Predictors of Women's Satisfaction with Hospital-Based Intrapartum Care in Asmara Public Hospitals, Eritrea

Background Exploring patient satisfaction contributes to provide quality maternity care, but there is paucity of epidemiologic data in Eritrea. Objectives To determine the predictors of women's satisfaction with intrapartum care in Asmara public maternity hospitals in Eritrea. Methods A cross-sectional study among 771 mothers who gave birth in three public Hospitals. Chi-square tests were done to analyze the difference in proportion and logistic regression to assess the predictors of satisfaction with intrapartum care. Results Overall, only 20.8% of the participants were satisfied with intrapartum service. The key predictors of satisfaction with intrapartum care were provision of clean bed and beddings (AOR = 18.87, 2.33–15.75), privacy during examinations (AOR = 10.22, 4.86–21.48), using understandable language (AOR = 8.72, 3.57–21.27), showing how to summon for help (AOR = 8.16, 4.30–15.48), showing baby immediately after birth (AOR = 8.14, 2.87–23.07), control of the delivery room (AOR = 6.86, 2.65–17.75), receiving back massage (AOR = 6.43, 3.23–12.81), toilet access and cleanliness (AOR = 6.09, 3.25–11.42), availability of chairs for relatives (AOR = 5.96, 3.14–11.30), allowing parents to stay during labour (AOR = 3.52, 1.299–9.56), and request for permission before any procedure (AOR = 2.39, 1.28–4.46). Conclusion To increase satisfaction with intrapartum care, maternity service providers need to address the general maternity ward cleanliness, improve the quality of physical facilities, and sensitize health providers for better communication with clients. Policy makers need to adopt strategies that ensure more women involvement in decision making and consideration of privacy and reassurance needs during the whole delivery process.


Background
With the increasing need of client-centered care, there has been a growing consensus that patient service quality perceptions are critical for maintaining and monitoring the quality of health care [1]. Women's satisfaction with maternity service is often associated with the quality of intrapartum care, as the nature of the support given during labour and childbirth is re ective of a positive birth experience [2].
Patient satisfaction measures the ability of services to meet consumers' expectations [3] and is an important determinant of the choice of health facility and its future utilization [4][5][6].
Satisfaction is a complex and multidimensional concept comprising structure, process, and outcome of care [7]. Assessing maternal satisfaction helps in the provision of a more responsive and culturally acceptable care which can lead to an increase in service utilization and better outcomes. Patient satisfaction also ensures that the views of the users are taken into account and helps to develop culturally appropriate services [8]. Furthermore, satis ed clients are more likely to return in the future [8], adhere to health provider's recommendations [9], and recommend the institution to their friends and relatives, e ecting an increased demand for the service [10].
In Eritrea, three-fourths of all health facilities provide maternal and child health services including antenatal care, delivery services, postnatal care, immunization services, growth monitoring, health education, and family planning. Consequently, signi cant achievements have been recorded in maternal and child health indices over the past two decades. Infant mortality rates per 1,000 live births have decreased from 92 in 1990 to 58 in 2000 and to 37 in 2012. Eritrea has already exceeded its MDG-5 target of maternal mortality ratio of 425 per 100,000 live births [11]. e maternal mortality ratio declined from 1,700 per 100,000 live births in 1990 to 670 in 2000 and 380 in 2013. Furthermore, access to emergency obstetric care services increased by more than 300 percent between 1995 (21%) and 2013 (88%) [12].
Despite these improvements, however, signi cant decits in the provision of quality maternity services continue to remain a considerable challenge. e current proportion of births with skilled attendance in Eritrea is 34.1%, a gure which has not increased much since 1995 (21%) [13]. e majority of maternity care services are provided by nurses, midwives, and health assistants. Inadequate sta ng and physical infrastructure, increasing maternal health care utilization, low use of family planning, and overloaded health care providers with limited training have also resulted in compromised quality of maternal health services [14,15].
In this context, studies that explore women's satisfaction with intrapartum care are timely and relevant. erefore, the objective of this study was to determine the factors associated with women's satisfaction with labour and childbirth services in public hospitals in Eritrea. Speci cally, this study sought to examine satisfaction in terms of sociodemographic characteristics and with four dimensions of care: provision of physical facilities, provision of consumables, pain management methods, and communication patterns of healthcare providers.

Study Design.
A descriptive cross-sectional design was used for this study.

