by a participant from Session 8, “We have a village in Leo, and all the women here say they will go to Leo to give birth. Why? When women in labor arrive, from the entrance, the midwives know it's an urgent case; they hurry to welcome you, help the woman enter the room. They joke with you until you give birth. Many women here say they will go there to give birth. There needs to be a change in our health center; otherwise, it won't work.” [Session 8] 3.6 Social Network Analysis This section presents the results of the social network analysis conducted on the identified factors before the literature-based prompting. Quality of maternal care was the most important outcome, both in terms of the number of arrows pointing toward it and the strength of those arrows (indegree centrality score of 7.69). Responsibility of women related to care (C21) was the second (indegree centrality score of 2.24) and medical care for pregnant women, and newborns before, during and after childbirth (C13) was the third (indegree centrality score of 2.00). This suggests that women’s responsibilities were perceived as an important intermediary influencing the quality of maternal care. These include negative behavior at health centers, not adhering to healthcare advice or intake of medications, poor personal hygiene, and inconsistent use of mosquito nets at home. Outdegree centrality identified medical care for pregnant women and newborns before, during, and after childbirth (C13) and availability of human resources (healthcare workers and centers) (C08) as the most important givers of influence on the main outcome and on other factors. Availability of human resources (healthcare workers and centers) (C08) was consistently prominent across all maps, with inadequate numbers of healthcare providers emerging as a recurrent theme across almost all sessions. “Of course, this has a negative impact on the quality of care. If I understand correctly. If there aren't enough of them to treat people well, we won't have good care, but if there are many and a single doctor can follow 50 or 40 women, he'll have a little time to follow them well, but if he's alone with 100 or 200 women, he'll do what he can only. May God only help us.” [Session 2] Exploring additional factors following prompting questions In addition to the initial mapping, women identified nine other factors after prompting, (Table 2) . Two of these factors (childbirth experience and pregnancy/childbirth history) formed a new category: Women’s experience of pregnancy and childbirth (C09) , while the other seven were integrated into existing categories (see revised map after prompting in Supplementary Material: Figure 2 ). The first factor of the new category (childbirth experience) emphasizes the importance of psychological preparation for the next birth and the second factor (pregnancy/childbirth history) involves the midwives’ understanding of the current medical needs/conditions. Women in four sessions noted the absence of these factors in current practices. One participant from Session 2 explained how limited consultation time hindered personalized attention: “It's important but health workers don't have the time to talk about it with women; […], for example if you're transferred, normally, they should take the time to ask you questions, but ah, you see no” [Session 2] This quote highlights the importance of psychological support and personal rapport with clinic staff. In the context of Burkina Faso’s fragmented healthcare system, women are often seen by multiple healthcare providers, making it difficult to establish a rapport and receive personalized care. Some factors (n = 10) listed in Table 2 appeared in some mapping sessions but not in others before the prompt and were subsequently added after the prompt. For example, early initiation of ANC visits had to be prompted in some sessions (n=5), as did discussions about (i) care for the woman/baby after delivery, (ii) reliable electricity with minimal outages, (iii) availability of running water, and (iv) the distance from the maternity hospital. Others like healthcare workers take good precautionary hygiene measures, and dishonesty of healthcare workers were rejected, because some participants did not experience these personally and felt they could not comment on it (although Session 4 noted corruption at their center). Discussion In this study, fuzzy cognitive mapping was used to identify factors influencing the quality of maternal care and assess their respective importance for women in Burkina Faso. Women independently identified a variety of factors that influenced their perception of the quality of maternal care, with key issues including inadequate medical equipment, insufficient continuous care for pregnant women and newborns, and poor hygiene standards in healthcare facilities. Participants highlighted social and structural barriers such as financial constraints, geographic access, behavior and communication of healthcare providers, and quality of reception at healthcare centers, which significantly shaped their overall care experiences. These insights will inform a more efficient quantitative measure of the quality of maternal care. Referring to Donabedian’s model, the participants’ perceptions of quality of maternal care mostly align with the structural, process, and outcome dimensions [ 21 ]. They particularly emphasized the structural dimensions of quality of maternal care, including cleanliness of facilities, availability of water and electricity, medical resources (e.g. medical equipment, beds, chairs), whether healthcare staff were skilled or trained, waiting times, and adequate number of healthcare workers within healthcare facilities. These were viewed as important influencers of their quality of care, mirroring findings from studies in Kenya, India, and Malawi where inadequate infrastructure and staffing shortages were identified as key barriers of high quality maternal care [ 17 , 48 , 49 ]. In our study, the structural aspects had the highest cumulative weight of influence on the perceived quality of maternal care. This confirms the importance of conducting audits or supervisory visits to health facilities, but our study suggests that such inspections are insufficient. Participants also recognized the importance of process-related, such as the healthcare worker-patient relationship, emotional support, and caregiver advice, and they expressed concerns about abuse, disrespect, negligence, and breaches of confidentiality. These findings align with studies from Nigeria, Uganda, and Ethiopia and underscore the importance of provider-patient communication in fostering responsiveness, empathy, and rapport-building, all of which are key components that influence women’s trust in the healthcare system [ 27 , 48 , 50 , 51 ]. The process aspect of Donabedian’s model has gained significant attention in qualitative research on maternal health, going beyond structural factors to explore how care is experienced by women [ 50 ]. In our study, the prominence of process-related categories (9 of 22) reflects this qualitative emphasis, showing that women prioritize how they are treated and supported during care as well as the more structural categories. Respectful maternity care, including provider communication and attitudes, has been linked to women’s choice of facility, as they prioritize settings where they expect better treatment from healthcare workers [ 52 – 54 ]. Despite its significance, quality assessments in sub-Saharan Africa often prioritize clinical and structural aspects, overlooking the importance of women’s experiences of respect and care during pregnancy and childbirth. The WHO has previously included respectful maternity care as a key component of its quality standards, stressing the need to balance both clinical and experiential factors to improve maternal care [ 55 ]. Continuity of care emerged as a central component of maternal care quality in our study, both as a process and outcome dimension. Social network analysis revealed it to be one of the most influential categories, with the highest out-degree centrality. This illustrates its association with other categories, such as medical procedures, healthcare advice, and the provider-patient relationship. Participants highlighted the importance of continuity across all stages of maternal care, from antenatal visits to postnatal follow-ups. This aligns with global research underscoring the critical role of continuity in improving maternal and neonatal outcomes, particularly in addressing preventable deaths during the postpartum period [ 56 , 57 ]. The emphasis on continuity of care in maternal health and quality of care literature is clear and is emphasized in several frameworks, including the Standards for Improving Quality of Maternal and Newborn Care and the Lancet Commission on High-Quality Systems [ 12 , 55 ]. Evaluating continuity of care remains challenging, as existing metrics often focus on the number of antenatal visits and fail to capture the relational and informational dimensions of care [ 58 ]. This underscores the need for standardized assessments that include interpersonal and informational factors [ 58 ]. The emergence of continuity of care as a major factor may call for more longitudinal assessments since cross-sectional contexts cannot capture or reconstruct continuous care pathways. Some commonly used quality indicators were not spontaneously mentioned by participants, and some factors volunteered by participants in our sessions are commonly overlooked by models and instruments, illustrating the shortcomings of current measurement approaches. This suggests that routine data sources, such as the Service Provision Assessment, the Demographic and Health Surveys, and other highly utilized secondary data sources, may lack key elements needed to comprehensively evaluate the quality of maternal care from the perspective of the women who receive it. While facility-based indicators (e.g., availability of essential equipment, electricity, and water) are easier to measure and frequently included in assessments, some important aspects—such as the quality of patient reception, healthcare worker-patient relationships, and the inclusion of relationship partners in healthcare—are often overlooked. Even facility-based structural indicators are not always appropriately taken into consideration. For example, it is not enough to record whether there is a functioning toilet in a given health facility (as does the WHO’s Service Availability and Readiness Assessment); it is important to document whether it is clean or not. Previous quantitative assessments of maternal care quality in Burkina Faso have relied largely on facility-based surveys that emphasize structural and clinical indicators like availability of essential drugs and continuity of care [ 59 ]. One study aimed at developing a maternal care quality measure in Burkina Faso used non-participatory observations of antenatal consultations, assessing factors such as provider discretion, whether or not clinic staff recorded vaccination and marital status, completeness of clinical and gynecological examinations, provision of advice, and therapeutic decision-making [ 60 ]. The Demographic and Health Surveys in Burkina Faso measure the quality of prenatal care based on the content of prenatal visits, including blood pressure measurement, laboratory tests, and prenatal health advice [ 32 ]. FCM has proven effective in engaging local communities across various areas of study, including maternal health [ 46 , 61 , 62 ]. This study is the first to apply FCM specifically to capture perceptions of maternal care quality, allowing us not only to gather women’s insights but also to empower them to directly express their needs and expectations. This emphasis on community engagement reflects a growing recognition in the literature of the importance of integrating patient perspectives into quality assessments [ 24 ]. Unlike previous mixed-methods studies in sub-Saharan Africa, such as those in Malawi and Zambia, which used qualitative data to complement quantitative measures to assess quality of maternal care, our study aims to inform the development of new quantitative metrics enriched by qualitative insights, broadening the scope of how maternal care quality is assessed [ 63 , 64 ]. Limitations We recognize several limitations in this study. First, the use of Donabedian's framework to categorize our findings into structural, process, and outcome dimensions may have been somewhat rigid, as some categories overlap [ 21 ]. For