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 [
Patient satisfaction measures the ability of services to meet consumers’ expectations [
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, significant 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 [
Despite these improvements, however, significant deficits in the provision of quality maternity services continue to remain a considerable challenge. The current proportion of births with skilled attendance in Eritrea is 34.1%, a figure which has not increased much since 1995 (21%) [
In this context, studies that explore women’s satisfaction with intrapartum care are timely and relevant. Therefore, 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. Specifically, 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.
A descriptive cross-sectional design was used for this study.
This study was conducted in Orotta Maternity National Referral Hospital (OMNRH), Edaga Hamus Hospital (EHH), and Villagio Community Hospital (VCH). These hospitals were selected because they generally have the patient’s profile that is characteristic of most public hospitals in Eritrea. OMNRH is the busiest maternity center with high turnover of mothers giving birth. This 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.
Using a temporal (period) sampling technique [
The questionnaire was developed after an extensive review of the literature. The tool was modified and finalized 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.
The final questionnaire had two sections. The first part included questions about the respondent’s age, religion, level of education, parity, mode of delivery, and marital status. The second section was a scale measuring women’s satisfaction with the four dimensions of intrapartum care. The scale was generated by summing up the mean and standard deviation scores of the four subscales.
The subscale items were formulated from extensive literature review and expert input. The subscale scores were constructed from responses to individual questions. They were summarized using the average (mean) score plus one standard deviation (SD). Scores above the mean and one standard deviation were considered satisfied [
Participants were asked to rate their satisfaction with intrapartum care on a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5). The 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.
After brief explanation of the study objectives, the respondents were assured about the confidentiality and anonymity of their responses. Written consent was then obtained to participate in the study. Four final year nursing students approached the women and made interviews in the wards behind closed curtains for privacy. After completing the interviews, the filled 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 were analyzed using the Statistical Package for the Social Sciences (SPSS) version 21. The 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 significant variables were then dichotomized. Responses of “very satisfied” and “satisfied” were classified as “satisfied” and responses of “very dissatisfied,” “dissatisfied,” and “neutral” as “unsatisfied.” Neutral responses were categorized as dissatisfied because the interview was done in the hospitals, and interviewer or social desirability bias might have had an effect in disclosing their dissatisfaction [
Totally, 771 women agreed to participate in the study. The mean age of the participants was 28.84 ± 5.877. Almost half (54.9%) of the respondents were between 25 and 34 years old. More than half (69.6%) were multiparous, 56.2% had spontaneous vaginal delivery, and 86.9% were married. Participant characteristics are shown in Table
Sociodemographic characteristics of study participants (
Variable | Total |
---|---|
|
|
15–24 | 211 (27.3) |
25–34 | 425 (54.9) |
35–44 | 131 (16.9) |
45–49 | 4 (0.9) |
|
|
Primipara | 234 (30.4) |
Multipara | 537 (69.6) |
|
|
No education | 24 (3.1) |
Primary | 95 (12.3) |
Junior | 249 (32.3) |
High school | 344 (44.6) |
College level | 59 (7.7) |
|
|
Spontaneous vaginal delivery | 433 (56.2) |
Assisted | 9 (1.2) |
Episiotomy | 329 (42.7) |
|
|
Christian | 632 (82) |
Muslim | 139 (18) |
|
|
Single | 96 (12.5) |
Married | 667 (86.5) |
Divorced | 4 (0.5) |
Living together | 3 (0.4) |
Widowed | 1 (0.1) |
|
|
The total mean satisfaction score was 72.36 (SD ± 10.56; range 43–107). Scores of ≥82 were considered positive towards increased satisfaction with intrapartum care. Only 20.8% (