Study Area.
is study was conducted in Orotta Maternity National Referral Hospital (OMNRH), Edaga Hamus Hospital (EHH), and Villagio Community Hospital (VCH). ese hospitals were selected because they generally have the patient's pro le that is characteristic of most public hospitals in Eritrea. OMNRH is the busiest maternity center with high turnover of mothers giving birth. is hospital has about 8000 normal deliveries annually, representing 34% of the total national normal deliveries. OMNRH is a teaching hospital and accommodates medical students, nurses, nurse midwives, and others. Edaga Hamus Hospital, which is located in North East of Asmara, was renovated in April 2014 and had a total of 467 deliveries in that year. In 2015, delivery services were provided for about 1060 mothers. Villagio Community Hospital is the third public hospital that gives delivery service. It is located in North West of Asmara and started providing delivery service in June 2014. Annual HMIS report indicates that there were about 206 deliveries in 2015.

Study Participants and Sampling
Technique. Using a temporal (period) sampling technique [16], 771 women (99.6% response rate) who gave birth at OMNRH, EHH, and VCH hospitals from March to May 2016 participated in the study. All women who delivered by spontaneous vaginal delivery successfully with or without episiotomy and women who were on their immediate postpartum care during the study period were enrolled in the study. Women who were seriously ill, not consented to participate, and with incomplete data and women who experienced birth complications requiring admission to a special care were excluded.

Measures.
e questionnaire was developed after an extensive review of the literature. e tool was modi ed and nalized according to the suggestions and recommendations of local experts (one gynecology and obstetrics specialist and lecturer at the Asmara College of Health Science, School of Nursing, two midwifery practitioners at the National Maternal and child health referral hospital, and a senior statistician at the Ministry of Health) and the research team. Content validity was secured through in-depth interviews and critical appraisal of the data collection instrument. e nal questionnaire had two sections. e rst part included questions about the respondent's age, religion, level of education, parity, mode of delivery, and marital status.
e second section was a scale measuring women's satisfaction with the four dimensions of intrapartum care. e scale was generated by summing up the mean and standard deviation scores of the four subscales. e subscale items were formulated from extensive literature review and expert input. e subscale scores were constructed from responses to individual questions. ey were summarized using the average (mean) score plus one standard deviation (SD). Scores above the mean and one standard deviation were considered satis ed [17,18]. Subscale one contained items related to the provision of physical facilities (6 items). e second subscale included questions regarding the provision of consumables (4 items). e third subscale included questions about women's satisfaction with pain management methods (3 items). e last subscale contained questions about the communication patterns of health care providers (7 items).
Participants were asked to rate their satisfaction with intrapartum care on a ve-point Likert scale ranging from strongly disagree (1) to strongly agree (5). e satisfaction scale had a reliability score of 0.702. To address for face validity, the questionnaire was piloted with a group of 20 childbearing women in Villagio Community Hospital.

Data Collection Method.
After brief explanation of the study objectives, the respondents were assured about the con dentiality and anonymity of their responses. Written consent was then obtained to participate in the study. Four nal year nursing students approached the women and made interviews in the wards behind closed curtains for privacy. After completing the interviews, the lled questionnaires were checked for completeness, consistency, and the presence of outliers. A database was developed in CSPro 6.2 and pretested before the start of data entry. Data entry was supervised by the researchers, and any suspect data were cross-checked against hard copies of the questionnaires.

Data Analysis Method.
Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 21. e properties of the instrument were assessed using Cronbach's alpha for reliability (0.702). Relationships between dependent variable (satisfaction with intrapartum care) and independent variables (demographic, obstetric, and intrapartum care indicator variables) were examined using chi-square tests. Statistically signi cant variables were then dichotomized.
Responses of "very satis ed" and "satis ed" were classi ed as "satis ed" and responses of "very dissatis ed," "dissatis ed," and "neutral" as "unsatis ed." Neutral responses were categorized as dissatis ed because the interview was done in the hospitals, and interviewer or social desirability bias might have had an e ect in disclosing their dissatisfaction [17,19]. Finally, to identify predictors of satisfaction with intrapartum care, binary and multiple logistic regression analyses were done. Statistical signi cance was set at P < 0.05.