instance, continuity of care is typically viewed as an outcome, based on the number of antenatal visits, but it also encompasses informational and relational continuity, which are more process-oriented [ 58 ]. These overlapping dimensions complicate the clear-cut categorization of certain factors: We noticed a lack of maternal “outcome” concerns raised by our participants. While our results show that women did not typically mention outcomes such as mortality, morbidity, or satisfaction, this absence may reflect the sensitivity of discussing these topics in group settings, as observed in other qualitative studies on maternal experiences [ 26 ]. Secondly, we did not define or discuss with participants a shared understanding of “quality of maternal care” as a central outcome. Defining this concept in advance might have provided a more structured framework, allowing participants to consider specific aspects of care in a more systematic way. However, it could also have influenced the overlooked factors participants identified voluntarily. Data was collected only in two areas in Burkina Faso—one urban and one rural. While this selection offers some diversity of perspectives, it does not claim to be representative of the country overall. Additionally, women with no prior childbirth experience were not included in the study, because the focus was on lived perceptions rather than expectations. Finally, we did not reach saturation in our mapping sessions, as new factors continued to emerge throughout. While further exploration of these factors would have been valuable, conducting additional FCM sessions was not feasible for logistical reasons. Instead, efforts were made to fully exploit the available qualitative material (FCM, notebooks, observations, etc.) to ensure a comprehensive analysis. Conclusion This study highlights the critical factors influencing the quality of maternal care in Burkina Faso, as perceived by women. Using FCM, women in Burkina Faso identified key structural and process-related dimensions that shape their experiences within maternal healthcare. Understanding these specific factors, their relative importance, and how they affect each other is essential for measuring service quality or informing changes to services. This research provides evidence and data needed to integrate women’s perspectives into an index that will capture the multifaceted nature of maternal care. This is particularly crucial in contexts affected by interventions like Burkina Faso’s free maternal care policy, ensuring that services align with women’s actual care needs. This focus helps health systems to adapt and improve, offering high-quality care that is equitable, patient-centered, and aligned with women's experiences and expectations [12]. Declarations Ethics approval All participants provided informed written consent to participate. The study was approved by the Comité d’éthique de la recherche en sciences de la santé at University of Montreal (Certificate #CERSES-2022-1809) and by the Comité d’éthique pour la Recherche en Santé in Burkina Faso (Deliberation #2023-03-051). Participants were compensated for transportation and provided with a meal at the end of each session. All methods were carried out in accordance with the guidelines and regulations in the Declaration of Helsinki. Consent to participate All participants provided informed written consent to participate. Consent for publication All participants provided informed written consent to publish the findings of the study. Data Availability Due to the confidentiality agreements with participants, the data collected for this study cannot be publicly shared. Researchers who wish to access the raw data for legitimate academic purposes may contact the corresponding author, Sarah Cooper, at [email protected] , or the research partner at SERSAP, Frank Bicaba. Competing interests The authors have no competing interests to declare Funding This work was supported by Queen Elizabeth II Diamond Jubilee Scholarship – « Renforcement des ressources humaines et de la recherche en santé des femmes, adolescentes et filles dans les pays associés à la CEDEAO et en République démocratique du Congo ». SC and MCG are supported by doctoral awards from the Fonds de recherche du Québec- Santé. Acknowledgements We would like to acknowledge the communities in the study areas who enabled this work to take place, the participants, the health district authorities (district and health facility managers), and the support from the Association Burkinabè pour le Bien-Être Familial (ABBEF) and the collaboration with Société d’Études et de Recherches en Santé Publique (SERSAP). We would like to acknowledge Hatou Bila from the SERSAP for her help in translating the session. We would also like to acknowledge the methodological support from our colleagues at the Participatory Research at McGill University (PRAM), specialized in fuzzy cognitive mapping, who helped in developing the tool and analyzing the results. We would also like to thank Federica Fregonese and Loula Burton for their support in proofreading this article. Author Contribution SC conceptualized the study under the supervision of TD. TD and FB supervised the project. SC and TD acquired funding. SC planned the project, developed methods and interview guides with consultation of AB, KK, FB, IS and TD. AB and NB facilitated discussions. FB and KK planned and organized the field work. SC performed the formal data analysis with consultation with MCG. Analysis results was verified with AB, NB and KK. SC drafted the manuscript. AB, KK, NB, MCG, IS, FB and TV critically revised the manuscript for intellectual content. All authors read and approved the final manuscript. 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Characteristics Overall (n=32) Age, in years, Median [Min, Max] 31.5 [Min= 18, Max= 43] Number of children, Median [Min, Max] 3 [Min= 0, Max= 8] Relationship status Married/common-law/In a relationship 31 (96.9%) Single/Separated/Divorce/Widowed 1 (03.1%) Gave birth in the last 12 months 15 (46.9%) Pregnant 17 (53.1%) If pregnant, how many months pregnant? 0-3 months 2 (11.8%) 4-6 months 8 (47.0%) 7-9 months 7 (41.2%) Table 2. Categorization of factors influencing quality of maternal care among women of reproductive age. Factors added after the prompt are highlighted in bold. Categories encompass both positive and negative factors. For example, category 1 on accessibility of infrastructure regroups factors such as ‘Accessibility of toilets’ (positive) and ‘Inadequate delivery table’ (negative). The direction of the causal relationships of some factors were switched to match the direction of the other factors in the category. Final category Factors C1. Quality of maternal care 1. Quality of maternal care C2. Accessibility of infrastructure and services for people with disabilities, reduced mobility, and other specific needs 1. Accessibility of toilets 2. accessibility of health services 3. Availability of pharmacy within the healthcare center 4. Inadequate delivery table C3. Geographical accessibility of health services 1. Accessibility of healthcare centers (including distance and precariousness of roads) 2. Distance to healthcare center C4. Medical procedures (maternal health and/or malaria) 1. Medical procedures (prescription) 2. Medical procedures (examination, tests, etc.) 3. Medical procedures (equipment, mosquito nets) 4. Medical procedures (treatment) C5. Crowding and waiting times 1. Crowding and waiting times 2. Demand exceeds supply C6. Inappropriate behaviors and communication of healthcare workers (towards women) 1. Verbal abuse (yelling, speaking rudely, judgment, poor assistance, etc.) 2. Good healthcare worker-patient relationship 3. Good behavior of healthcare workers 4. Easy communication on the phone with the healthcare worker 5. Confidentiality during antenatal and childbirth C7. Appropriate counseling and support in maternal health and family planning 1. Healthcare worker advice to women during antenatal care visit 2. Advice from healthcare workers on nutrition 3. Advice from healthcare workers to women to take iron and malaria medications 4. Family planning advice from healthcare workers 5. Assistance with breastfeeding C8. Availability of human resources (healthcare workers and centers) 1. Availability of healthcare workers during childbirth 2. Unavailability of depot pharmacist 3. Insufficient healthcare workers 4. Excess of healthcare centers 5. Presence of healthcare workers during transfer C9. Women's experiences of pregnancy and childbirth 1. Childbirth experience (i.e. previous experience of woman in childbirth and psychological preparation) 2. Pregnancy and/or childbirth history (medical history of woman) C10. Management of medicine stocks (stockouts) 1. Medical procedures stock out (iron or malaria medication) 2. Irregularity in availability of malaria medication 3. Medicine stockouts C11. Unavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care, childbirth, and postpartum care 1. Insufficient seating during antenatal care 2. Availability of space for childbirth and antenatal care 3. Availability of products in the health depot 4. Insufficient postpartum rooms 5. Insufficient delivery tables 6. Insufficient beds in postpartum rooms 7.Quality of medical equipment 8. Availability of equipment for medical procedures (antenatal care, childbirth) 9. Lack of first-use equipment for the baby and mother at the healthcare center 10. Insufficient medical supplies C12. Insufficiency/lack of healthcare infrastructure 1. Absence of equipment (or device) to heat water during childbirth 2. Absence/insufficiency of toilets 3. Availability of running water 4. Defective state of healthcare centers 5. Continuous electricity lighting C13. Medical care for pregnant women and newborns before, during, and after childbirth 1. Care for the baby after childbirth 2. Care for the woman after childbirth 3. Early initiation of antenatal care visit 4. Regular antenatal care follow up visits 5. Follow up of women by healthcare workers during pregnancy and childbirth C14. Lack of rigor and skills of healthcare workers (in care) 1. Unexplored diagnosis 2. Lack of caregiver knowledge 3. Insufficient experience of interns 4. Incompetence in medical procedure treatment 5. Poor service quality (delay before performing caesarean section) 6. Dishonesty of healthcare workers 7. Negligence of healthcare workers 8. Healthcare workers inquire about women's health 9. Women's follow-up by interns not appreciated 10. Gathering of interns around the woman during childbirth C15. Hygiene and health standards in an establishment 1. Presence of mosquitos in the rooms 2. Excessive presence of bats 3. Cleanliness of places (courtyard-delivery room, ANC, maternity ward) 4. Cleanliness of toilets C16. Financial barriers to needs in maternal healthcare under the free care policy 1. Purchase of delivery material (bleach and gloves) due to lack of resources 2. Medical procedures (iron-based medications, malaria medications) effectiveness of free care 3. Effectiveness of free healthcare policy 4. Strict referral C17. Quality of reception at healthcare center 1. Reception C18. Quality of work life for healthcare workers 1. Working atmosphere within the healthcare team 2. Healthcare staff fatigue C19. Responsiveness of emergency health services 1. Availability of emergency transportation 2. Emergency transfer by ambulance C20. Reputation of the maternal health center 1. Maternity reputation C21. Responsibility of women related to care 1. Women’s negative behavior at health center 2. Healthcare advice not being adhered by women 3. Women’s consistent intake of medications (iron and malaria) 4. Women's personal hygiene 5. Women’s consistent use of mosquito nets by women C22. Support from healthcare workers for involvement of partners 1. Healthcare provider advice to caregivers 2. Summoning and sensitizing spouses by caregivers Table 3. Pattern Matching Table of Categories Influencing Women’s Quality of Maternal Care and Their Relative Weightings. Category Weight before the prompt Weight after prompt Difference in weight Unavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care, childbirth, and postpartum care (C11) -1.0 (1) -0.56 (2) +0.44 Medical care for pregnant women and newborns before, during, and after childbirth (C13) 0.93 (2) 1 (1) +0.07 Hygiene and health standards in an establishment (C15) 0.81 (3) 0.42 (5) -0.39 Availability of human resources (healthcare workers and centers) (C08) 0.58 (4) 0.30 -0.28 Inappropriate behaviors and communication of healthcare workers (towards women) (C06) -0.57 (5) -0.38 +0.19 Appropriate counseling and support in maternal health and family planning (C07) 0.54 0.51 (3) -0.03 Insufficiency/lack of healthcare infrastructure (C12) -0.52 -0.43 (4) +0.09 Medical procedures (maternal health and/or malaria) (C04) 0.48 0.31 -0.17 Responsibility of women related to care (C21) 0.41 0.27 -0.14 Quality of reception at healthcare center (C17) 0.38 0.20 -0.18 Crowding and waiting times (C05) -0.29 -0.15 +0.14 Financial barriers to needs in maternal healthcare under the free care policy (C16) -0.25 -0.11 +0.14 Lack of rigor and skills of healthcare workers (in care) (C14) -0.24 -0.26 -0.02 Accessibility of infrastructure and services for people with disabilities, reduced mobility, and other specific needs (C02) 0.16 0.09 -0.05 Support from healthcare workers for involvement of support (C22) 0.15 0.08 -0.07 Quality of work life for healthcare workers (C18) 0.14 0.07 -0.07 Responsiveness of emergency health services (C19) 0.10 0.12 +0.02 Management of medicine stocks (stockouts) (C10) -0.07 0 +0.07 Geographical accessibility of health services (C03) 0.06 0.09 +0.03 Women's experiences of pregnancy and childbirth (C09) 0 0.18 +0.18 (5) Reputation of the maternal health center (C20) --- --- --- Legend: The weights are considering direct and indirect pathways. Categories are sorted by their weight on the quality of maternal care (before the prompt), in order of the greatest absolute weight on the outcome. In brackets are the rankings of the categories with the greatest absolute weights on the outcome: the top five weights before the prompt, after the prompt, and the five largest differences in absolute weights between before and after the prompt. Additional Declarations No competing interests reported. 