Predictors of Satisfaction with Intrapartum Care.
ere was no association between women's sociodemographic data (age, education, religion, parity, and mode of delivery) and satisfaction with intrapartum care. Variables associated with the outcome variable were entered in a binary logistic regression analysis. e nal multivariate logistic regression model showed eleven in uential predictors of low satisfaction with intrapartum care. e results are as shown in Table 3.
From the rst indicator (provision of physical facilities), women who reported that they were not given clean bed and beddings were more likely (AOR � 18.87) to be dissatis ed with intrapartum care. Similarly, women who reported poor toilet cleanliness and ease of access were more likely (AOR � 6.09) to be dissatis ed with intrapartum care. On the question of women's perceived control of the delivery room, respondents who reported that they had no control were more likely to be dissatis ed with intrapartum care. Moreover, unavailability of comfortable chairs for relatives was a positive predictor (AOR � 5.96) of low satisfaction with intrapartum care (Table 3). From the second indicator (provision of consumables), all of the predictor variables did not have statistically signi cant association with the outcome variable and were excluded from the regression model. However, some signi cant ndings did emerge. Majority (98.3%) of the respondents reported unavailability of water for showering, 95.8% reported sanitary pads were not provided after delivery, and more than two-thirds reported that adequate food and hot drinks were not provided.
In the third indicator (pain management methods), women who reported that they were not taught how to breath in deeply during severe pain and to rest when pain wore o were more likely to be dissatis ed with the care they received. Moreover, women who perceived that they were not given adequate privacy during examinations were ten times more likely (AOR � 10.22) to be dissatis ed with intrapartum care.
Women who did not receive adequate back massage were six times more likely (AOR � 6.43) to be dissatis ed than the ones who felt they did receive adequate back massage (Table 3).
From the fourth indicator (communication patterns of health care providers), women who reported that the sta did not ask for permission before any procedure were more likely (AOR � 2.39) to be dissatis ed with intrapartum care. Moreover, women who perceived that they were not given adequate privacy during examinations were ten times more likely (AOR � 10.22) to be dissatis ed with intrapartum care. Women reporting that the sta did not use a language that they could easily understand were at higher odds (AOR � 8.72) to be dissatis ed to those who said they did. Women who reported  that the sta did not greet them with a smile and give a warm welcome, sta not showing a genuine interest in their wellbeing, sta not showing how to summon for help from them, not allowing relatives to stay during labour, and not showing baby immediately after birth were also important positive predictors of low satisfaction with intrapartum scale ( Table 3).
As an overall evaluation of future maternity care utilization, participants were asked if they would return to the hospital next time, and 83.4% responded favorably. Moreover, 86.1% of the women would recommend it for friends or relatives.