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01:19:41","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":188804,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7199612/v1/41ee18f9ccb9d5d46b737942.html"},{"id":92682650,"identity":"e50302fe-7749-404f-a57b-d6e15ebfb6e7","added_by":"auto","created_at":"2025-10-03 01:19:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":168232,"visible":true,"origin":"","legend":"\u003cp\u003eStudy sites in Burkina Faso\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7199612/v1/0c5bd12b1391e3c41725715c.png"},{"id":92682237,"identity":"19026544-ba11-4fa0-a34e-7496bc93fc86","added_by":"auto","created_at":"2025-10-03 01:11:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":768240,"visible":true,"origin":"","legend":"\u003cp\u003ePicture of one of the original fuzzy cognitive maps from a group session.\u003cstrong\u003e \u003c/strong\u003eOne trained facilitator and a note-taker led mapping sessions with groups of women of reproductive age. A facilitator drew the map on a large sheet of paper following the indications of participants. At the end of the session, group members checked the map’s content. After they approved the final version, the facilitators took a picture of the map.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7199612/v1/2b205ebdb79f2bed832ff109.png"},{"id":92682245,"identity":"9678fe57-0b7c-48db-9929-6ff009564552","added_by":"auto","created_at":"2025-10-03 01:11:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":251142,"visible":true,"origin":"","legend":"\u003cp\u003eCategory maps of perception of women of reproductive age on factors influencing quality of maternal care (pre-prompt). Legend: This map illustrates the five strongest category-level relationships with quality of maternal care prior to the prompt. Bolder lines indicate stronger relationships. Dashed lines indicate negative relationships.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7199612/v1/078d094422e218c97344c7d1.png"},{"id":92683113,"identity":"551087f5-2ab7-4d95-9863-681672f0ee34","added_by":"auto","created_at":"2025-10-03 01:35:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5022698,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7199612/v1/ddbb07ba-2d3b-4246-8922-dc68a5ce25d3.pdf"},{"id":92682243,"identity":"7fc78f52-983b-4beb-9310-e8d3b5039963","added_by":"auto","created_at":"2025-10-03 01:11:40","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":423264,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-7199612/v1/e0615e9994c749f320fde571.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring women’s views on factors influencing the quality of maternal care among women of reproductive age in Burkina Faso: a fuzzy cognitive mapping study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMaternal mortality remains a significant global health issue. In 2020, almost 95% of maternal deaths occurred in low- and middle-income countries (LMICs), where 287,000 women died during pregnancy and childbirth [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The Sustainable Development Goals (SDGs), established by the United Nations in 2015, aimed to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, by 2020, this ratio had only slightly decreased from 227 to 223 maternal deaths per 100,000 live births [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and 72% of those occurred in sub-Saharan Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo reduce maternal mortality rates, sub-Saharan African countries have implemented interventions aimed at improving access to reproductive healthcare [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], including newly built health facilities with maternity services, performance-based incentives for healthcare staff, user fee exemptions, and maternity waiting homes (lodging near medical facilities for women approaching delivery) [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Underscoring persistent regional disparities, skilled birth attendance in sub-Saharan Africa increased from 57% in 2015 to 73% in 2023, even as global rates increased from 80–86% over the same period [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite improvements in access indicators, reduced financial barriers, and increased births attended by skilled providers, utilization indicators (including antenatal care visits and facility-based deliveries) reveal that maternal morbidity and mortality rates have not shown similar progress [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This persistent gap highlights the limitations of these interventions in achieving their intended outcomes.\u003c/p\u003e\u003cp\u003eThe suboptimal quality of maternal health services is often cited as a key reason for persistent gaps in improving maternal health outcomes. While reducing financial access barriers in LMICs, including providing care at no cost to patients, has increased healthcare utilization, the effect of these measures on quality of care remains unclear [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A systematic scoping review in sub-Saharan Africa revealed that in 8 out of 13 studies, pregnant women perceived care quality as poor under free maternal healthcare policies, although this perception might not be directly linked to the policies themselves [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and evidence regarding how no-cost care affects quality is inconsistent. Some studies have linked fee removal to challenges like insufficient supplies and medications, increased workload for healthcare staff, poor infrastructure, and decreased morale among providers; others have reported improvements in service reliability, enhanced antenatal care education, better support at reception for prenatal services, and improved screening of vital signs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. According to the Lancet Commission on High-Quality Health Systems in 2018 and other studies, improving healthcare access and use is insufficient, and poor quality of maternal care remains a critical barrier to reducing mortality in LMICs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImportant questions then arise: What do we mean by “quality of maternal care,” and how do we measure it? Traditionally, it has been measured using a set of standardized indicators articulated in an overall framework. The most commonly cited of these in the last 50 years is the Donabedian model [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], which categorizes quality into three dimensions: structure, process, and outcome [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The WHO Quality of Care Framework for Maternal and Newborn Health, developed in 2015, integrates the Donabedian model's dimensions of structure, process, and outcome with six key attributes from the US Department of Health and Human Services Institute of Medicine (IOM) framework: safety, effectiveness, timeliness, efficiency, equity, and people-centeredness [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This comprehensive approach states that the quality of maternal and newborn health reflects the health system (structure) which allows access to quality care and interlinked dimensions of provision and experience of care (process), which are in turn linked to better individual and facility-level outcomes. These two frameworks, frequently used to assess the quality of maternal care, rely on a large set of comparable indicators often described as “objective” and include diverse measures like the proportion of births attended by skilled personnel and whether blood pressure and weight are recorded during antenatal care visits. While these indicators are important, the frameworks have been criticized for failing to capture the subjective perceptions held by women, which are also an important measure of quality of maternal care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. More comprehensive models of maternal health have thus been developed to include women’s perceptions about the extent to which maternal healthcare services meet their needs and expectations [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLiterature has increasingly confirmed the association between women’s perceptions of healthcare quality and their health-seeking practices [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e–\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, there is growing criticism of the tools used to quantify these perceptions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Few studies engage communities or integrate women’s perspectives into quantitative measures to improve the quality of maternal care. In Burkina Faso, we employed fuzzy cognitive mapping (FCM), a participatory qualitative research tool, to explore and organize how women of reproductive age perceive the quality of maternal health services. This approach, within the framework of a larger mixed-methods study, aims to identify the key concepts and factors that shape women's perceptions of the quality of maternal care in Burkina Faso.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBurkina Faso is a landlocked Sahelian country with a population of ~20 million [29], of which two thirds reside in rural areas [30]. It has one of the highest fertility rates in the world (4.7 births per woman) and half of the population is under 15 years old [31]. The proportion of women receiving prenatal care from a qualified provider has significantly increased from 60% in 1993 to 74% in 2003, 96% in 2010, and 98% in 2021 [32]. The most recent Demographic and Health Survey reported that nearly all births in 2021 (96%) were attended by skilled health personnel [32].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn July 2016, Burkina Faso implemented a national policy that eliminated clinic fees for pregnant and postpartum women and children under five years of age [33]. The policy covers comprehensive prenatal and postnatal care, delivery, emergency obstetric care and evacuation, and cesarean sections [34]. Four years later, user fees for family planning services (i.e., contraception) were also removed [35]. These policies have improved access to maternal healthcare in all public health facilities [33].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDesign \u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study is the qualitative phase of a larger exploratory sequential mixed methods project to integrate women\u0026rsquo;s perceptions into quantitative measures of the quality of maternal care in Burkina Faso. The findings presented in this manuscript will inform the development of a compositive quantitative index: a culturally relevant and context-specific tool to measure quality of maternal care [36, 37].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in the rural health district of Leo and in the capital city of Ouagadougou, (\u003cstrong\u003eFigure 1\u003c/strong\u003e). Data collection was completed between June and July of 2023.\u003c/p\u003e\n\u003cp\u003eFIGURE 1 INSERT HERE\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eStudy participants and recruitment\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSampling was convenient: Participants were recruited during visits to health facilities or by phone, with the help of healthcare workers or the Burkinabe Association for Family Welfare [38]. Recruitment was stratified according to age (15\u0026ndash;30 vs. 31\u0026ndash;49 years old) and maternal status (pregnant vs. postnatal), as in purposive sampling. Eight FCM sessions were conducted: 4 in the rural district of Leo and 4 in the capital of Ouagadougou. The sessions were stratified by maternal status to account for power differentials and variability of experience [39]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eInstrument and procedure: Fuzzy Cognitive Mapping \u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe used FCM to generate visual maps of collective perspectives on the quality of maternal health care [40]. This method is widely employed for stakeholder engagement, as it integrates diverse perspectives into composite frameworks to inform decision-making [41, 42]. FCM is increasingly used in different cultural contexts to explore determinants of health from stakeholders\u0026apos; perspectives \u0026nbsp;[42].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring group mapping session, women of reproductive aged 15 to 49 were asked to identify factors associated with more quality of maternal care and how those factors relate to each other. Each factor was represented as a node linked to other factors (nodes) by edges (arrows) [39], generating a map. Participants assigned weights to the arrows to indicate the perceived causal strength of each link, denoting the influences of different factors on one another.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach mapping session was facilitated by two women: one experienced qualitative researcher who was the facilitator (AB) and one research assistant who was the note taker (HNB), in Moor\u0026eacute; or French according to the participant\u0026rsquo;s preference. The facilitators initiated the discussions and drew the map on a large sheet of paper with sticky notes representing nodes following participant directions. Each participant also completed a brief demographic questionnaire. Facilitators guided participants in creating maps using an adapted standard protocol for FCM (for more details, please refer to [39]). Participants identified and discussed factors influencing the quality of prenatal, delivery, and postnatal care. Group consensus from participants in real time determined: 1) which factors appeared on the map; 2) direct and indirect links (arrows); and 3) arrow weights from 1 (weakest) to 5 (strongest) to indicate the strength (positive or negative) of the relationships between factors. Once participants deemed the map complete, it was photographed (\u003cstrong\u003eFigure 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eFIGURE 2 INSERT HERE\u003c/p\u003e\n\u003cp\u003eParticipants were next presented with a list of factors commonly recognized in maternal care literature as measures of quality (\u003cstrong\u003eSupplementary Material: Table 1)\u003c/strong\u003e. After being prompted with this list of factors, the participants decided whether to incorporate these elements and their weighted relationships into the map. A photograph of the updated map was taken. The FCM sessions were audio-recorded, translated, and transcribed verbatim by a local researcher in French. The maps were digitized from the photos in freeware yEd.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFuzzy Cognitive Mapping Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe lead author, along with another qualitative researcher (MCG), standardized\u003cem\u003e\u0026nbsp;\u003c/em\u003enode names across all maps to unify terms with similar meanings. For example, factors such as \u0026quot;advice on nutrition and pregnancy by healthcare workers,\u0026quot; \u0026quot;nutrition advice from healthcare workers,\u0026quot; and \u0026quot;lack of advice (no nutrition advice after cesarean)\u0026quot; were standardized to \u0026quot;healthcare workers\u0026rsquo; advice on nutrition.\u0026quot; Positive or negative connotations of factors were adjusted accordingly, including reversing the signs of their relationships if necessary. This iterative standardization process incorporated input from the note-taker (HNB) and the facilitator (AB).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe standardized maps were converted into individual adjacency matrices, with rows and columns representing factors and cell values reflecting normalized relationship weights (+/-0\u0026ndash;1). Using CIETmap 2.2 [43] fuzzy transitive closure (TC) was applied to estimate the maximum direct and indirect influence of each factor. The average weights from TC matrices were then calculated to define factor-level relationships [44]. Through qualitative thematic analysis, these factors were grouped into categories, validated by the research team, and used to create a category-level map [45, 46]. Category relationships weights were calculated by aggregating mean weights of factor-level relationships and normalizing these values by dividing by the maximum absolute of all sums to a range between -1 and +1. An adjacency matrix is a mathematical representation of the relationships between categories, where each cell indicates the presence and strength of a connection between two categories (\u003cstrong\u003eSupplementary Materials: Table 2).\u003c/strong\u003e This matrix was used to digitize the final full category map and to identify the relationships with the strongest impact on the quality of maternal care.\u003c/p\u003e\n\u003cp\u003eIndegree and outdegree centrality measures (key influencing categories) were used to analyze the category map [40]. Outdegree centrality (sums of weights of absolute values of outgoing arrows) reflected categories exerting the most influence on the main outcome, while indegree centrality (sums of weights of incoming arrows) highlighted categories most impacted by others.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative Thematic Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAudio transcriptions from mapping sessions were analyzed using inductive and deductive thematic analysis to validate and refine categories identified in the physical maps [47]. Deductive coding incorporated predefined factors from the FCM aalysis, while inductive coding allowed new themes to emerge. Coding, conducted primarily by the lead author using QSR NVivo version 10, identified patterns, similarities, and differences across sessions according to the categories defined in the FCM analysis [45]. After preliminary analysis, the intermediate results and digitization of the maps were validated during three peer debriefing sessions between authors in Canada and in Burkina Faso. The digitization of maps was triangulated with the transcriptions and field notes recorded during data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical considerations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided informed written consent. The study was approved by the Comit\u0026eacute; d\u0026rsquo;\u0026eacute;thique de la recherche en sciences de la sant\u0026eacute; at University of Montreal (Certificate #CERSES-2022-1809) and by the Comit\u0026eacute; d\u0026rsquo;\u0026eacute;thique pour la Recherche en Sant\u0026eacute; in Burkina Faso (Deliberation #2023-03-051). Participants were compensated for transportation and provided with a meal at the end of each session.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 32 women aged 15–49 years old participated in 8 mapping sessions. \u003cstrong\u003eTable 1\u003c/strong\u003e presents the characteristics of study participants. Thirty women had given birth at least once before (21 in a primary health facility, 8 in a medical center with a surgical maternity unit, and one in a larger regional hospital, for the last pregnancy). Seventeen women were pregnant at the time, including two women with no previous pregnancies.\u003c/p\u003e\n\u003cp\u003eTABLE 1 INSERT HERE\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.1 Factors influencing quality of maternal care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe main analysis presented here focuses on the factors, categories, and themes identified during the initial mapping sessions—prior to any literature-based prompting—since this approach allows us to capture the participants’ unmediated experiences and perspectives. The literature-based prompting, which is presented later in the results, serves to explore additional factors that may not have emerged spontaneously but may be relevant. Before the prompt, the eight maps had an average number of 21 categories (range 17–25) and 44 relationships after TC, with 75 unique concepts (\u003cstrong\u003eTable 2)\u003c/strong\u003e. Factors were condensed into 21 categories interacting through 111 relationships (see \u003cstrong\u003eSupplementary Material: Figure 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTABLE 2 INSERT HERE\u003c/p\u003e\n\u003cp\u003eThe five most influential categories on quality of maternal care were, in order with the biggest:\u003cem\u003e\u0026nbsp;Unavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care (ANC), childbirth, and postpartum care (C11); Medical care for pregnant women and newborns before, during, and after childbirth (C13); Hygiene and health standards in an establishment (C15); Availability of human resources (healthcare workers and centers) (C08);\u0026nbsp;\u003c/em\u003eand \u003cem\u003eInappropriate behaviors and communication of healthcare workers (towards women) (C06)\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e(Figure 3)\u003c/strong\u003e. \u003cstrong\u003eTable 3\u003c/strong\u003e lists the category weights on quality of maternal care and their related weighted importance on a scale of -1 to +1. The weights account for both the direct and indirect pathways through which the categories influence the quality of maternal care.\u003c/p\u003e\n\u003cp\u003eFIGURE 3 INSERT HERE\u003c/p\u003e\n\u003cp\u003eTABLE 3 INSERT HERE\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUnavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care (ANC), childbirth, and postpartum care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003eunavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care (ANC), childbirth, and postpartum care (C11)\u003c/em\u003e had the highest negative influence on quality of maternal care according to our participants (\u003cstrong\u003eTable 3\u003c/strong\u003e). This category included nine factors such as lack of seating, delivery tables, rooms, and medical equipment/supplies. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn session 7, women mentioned health centers having only one delivery bed available, even when multiple women were giving birth simultaneously. As one participant from session 7 highlighted,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The delivery table is also missing; we only have one delivery table; there are 3 beds in the postpartum recovery room. But there can be 5 women giving birth at the same time, so some women end up giving birth on the floor and have to lie down on the floor with their baby.”\u0026nbsp;\u003c/em\u003e[Session 7]\u003c/p\u003e\n\u003cp\u003eThe lack of sufficient seating in waiting rooms during ANC visits was a recurring worry.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[Lack of sufficient seating in the waiting room] is an important concept for quality of care. If there were no seats here, women would have to stand up, and that's not good for their health or the baby's health.”