Discussion
Overall, only 20.8% (n � 161) of the participants were satis ed with intrapartum care. is rate was very low compared to study reports from Sri Lanka (48%) [20], Kenya (56%) [21], Côte d'Ivoire (92.5%) [22], or Ethiopia (81.7%) [23]. is variations may be due to a real di erence in the quality of services provided, expectation of mothers, type of health facilities, or a combination of them [1,9]. Worldwide, available ndings regarding the association between demographic variables and satisfaction with intrapartum care are mixed, with some studies reporting that age, parity, and marital status were associated with satisfaction with intrapartum care [20,24,25]. Consistent with previous studies conducted in Kenya [21] and Jordan [17], this study found no association between women's sociodemographic data and satisfaction with intrapartum care.
Studies indicate that satisfaction with the physical environment is a signi cant predictor of women's overall satisfaction and positive experience of labour and delivery services [26,27]. Similar to the ndings of Lumadi and Buch [28], this study found higher rate of satisfaction with the cleanliness of the delivery environment (cleanliness of bed and beddings). is could be due to the fact that the cleaners are strictly supervised by the nurses in charge of the wards. On the other hand, more than half of the respondents were dissatis ed with toilet cleanliness and accessibility. is was similar with study ndings from South Africa [29] and Kenya [30] but higher with one Ethiopian study [23]. In our setting, the reason for this could be due to the lack of adequate and continuous water supply, especially in Orotta and Edaga Hamus Hospitals. Toilet cleanliness is not well checked regularly by a responsible person in charge. is was exacerbated as the cleaners do not work on Sundays. Moreover, the high labour and delivery turnover are in lower proportions with the number of cleaners and hence cannot cope with the frequency of cleaning the available toilets.
Although variables related to the provision of consumables were not statistically associated with overall satisfaction, there was high dissatisfaction (83.4%) in all study cites. Regarding the provision of food and hot drinks, there was no regular provision during the three meal times. Women who deliver on weekends and women who came from rural areas highly commented on the provision of food and hot drinks. Similarly, sanitary pads were not adequately provided. Instead, women bring their own sanitary items at their own expense. Water scarcity is also a big challenge, especially in Orotta and Edaga Hamus Hospitals. ere has been growing evidence that events such as operative births, long and painful labour, inadequate pain relief, and increased obstetric interventions can adversely a ect satisfaction with intrapartum care [24,25,31,32,34]. Our ndings showed that only 18.4% of the participants were satis ed with pain management methods.
is result coincides with previous studies [17,28], where painful labour and being unhappy with the pain management methods were highly associated with low satisfaction rates.
Studies have reported that support from the health care providers during labour tends to improve childbirth outcomes and women's satisfaction [30]. Perceptions of satisfaction can also be a ected through involvement in decisions about labour procedures [16,18,25]. is study found that women who were not given adequate privacy during examination were more likely to be dissatis ed with the services. Respondents who were not taught how to breathe in deeply during severe pain and to rest when pain wore o were more likely to be dissatis ed as were women who did not receive any back massage application. Although there is inadequate sta in the hospitals, breathing skills were not communicated even with the present number, suggesting it could well be the same even when sta number increases.
Interpersonal processes including perceived empathy, perceived technical competency, nonverbal communication, and patient enablement are believed to signi cantly in uence patient satisfaction [25,26,33]. Most of the respondents were satis ed with the general approach of the sta during arrival which is consistent with one Eritrean study [35]. Almost half of the participants were not happy with the level of privacy of the wards. is nding was consistent with a study done in Kenya [30] but inconsistent with the other study [23]. Higher dissatisfaction in Orotta Hospital could be attributed to being a teaching hospital where a large number of students make it di cult to maintain privacy.
Satisfaction has been associated with interpersonal factors such as providing opportunities to have an active say during labour and birth, deciding when certain actions will be done, and being given information as to why such decisions are necessary [19,25,27,31,34]. In this study, high rate of dissatisfaction was disclosed on whether permission was requested before any procedure and the degree of involvement in decision making. is was alarming in view that, a recent systematic review has shown that participation in decision making and having an active say in decisions about one's care was an important dimension of satisfaction with health facility delivery [24]. One possible reason could be the health providers were not giving much attention to what women want or expect and give more priority in conducting the procedures before asking permission in advance. is issue is an emerging concern in Eritrea partly because for the past two decades, there has been a pressing need to make health services more accessible and the concept of clientcentered service provision has been largely ignored until recently [11]. With increasing service utilization and awareness of the general public, the importance of optimal interpersonal communication and involvement of mothers in every decision making is likely to be a crucial dimension to maintain or increase the quality of health services.

Obstetrics and Gynecology International
Studies have shown that when mothers are assured that they can inquire anything about the whole delivery process and can summon health workers at any time, the overall satisfaction increases substantially [19,25]. In the present study, almost half of the respondents were dissatis ed on sta showing how to summon them whenever they need. e weight of this issue was signi cant as women reporting that the health workers were not showing how to summon for help were eight times more likely to be dissatis ed. is was consistent with the ndings of Nyaberi [30], where 56% of the respondents were dissatis ed.
Previous studies have suggested that many of the standard elements of quality of care have less e ect on return behavior, whereas time and attention paid to health care users were the strongest predictors of returning to a health institution [19]. Our nding shows that more than two-thirds of all women would recommend the delivery care to their friends and family. Given that there was a relatively higher score on interpersonal communication of health care providers, this study suggests that although the proportion of mothers who were satis ed with delivery care was low, the respondents value the importance of health workers general behavior and interest in one's well-being. is attitude seems to override their ideal personal expectations and subsequent satisfaction with care. e ndings also imply that there is plenty of room for substantial improvements for a more comprehensive, culturally acceptable, and quality intrapartum care.

Conclusion
e proportion of mothers who were satis ed with delivery care was low. Satisfaction and thus continued use can be achieved by addressing the general maternity ward cleanliness, improving the quality of physical facilities, and sensitizing health providers for better interpersonal communication with clients.
Health care professionals should also adopt strategies that ensure more women involvement in decision making, increasing individualized care, and support in labour and reassurance needs to improve satisfaction during the whole delivery process. Policy makers need to review the procedures and policies regarding childbirth practices in their hospitals. is information will help in planning and implementing appropriate strategies to assist women have a positive birth experience.

Ethical Approval
Ethical approval for this study was granted by Asmara College of Health Sciences research ethical approval committee.

Consent
After brief explanation of the purpose of the study, written consent was obtained from the study participants and those who volunteered participated in the study.

Conflicts of Interest
e authors declare that they do not have any con icts of interest.