\u0026nbsp;\u003c/em\u003e[Session 8]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMedical care for pregnant women and newborns before, during, and after childbirth\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMedical care for pregnant women and newborns before, during, and after childbirth (C13)\u0026nbsp;\u003c/em\u003ehas the second strongest influence on quality of maternal care. This category has a positive relation and consists of five factors (\u003cstrong\u003eTable 2\u003c/strong\u003e): Early initiation of ANC visits, regular ANC follow-up visits, follow-up of women by healthcare workers during pregnancy and childbirth, care for the baby after childbirth, and care for the women after childbirth.Participants described regular ANC follow-up visits as the most influential factor, closely related to other aspects, such as medical procedures, prescriptions, mosquito nets, and healthcare provider advice to patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“What is important for pregnant women [and quality of maternal care] is regular prenatal check-ups; if you do not attend regularly, you cannot get the products to take regularly; but if the check-ups are regular, you also take the medications and your delivery will be easier.”\u0026nbsp;\u003c/em\u003e[Session 7]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHygiene and health standards in an establishment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHygiene and health standards in an establishment\u0026nbsp;\u003c/em\u003ehad the third strongest influence on the quality of maternal care. This category consists of four factors (\u003cstrong\u003eTable 2\u003c/strong\u003e): cleanliness of places (courtyard-delivery room, ANC, maternity ward), cleanliness of toilets, presence of mosquitos in the rooms, and excessive presence of bats. Cleanliness of toilets was one of the more influential factors in seven out of eight maps. From the participants’ perspectives, poor hygiene can lead to the spread of diseases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The cleanliness of the premises, and especially the toilets, is very important because if the toilets are not clean, you can catch diseases since many people use them; you can easily contract diseases that cause itching in the genital area of women (sexually transmitted diseases).”\u0026nbsp;\u003c/em\u003e[Session 1]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOther categories influencing quality of maternal care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003eavailability of human resources (healthcare workers and centers) (C08)\u003c/em\u003e ranked fourth as positively influencing the quality of maternal care. This category included availability of healthcare workers during childbirth, availability of depot pharmacists, sufficient number of healthcare workers, sufficient number of healthcare workers, and the presence of healthcare workers during transfer \u003cstrong\u003e(Table 2)\u003c/strong\u003e. Conversely, \u003cem\u003einappropriate behaviors and communications of healthcare workers (towards women) (C06)\u003c/em\u003e, ranked fifth in importance, negatively influenced quality (\u003cstrong\u003eTable 3\u003c/strong\u003e). Specifically, verbal abuse by healthcare workers, lack of confidentiality, bad attitude, bad healthcare worker-patient relationship, and difficulty in phone communication were linked to a decrease in the quality of maternal care. The discourse in Session 6 among young postnatal women highlighted several factors related to verbal abuse, attitude, and communication skills of healthcare workers and the importance of these factors in the overall experience of care. One participant expressed frustration with the lack of clear communication from healthcare workers:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Participant 1: If you arrive and you don’t understand something, instead of explaining it to you, they’ll start talking badly to you, so you too go where you can have peace of mind\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant 2: It’s true; getting good care isn’t just about the products, already if the relationships isn’t good with the person who’s going to look after you, it's not good; you'll go back to being discouraged; that doesn't help you heal. Some health workers don't try to understand. It's because we're listened […] that we come [here] for consultation.”\u0026nbsp;\u003c/em\u003e[Session 6]\u003c/p\u003e\n\u003cp\u003eOne category, \u003cem\u003equality of reception at healthcare center (C17)\u003c/em\u003e, consisting of a single factor, had a weight of 0.63, making it the most important factor of quality of maternal care at the individual factor level. This factor was a dominant theme across nearly all mapping sessions, with transcriptions revealing frequent references to its importance. According to participants, the initial reception received at healthcare centers strongly influenced women’s perceptions of quality of maternal care and influenced their decisions to seek services. The behavior of midwives—whether welcoming and supportive or not—can either encourage or deter women from attending consultations.\u003c/p\u003e\n\u003cp\u003eAs articulated by a participant from Session 8,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We have a village in Leo, and all the women here say they will go to Leo to give birth. Why? When women in labor arrive, from the entrance, the midwives know it's an urgent case; they hurry to welcome you, help the woman enter the room. They joke with you until you give birth. Many women here say they will go there to give birth. There needs to be a change in our health center; otherwise, it won't work.” [Session 8]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.6 Social Network Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis section presents the results of the social network analysis conducted on the identified factors before the literature-based prompting.\u0026nbsp;\u003cem\u003eQuality of maternal care\u003c/em\u003e was the most important outcome, both in terms of the number of arrows pointing toward it and the strength of those arrows (indegree centrality score of 7.69). \u003cem\u003eResponsibility of women related to care (C21)\u003c/em\u003e was the second (indegree centrality score of 2.24) \u003cem\u003eand medical care for pregnant women, and newborns before, during and after childbirth (C13)\u003c/em\u003e was the third (indegree centrality score of 2.00). This suggests that women’s responsibilities were perceived as an important intermediary influencing the quality of maternal care. These include negative behavior at health centers, not adhering to healthcare advice or intake of medications, poor personal hygiene, and inconsistent use of mosquito nets at home. Outdegree centrality identified \u003cem\u003emedical care for pregnant women and newborns before, during, and after childbirth (C13)\u0026nbsp;\u003c/em\u003eand \u003cem\u003eavailability of human resources (healthcare workers and centers) (C08)\u003c/em\u003e as the most important givers of influence on the main outcome and on other factors. \u003cem\u003eAvailability of human resources (healthcare workers and centers) (C08)\u0026nbsp;\u003c/em\u003ewas consistently prominent across all maps, with inadequate numbers of healthcare providers emerging as a recurrent theme across almost all sessions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Of course, this has a negative impact on the quality of care. If I understand correctly. If there aren't enough of them to treat people well, we won't have good care, but if there are many and a single doctor can follow 50 or 40 women, he'll have a little time to follow them well, but if he's alone with 100 or 200 women, he'll do what he can only. May God only help us.”\u003c/em\u003e [Session 2]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExploring additional factors following prompting questions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the initial mapping, women identified nine other factors after prompting, \u003cstrong\u003e(Table 2)\u003c/strong\u003e. Two of these factors (childbirth experience and pregnancy/childbirth history) formed a new category: \u003cem\u003eWomen’s experience of pregnancy and childbirth (C09)\u003c/em\u003e, while the other seven were integrated into existing categories (see revised map after prompting in \u003cstrong\u003eSupplementary Material: Figure 2\u003c/strong\u003e). The first factor of the new category (childbirth experience) emphasizes the importance of psychological preparation for the next birth and the second factor (pregnancy/childbirth history) involves the midwives’ understanding of the current medical needs/conditions. Women in four sessions noted the absence of these factors in current practices. One participant from Session 2 explained how limited consultation time hindered personalized attention:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It's important but health workers don't have the time to talk about it with women; […], for example if you're transferred, normally, they should take the time to ask you questions, but ah, you see no”\u003c/em\u003e [Session 2]\u003c/p\u003e\n\u003cp\u003eThis quote highlights the importance of psychological support and personal rapport with clinic staff. In the context of Burkina Faso’s fragmented healthcare system, women are often seen by multiple healthcare providers, making it difficult to establish a rapport and receive personalized care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome factors (n = 10) listed in \u003cstrong\u003eTable 2\u003c/strong\u003e appeared in some mapping sessions but not in others before the prompt and were subsequently added after the prompt. For example, early initiation of ANC visits had to be prompted in some sessions (n=5), as did discussions about (i) care for the woman/baby after delivery, (ii) reliable electricity with minimal outages, (iii) availability of running water, and (iv) the distance from the maternity hospital. Others like healthcare workers take good precautionary hygiene measures, and dishonesty of healthcare workers were rejected, because some participants did not experience these personally and felt they could not comment on it (although Session 4 noted corruption at their center).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, fuzzy cognitive mapping was used to identify factors influencing the quality of maternal care and assess their respective importance for women in Burkina Faso. Women independently identified a variety of factors that influenced their perception of the quality of maternal care, with key issues including inadequate medical equipment, insufficient continuous care for pregnant women and newborns, and poor hygiene standards in healthcare facilities. Participants highlighted social and structural barriers such as financial constraints, geographic access, behavior and communication of healthcare providers, and quality of reception at healthcare centers, which significantly shaped their overall care experiences. These insights will inform a more efficient quantitative measure of the quality of maternal care.\u003c/p\u003e\u003cp\u003eReferring to Donabedian\u0026rsquo;s model, the participants\u0026rsquo; perceptions of quality of maternal care mostly align with the structural, process, and outcome dimensions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. They particularly emphasized the structural dimensions of quality of maternal care, including cleanliness of facilities, availability of water and electricity, medical resources (e.g. medical equipment, beds, chairs), whether healthcare staff were skilled or trained, waiting times, and adequate number of healthcare workers within healthcare facilities. These were viewed as important influencers of their quality of care, mirroring findings from studies in Kenya, India, and Malawi where inadequate infrastructure and staffing shortages were identified as key barriers of high quality maternal care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e In our study, the structural aspects had the highest cumulative weight of influence on the perceived quality of maternal care. This confirms the importance of conducting audits or supervisory visits to health facilities, but our study suggests that such inspections are insufficient. Participants also recognized the importance of process-related, such as the healthcare worker-patient relationship, emotional support, and caregiver advice, and they expressed concerns about abuse, disrespect, negligence, and breaches of confidentiality. These findings align with studies from Nigeria, Uganda, and Ethiopia and underscore the importance of provider-patient communication in fostering responsiveness, empathy, and rapport-building, all of which are key components that influence women\u0026rsquo;s trust in the healthcare system [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe process aspect of Donabedian\u0026rsquo;s model has gained significant attention in qualitative research on maternal health, going beyond structural factors to explore how care is experienced by women [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In our study, the prominence of process-related categories (9 of 22) reflects this qualitative emphasis, showing that women prioritize how they are treated and supported during care as well as the more structural categories. Respectful maternity care, including provider communication and attitudes, has been linked to women\u0026rsquo;s choice of facility, as they prioritize settings where they expect better treatment from healthcare workers [\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Despite its significance, quality assessments in sub-Saharan Africa often prioritize clinical and structural aspects, overlooking the importance of women\u0026rsquo;s experiences of respect and care during pregnancy and childbirth. The WHO has previously included respectful maternity care as a key component of its quality standards, stressing the need to balance both clinical and experiential factors to improve maternal care [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eContinuity of care emerged as a central component of maternal care quality in our study, both as a process and outcome dimension. Social network analysis revealed it to be one of the most influential categories, with the highest out-degree centrality. This illustrates its association with other categories, such as medical procedures, healthcare advice, and the provider-patient relationship. Participants highlighted the importance of continuity across all stages of maternal care, from antenatal visits to postnatal follow-ups. This aligns with global research underscoring the critical role of continuity in improving maternal and neonatal outcomes, particularly in addressing preventable deaths during the postpartum period [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe emphasis on continuity of care in maternal health and quality of care literature is clear and is emphasized in several frameworks, including the Standards for Improving Quality of Maternal and Newborn Care and the Lancet Commission on High-Quality Systems [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Evaluating continuity of care remains challenging, as existing metrics often focus on the number of antenatal visits and fail to capture the relational and informational dimensions of care [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. This underscores the need for standardized assessments that include interpersonal and informational factors [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. The emergence of continuity of care as a major factor may call for more longitudinal assessments since cross-sectional contexts cannot capture or reconstruct continuous care pathways.\u003c/p\u003e\u003cp\u003eSome commonly used quality indicators were not spontaneously mentioned by participants, and some factors volunteered by participants in our sessions are commonly overlooked by models and instruments, illustrating the shortcomings of current measurement approaches. This suggests that routine data sources, such as the Service Provision Assessment, the Demographic and Health Surveys, and other highly utilized secondary data sources, may lack key elements needed to comprehensively evaluate the quality of maternal care from the perspective of the women who receive it. While facility-based indicators (e.g., availability of essential equipment, electricity, and water) are easier to measure and frequently included in assessments, some important aspects\u0026mdash;such as the quality of patient reception, healthcare worker-patient relationships, and the inclusion of relationship partners in healthcare\u0026mdash;are often overlooked. Even facility-based structural indicators are not always appropriately taken into consideration. For example, it is not enough to record whether there is a functioning toilet in a given health facility (as does the WHO\u0026rsquo;s Service Availability and Readiness Assessment); it is important to document whether it is clean or not.\u003c/p\u003e\u003cp\u003ePrevious quantitative assessments of maternal care quality in Burkina Faso have relied largely on facility-based surveys that emphasize structural and clinical indicators like availability of essential drugs and continuity of care [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. One study aimed at developing a maternal care quality measure in Burkina Faso used non-participatory observations of antenatal consultations, assessing factors such as provider discretion, whether or not clinic staff recorded vaccination and marital status, completeness of clinical and gynecological examinations, provision of advice, and therapeutic decision-making [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. The Demographic and Health Surveys in Burkina Faso measure the quality of prenatal care based on the content of prenatal visits, including blood pressure measurement, laboratory tests, and prenatal health advice [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFCM has proven effective in engaging local communities across various areas of study, including maternal health [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. This study is the first to apply FCM specifically to capture perceptions of maternal care quality, allowing us not only to gather women\u0026rsquo;s insights but also to empower them to directly express their needs and expectations. This emphasis on community engagement reflects a growing recognition in the literature of the importance of integrating patient perspectives into quality assessments [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Unlike previous mixed-methods studies in sub-Saharan Africa, such as those in Malawi and Zambia, which used qualitative data to complement quantitative measures to assess quality of maternal care, our study aims to inform the development of new quantitative metrics enriched by qualitative insights, broadening the scope of how maternal care quality is assessed [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWe recognize several limitations in this study. First, the use of Donabedian's framework to categorize our findings into structural, process, and outcome dimensions may have been somewhat rigid, as some categories overlap [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For instance, continuity of care is typically viewed as an outcome, based on the number of antenatal visits, but it also encompasses informational and relational continuity, which are more process-oriented [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. These overlapping dimensions complicate the clear-cut categorization of certain factors: We noticed a lack of maternal \u0026ldquo;outcome\u0026rdquo; concerns raised by our participants. While our results show that women did not typically mention outcomes such as mortality, morbidity, or satisfaction, this absence may reflect the sensitivity of discussing these topics in group settings, as observed in other qualitative studies on maternal experiences [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSecondly, we did not define or discuss with participants a shared understanding of \u0026ldquo;quality of maternal care\u0026rdquo; as a central outcome. Defining this concept in advance might have provided a more structured framework, allowing participants to consider specific aspects of care in a more systematic way. However, it could also have influenced the overlooked factors participants identified voluntarily. Data was collected only in two areas in Burkina Faso\u0026mdash;one urban and one rural. While this selection offers some diversity of perspectives, it does not claim to be representative of the country overall. Additionally, women with no prior childbirth experience were not included in the study, because the focus was on lived perceptions rather than expectations.\u003c/p\u003e\u003cp\u003eFinally, we did not reach saturation in our mapping sessions, as new factors continued to emerge throughout. While further exploration of these factors would have been valuable, conducting additional FCM sessions was not feasible for logistical reasons. Instead, efforts were made to fully exploit the available qualitative material (FCM, notebooks, observations, etc.) to ensure a comprehensive analysis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the critical factors influencing the quality of maternal care in Burkina Faso, as perceived by women. Using FCM, women in Burkina Faso identified key structural and process-related dimensions that shape their experiences within maternal healthcare. Understanding these specific factors, their relative importance, and how they affect each other is essential for measuring service quality or informing changes to services. This research provides evidence and data needed to integrate women\u0026rsquo;s perspectives into an index that will capture the multifaceted nature of maternal care. This is particularly crucial in contexts affected by interventions like Burkina Faso\u0026rsquo;s free maternal care policy, ensuring that services align with women\u0026rsquo;s actual care needs. This focus helps health systems to adapt and improve, offering high-quality care that is equitable, patient-centered, and aligned with women\u0026apos;s experiences and expectations [12].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided informed written consent to participate. The study was approved by the Comit\u0026eacute; d\u0026rsquo;\u0026eacute;thique de la recherche en sciences de la sant\u0026eacute; at University of Montreal (Certificate #CERSES-2022-1809) and by the Comit\u0026eacute; d\u0026rsquo;\u0026eacute;thique pour la Recherche en Sant\u0026eacute; in Burkina Faso (Deliberation #2023-03-051). Participants were compensated for transportation and provided with a meal at the end of each session. All methods were carried out in accordance with the guidelines and regulations in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided informed written consent to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided informed written consent to publish the findings of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the confidentiality agreements with participants, the data collected for this study cannot be publicly shared. Researchers who wish to access the raw data for legitimate academic purposes may contact the corresponding author, Sarah Cooper, at [email protected], or the research partner at SERSAP, Frank Bicaba.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Queen Elizabeth II Diamond Jubilee Scholarship \u0026ndash; \u0026laquo; Renforcement des ressources humaines et de la recherche en sant\u0026eacute; des femmes, adolescentes et filles dans les pays associ\u0026eacute;s \u0026agrave; la CEDEAO et en R\u0026eacute;publique d\u0026eacute;mocratique du Congo \u0026raquo;. SC and MCG are supported by doctoral awards from the Fonds de recherche du Qu\u0026eacute;bec- Sant\u0026eacute;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the communities in the study areas who enabled this work to take place, the participants, the health district authorities (district and health facility managers), and the support from the Association Burkinab\u0026egrave; pour le Bien-\u0026Ecirc;tre Familial (ABBEF) and the collaboration with Soci\u0026eacute;t\u0026eacute; d\u0026rsquo;\u0026Eacute;tudes et de Recherches en Sant\u0026eacute; Publique (SERSAP). We would like to acknowledge Hatou Bila from the SERSAP for her help in translating the session. We would also like to acknowledge the methodological support from our colleagues at the Participatory Research at McGill University (PRAM), specialized in fuzzy cognitive mapping, who helped in developing the tool and analyzing the results. We would also like to thank Federica Fregonese and Loula Burton for their support in proofreading this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSC conceptualized the study under the supervision of TD. TD and FB supervised the project. SC and TD acquired funding. SC planned the project, developed methods and interview guides with consultation of AB, KK, FB, IS and TD. AB and NB facilitated discussions. FB and KK planned and organized the field work. SC performed the formal data analysis with consultation with MCG. Analysis results was verified with AB, NB and KK. SC drafted the manuscript. AB, KK, NB, MCG, IS, FB and TV critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eMaternal mortality \u003c/strong\u003e[https://www.who.int/news-room/fact-sheets/detail/maternal-mortality]\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGoal 3: Ensure healthy lives and promote well-being for all at all ages \u003c/strong\u003e[https://sdgs.un.org/goals/goal3#targets_and_indicators]\u003c/li\u003e\n \u003cli\u003eOrganization WH: \u003cstrong\u003eTrends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division\u003c/strong\u003e: World Health Organization; 2023.\u003c/li\u003e\n \u003cli\u003eAnsu-Mensah M, Danquah FI, Bawontuo V, Ansu-Mensah P, Kuupiel D: \u003cstrong\u003eMaternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review\u003c/strong\u003e. \u003cem\u003eBMC health services research \u003c/em\u003e2020, \u003cstrong\u003e20\u003c/strong\u003e:1-11.\u003c/li\u003e\n \u003cli\u003eWekesah FM, Mbada CE, Muula AS, Kabiru CW, Muthuri SK, Izugbara CO: \u003cstrong\u003eEffective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review\u003c/strong\u003e. \u003cem\u003eSystematic reviews \u003c/em\u003e2016, \u003cstrong\u003e5\u003c/strong\u003e:1-18.\u003c/li\u003e\n \u003cli\u003eElmusharaf K, Byrne E, O’Donovan D: \u003cstrong\u003eStrategies to increase demand for maternal health services in resource-limited settings: challenges to be addressed\u003c/strong\u003e. \u003cem\u003eBMC public health \u003c/em\u003e2015, \u003cstrong\u003e15\u003c/strong\u003e:1-10.\u003c/li\u003e\n \u003cli\u003eLori JR, Wadsworth AC, Munro ML, Rominski S: \u003cstrong\u003ePromoting access: the use of maternity waiting homes to achieve safe motherhood\u003c/strong\u003e. \u003cem\u003eMidwifery \u003c/em\u003e2013, \u003cstrong\u003e29\u003c/strong\u003e(10):1095-1102.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eThe Sustainable Development Goals Extended Report 2024: 3 Good health and well-being\u003c/strong\u003e. 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3,003 Tanzanian women\u003c/strong\u003e. \u003cem\u003ePloS one \u003c/em\u003e2015, \u003cstrong\u003e10\u003c/strong\u003e(8):e0135621.\u003c/li\u003e\n \u003cli\u003eOrganization WH: \u003cstrong\u003eStandards for improving quality of maternal and newborn care in health facilities\u003c/strong\u003e. 2016.\u003c/li\u003e\n \u003cli\u003eSeidu A-A, Ahinkorah BO, Aboagye RG, Okyere J, Budu E, Yaya S: \u003cstrong\u003eContinuum of care for maternal, newborn, and child health in 17 sub-Saharan African countries\u003c/strong\u003e. \u003cem\u003eBMC Health Services Research \u003c/em\u003e2022, \u003cstrong\u003e22\u003c/strong\u003e(1):1394.\u003c/li\u003e\n \u003cli\u003eNyamtema AS, Urassa DP, van Roosmalen J: \u003cstrong\u003eMaternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change\u003c/strong\u003e. \u003cem\u003eBMC pregnancy and childbirth \u003c/em\u003e2011, \u003cstrong\u003e11\u003c/strong\u003e:1-12.\u003c/li\u003e\n \u003cli\u003eHaggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R: \u003cstrong\u003eContinuity of care: a multidisciplinary review\u003c/strong\u003e. \u003cem\u003eBmj \u003c/em\u003e2003, \u003cstrong\u003e327\u003c/strong\u003e(7425):1219-1221.\u003c/li\u003e\n \u003cli\u003eDuysburgh E, Temmerman M, Yé M, Williams A, Massawe S, Williams J, Mpembeni R, Loukanova S, Haefeli WE, Blank A: \u003cstrong\u003eQuality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study\u003c/strong\u003e. \u003cem\u003eTropical Medicine \u0026amp; International Health \u003c/em\u003e2016, \u003cstrong\u003e21\u003c/strong\u003e(1):70-83.\u003c/li\u003e\n \u003cli\u003eNikiema L, Kameli Y, Capon G, Sondo B, Martin-Prével Y: \u003cstrong\u003eQuality of antenatal care and obstetrical coverage in rural Burkina Faso\u003c/strong\u003e. \u003cem\u003eJournal of health, population, and nutrition \u003c/em\u003e2010, \u003cstrong\u003e28\u003c/strong\u003e(1):67.\u003c/li\u003e\n \u003cli\u003eSarmiento I, Ansari U, Omer K, Gidado Y, Baba MC, Gamawa AI, Andersson N, Cockcroft A: \u003cstrong\u003eCauses of short birth interval (kunika) in Bauchi State, Nigeria: systematizing local knowledge with fuzzy cognitive mapping\u003c/strong\u003e. \u003cem\u003eReproductive health \u003c/em\u003e2021, \u003cstrong\u003e18\u003c/strong\u003e:1-18.\u003c/li\u003e\n \u003cli\u003eSarmiento I, Paredes-Solís S, Loutfi D, Dion A, Cockcroft A, Andersson N: \u003cstrong\u003eFuzzy cognitive mapping and soft models of indigenous knowledge on maternal health in Guerrero, Mexico\u003c/strong\u003e. \u003cem\u003eBMC medical research methodology \u003c/em\u003e2020, \u003cstrong\u003e20\u003c/strong\u003e(1):125.\u003c/li\u003e\n \u003cli\u003eKambala C, Lohmann J, Mazalale J, Brenner S, Sarker M, Muula AS, De Allegri M: \u003cstrong\u003ePerceptions of quality across the maternal care continuum in the context of a health financing intervention: Evidence from a mixed methods study in rural Malawi\u003c/strong\u003e. \u003cem\u003eBMC health services research \u003c/em\u003e2017, \u003cstrong\u003e17\u003c/strong\u003e:1-19.\u003c/li\u003e\n \u003cli\u003eBonawitz R, McGlasson KL, Kaiser JL, Ngoma T, Fong RM, Biemba G, Bwalya M, Hamer DH, Scott NA: \u003cstrong\u003eQuality and utilization patterns of maternity waiting homes at referral facilities in rural Zambia: A mixed-methods multiple case analysis of intervention and standard of care sites\u003c/strong\u003e. \u003cem\u003ePLoS ONE \u003c/em\u003e2019, \u003cstrong\u003e14\u003c/strong\u003e(11):e0225523.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eParticipant characteristics.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n=32)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eAge, in years, Median [Min, Max]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e31.5 [Min= 18, Max= 43]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eNumber of children, Median [Min, Max]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e3 [Min= 0, Max= 8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eRelationship status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eMarried/common-law/In a relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e31 (96.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eSingle/Separated/Divorce/Widowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1 (03.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eGave birth in the last 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e15 (46.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003ePregnant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e17 (53.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eIf pregnant, how many months pregnant?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e0-3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e4-6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e8 (47.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e7-9 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e7 (41.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e \u003cstrong\u003eCategorization of factors influencing quality of maternal care among women of reproductive age.\u003c/strong\u003e Factors added after the prompt are highlighted in bold. Categories encompass both positive and negative factors. For example, category 1 on accessibility of infrastructure regroups factors such as \u0026lsquo;Accessibility of toilets\u0026rsquo; (positive) and \u0026lsquo;Inadequate delivery table\u0026rsquo; (negative). The direction of the causal relationships of some factors were switched to match the direction of the other factors in the category.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC1. Quality of maternal care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Quality of maternal care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC2. Accessibility of infrastructure and services for people with disabilities, reduced mobility, and other specific needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Accessibility of toilets\u003c/p\u003e\n \u003cp\u003e2. accessibility of health services\u003c/p\u003e\n \u003cp\u003e3. Availability of pharmacy within the healthcare center\u003c/p\u003e\n \u003cp\u003e4. Inadequate delivery table\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC3. Geographical accessibility of health services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Accessibility of healthcare centers (including distance and precariousness of roads)\u003c/p\u003e\n \u003cp\u003e2. Distance to healthcare center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC4. Medical procedures (maternal health and/or malaria)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Medical procedures (prescription)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2. Medical procedures (examination, tests, etc.)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3. Medical procedures (equipment, mosquito nets)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4. Medical procedures (treatment)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC5. Crowding and waiting times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Crowding and waiting times\u003c/p\u003e\n \u003cp\u003e2. Demand exceeds supply\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC6. Inappropriate behaviors and communication of healthcare workers (towards women)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Verbal abuse (yelling, speaking rudely, judgment, poor assistance, etc.)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2. Good healthcare worker-patient relationship\u003c/p\u003e\n \u003cp\u003e3. Good behavior of healthcare workers\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e4. Easy communication on the phone with the healthcare worker\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e5. Confidentiality during antenatal and childbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC7. Appropriate counseling and support in maternal health and family planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Healthcare worker advice to women during antenatal care visit\u003c/p\u003e\n \u003cp\u003e2. Advice from healthcare workers on nutrition\u003c/p\u003e\n \u003cp\u003e3. Advice from healthcare workers to women to take iron and malaria medications\u003c/p\u003e\n \u003cp\u003e4. Family planning advice from healthcare workers\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e5. Assistance with breastfeeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC8. Availability of human resources (healthcare workers and centers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Availability of healthcare workers during childbirth\u003c/p\u003e\n \u003cp\u003e2. Unavailability of depot pharmacist\u003c/p\u003e\n \u003cp\u003e3. Insufficient healthcare workers\u003c/p\u003e\n \u003cp\u003e4. Excess of healthcare centers\u003c/p\u003e\n \u003cp\u003e5. Presence of healthcare workers during transfer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC9. \u003cstrong\u003eWomen\u0026apos;s experiences of pregnancy and childbirth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Childbirth experience (i.e. previous experience of woman in childbirth and psychological preparation)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2. Pregnancy and/or childbirth history (medical history of woman)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC10. Management of medicine stocks (stockouts)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Medical procedures stock out (iron or malaria medication)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2. Irregularity in availability of malaria medication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3. Medicine stockouts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC11. Unavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care, childbirth, and postpartum care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Insufficient seating during antenatal care\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2. Availability of space for childbirth and antenatal care\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e3. Availability of products in the health depot\u003c/p\u003e\n \u003cp\u003e4. Insufficient postpartum rooms\u003c/p\u003e\n \u003cp\u003e5. Insufficient delivery tables\u003c/p\u003e\n \u003cp\u003e6. Insufficient beds in postpartum rooms\u003c/p\u003e\n \u003cp\u003e7.Quality of medical equipment\u003c/p\u003e\n \u003cp\u003e8. Availability of equipment for medical procedures (antenatal care, childbirth)\u003c/p\u003e\n \u003cp\u003e9. Lack of first-use equipment for the baby and mother at the healthcare center\u003c/p\u003e\n \u003cp\u003e10. Insufficient medical supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC12. Insufficiency/lack of healthcare infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Absence of equipment (or device) to heat water during childbirth\u003c/p\u003e\n \u003cp\u003e2. Absence/insufficiency of toilets\u003c/p\u003e\n \u003cp\u003e3. Availability of running water\u003c/p\u003e\n \u003cp\u003e4. Defective state of healthcare centers\u003c/p\u003e\n \u003cp\u003e5. Continuous electricity lighting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC13. Medical care for pregnant women and newborns before, during, and after childbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Care for the baby after childbirth\u003c/p\u003e\n \u003cp\u003e2. Care for the woman after childbirth\u003c/p\u003e\n \u003cp\u003e3. Early initiation of antenatal care visit\u003c/p\u003e\n \u003cp\u003e4. Regular antenatal care follow up visits\u003c/p\u003e\n \u003cp\u003e5. Follow up of women by healthcare workers during pregnancy and childbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC14. Lack of rigor and skills of healthcare workers (in care)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Unexplored diagnosis\u003c/p\u003e\n \u003cp\u003e2. Lack of caregiver knowledge\u003c/p\u003e\n \u003cp\u003e3. Insufficient experience of interns\u003c/p\u003e\n \u003cp\u003e4. Incompetence in medical procedure treatment\u003c/p\u003e\n \u003cp\u003e5. Poor service quality (delay before performing caesarean section)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e6. Dishonesty of healthcare workers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e7. Negligence of healthcare workers\u003c/p\u003e\n \u003cp\u003e8. Healthcare workers inquire about women\u0026apos;s health\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9. Women\u0026apos;s follow-up by interns not appreciated\u003c/p\u003e\n \u003cp\u003e10. Gathering of interns around the woman during childbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC15. Hygiene and health standards in an establishment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Presence of mosquitos in the rooms\u003c/p\u003e\n \u003cp\u003e2. Excessive presence of bats\u003c/p\u003e\n \u003cp\u003e3. Cleanliness of places (courtyard-delivery room, ANC, maternity ward)\u003c/p\u003e\n \u003cp\u003e4. Cleanliness of toilets\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC16. Financial barriers to needs in maternal healthcare under the free care policy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Purchase of delivery material (bleach and gloves) due to lack of resources\u003c/p\u003e\n \u003cp\u003e2. Medical procedures (iron-based medications, malaria medications) effectiveness of free care\u003c/p\u003e\n \u003cp\u003e3. Effectiveness of free healthcare policy\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e4. Strict referral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC17. Quality of reception at healthcare center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Reception\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC18. Quality of work life for healthcare workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Working atmosphere within the healthcare team\u003c/p\u003e\n \u003cp\u003e2. Healthcare staff fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC19. Responsiveness of emergency health services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Availability of emergency transportation\u003c/p\u003e\n \u003cp\u003e2. Emergency transfer by ambulance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC20. Reputation of the maternal health center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Maternity reputation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC21. Responsibility of women related to care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Women\u0026rsquo;s negative behavior at health center\u003c/p\u003e\n \u003cp\u003e2. Healthcare advice not being adhered by women\u003c/p\u003e\n \u003cp\u003e3. Women\u0026rsquo;s consistent intake of medications (iron and malaria)\u003c/p\u003e\n \u003cp\u003e4. Women\u0026apos;s personal hygiene\u003c/p\u003e\n \u003cp\u003e5. Women\u0026rsquo;s consistent use of mosquito nets by women\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003eC22. Support from healthcare workers for involvement of partners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 432px;\"\u003e\n \u003cp\u003e1. Healthcare provider advice to caregivers\u003c/p\u003e\n \u003cp\u003e2. Summoning and sensitizing spouses by caregivers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003ePattern Matching Table of Categories Influencing Women\u0026rsquo;s Quality of Maternal Care and Their Relative Weightings.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight before the prompt\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight after prompt\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifference in weight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eUnavailability or insufficiency of necessary medical equipment and materials to ensure quality care during antenatal care, childbirth, and postpartum care (C11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-1.0 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e-0.56 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eMedical care for pregnant women and newborns before, during, and after childbirth (C13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.93 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eHygiene and health standards in an establishment (C15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.81 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.42 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.39\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eAvailability of human resources (healthcare workers and centers) (C08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.58 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eInappropriate behaviors and communication of healthcare workers (towards women) (C06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.57 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e-0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.19\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eAppropriate counseling and support in maternal health and family planning (C07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.51 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eInsufficiency/lack of healthcare infrastructure (C12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e-0.43 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eMedical procedures (maternal health and/or malaria) (C04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eResponsibility of women related to care (C21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eQuality of reception at healthcare center (C17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.18\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eCrowding and waiting times (C05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eFinancial barriers to needs in maternal healthcare under the free care policy (C16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e-0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eLack of rigor and skills of healthcare workers (in care) (C14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e-0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eAccessibility of infrastructure and services for people with disabilities, reduced mobility, and other specific needs (C02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eSupport from healthcare workers for involvement of support (C22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eQuality of work life for healthcare workers (C18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eResponsiveness of emergency health services (C19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eManagement of medicine stocks (stockouts) (C10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eGeographical accessibility of health services (C03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eWomen\u0026apos;s experiences of pregnancy and childbirth (C09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e+0.18 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003eReputation of the maternal health center (C20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100px;\"\u003e\n \u003cp\u003eLegend: The weights are considering direct and indirect pathways. Categories are sorted by their weight on the quality of maternal care (before the prompt), in order of the greatest absolute weight on the outcome. In brackets are the rankings of the categories with the greatest absolute weights on the outcome: the top five weights before the prompt, after the prompt, and the five largest differences in absolute weights between before and after the prompt.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Quality of care, maternal care, qualitative research, participatory methods, Burkina Faso","lastPublishedDoi":"10.21203/rs.3.rs-7199612/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7199612/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAssessing the quality of maternal care as perceived by patients remains a challenge. Integrating community perspectives is an important but underused approach for identifying indicators to measure the quality of maternal healthcare services.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis qualitative study employed fuzzy cognitive mapping (FCM) to explore women\u0026rsquo;s perceptions of maternal care quality in Burkina Faso.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This study used a qualitative participatory method called FCM to describe and visualize women\u0026rsquo;s views on maternal care quality. Women identified and weighted factors influencing their experiences with reproductive care. A total of eight FCM sessions were conducted in rural and urban areas. Data was analyzed using thematic analysis to categorize influencing factors and determine their relative importance.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003e A total of 32 women (aged 15\u0026ndash;49 years) participated in eight mapping sessions, identifying 21 key categories influencing maternal care quality through 111 interconnections. Significant factors included inadequate medical equipment, availability of healthcare providers, hygiene standards, continuity of care, and provider-patient interactions. Additional insights highlighted the importance of personal experiences and psychological support in shaping perceptions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe maps offer a visual language to present and discuss women\u0026rsquo;s perspectives on maternal care quality, integrating their experiences to inform research and decision-making.\u003c/p\u003e","manuscriptTitle":"Exploring women’s views on factors influencing the quality of maternal care among women of reproductive age in Burkina Faso: a fuzzy cognitive mapping study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 01:11:35","doi":"10.21203/rs.3.rs-7199612/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-07T09:25:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T14:31:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251775324195350287327623661182847639694","date":"2025-10-28T18:36:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T14:35:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83670363694169751856136913046881265353","date":"2025-09-29T07:44:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163861501120531995308099802678888368409","date":"2025-09-29T06:14:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"114184459064814493230246656408794115398","date":"2025-09-27T12:29:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-21T22:29:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-05T08:08:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-01T19:19:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-01T19:16:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"297a5fca-d16f-4e56-9c52-5f3c33523e75","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-21T12:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-03 01:11:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7199612","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7199612","identity":"rs-7199612","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}