The mean subscale score for the provision of physical facilities was 26.78 (SD ± 4.371), range 8–35. Scores of ≥31 were considered positive. Only 13.1% of the participants (
The mean subscale score for provision of consumables was 5.65 (SD ± 2.588), range 5–20. Scores of ≥8 were considered positive. Only 16.6% of the participants (
The mean subscale score for pain management methods was 7.25 (SD ± 2.564). Scores of ≥10 were considered positive (range 3–15). Only 18.4% of the participants (
The mean subscale score for communication patterns of health care providers was 30.14 (SD ± 5.573), range 12–40. Scores of ≥36 were considered positive. Only 22.3% of the participants (
Satisfaction with intrapartum care scale, subscale items with satisfaction mean and standard deviation scores (
Characteristic | Mean |
SD |
---|---|---|
|
|
|
|
|
|
(1) Provided with clean and nicely decorated room | 4.81 | 0.579 |
(2) Provided with clean bed and beddings | 4.62 | 0.796 |
(3) Toilet ease of access and cleanliness | 3.17 | 1.527 |
(4) Given a locker to keep personal items | 3.74 | 0.860 |
(5) Chairs available for relatives | 2.21 | 1.514 |
(6) Control of the delivery room | 3.78 | 1.506 |
|
|
|
(1) Provision of hot water for showering | 1.06 | 0.463 |
(2) Provision of sanitary pads after delivery | 1.15 | 0.731 |
(3) Provision of adequate food | 1.81 | 1.585 |
(4) Provision of hot drinks | 1.61 | 1.420 |
|
|
|
(1) Parents/sibling allowed to stay during labour | 1.32 | 1.049 |
(2) Taught how to breath in deeply during severe pain and to rest when pain wore off | 4.12 | 1.396 |
(3) Received adequate back massage | 1.81 | 1.491 |
|
|
|
(1) Staff greeted with a smile | 4.66 | 0.881 |
(2) Given adequate privacy during examination | 3.32 | 1.569 |
(3) Staff requested for permission before any procedure | 2.25 | 1.545 |
(4) Staff showed a genuine interest in one’s well-being | 4.42 | 1.002 |
(5) Staff used understandable language | 3.79 | 1.550 |
(6) Staff showed how to summon for help | 2.96 | 1.691 |
(7) Baby shown immediately after birth | 4.19 | 1.522 |
There 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. The final multivariate logistic regression model showed eleven influential predictors of low satisfaction with intrapartum care. The results are as shown in Table
Bivariate and multivariate logistic regression analysis to identify predictors of low satisfaction with intrapartum care (
Odds ratio with 95% confidence interval | ||
---|---|---|
Crude OR | Adjusted OR | |
Provision of clean bed and beddings | 30.47 (2.91–3.51) |
18.87 (2.33–15.75) |
Toilet ease of access and cleanliness | 6.64 (3.38–13.03) |
6.09 (3.25–11.42) |
Given a locker to keep personal items | 2.62 (0.70–9.74) | NA |
Control of the delivery room | 5.58 (2.00–15.54) |
6.8 (2.65–17.75) |
Parents/sibling allowed to stay during labour | 7.78 (2.24–26.93) |
3.52 (1.299–9.56) |
Chairs available for your relatives | 6.57 (3.30–13.08) |
5.96 (3.14–11.30) |
Taught breathing techniques | 1.40 (0.48–4.11) | NA |
Received adequate back massage | 9.17 (4.22–19.91) |
6.43 (3.23–12.81) |
Given adequate privacy during examinations | 11.52 (5.05–26.26) |
10.22 (4.86–21.48) |
Staff gave warm welcome | 13.39 (2.24–19.91) |
NA |
Permission requested before any procedure | 3.04 (1.53–6.06) |
2.39 (1.28–4.46) |
Staff showed a genuine interest | 11.52 (5.05–26.26) |
NA |
Staff used understandable language | 8.03 (3.11–20.72) |
8.72 (3.57–21.27) |
Staff showed women how to summon help | 7.49 (3.79–14.78) |
8.16 (4.30–15.48) |
Baby shown immediately after birth | 8.06 (2.60–24.99) |
8.14 (2.87–23.07) |
Bivariate model:
From the first 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 dissatisfied with intrapartum care. Similarly, women who reported poor toilet cleanliness and ease of access were more likely (AOR = 6.09) to be dissatisfied 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 dissatisfied with intrapartum care. Moreover, unavailability of comfortable chairs for relatives was a positive predictor (AOR = 5.96) of low satisfaction with intrapartum care (Table
From the second indicator (provision of consumables), all of the predictor variables did not have statistically significant association with the outcome variable and were excluded from the regression model. However, some significant findings 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 off were more likely to be dissatisfied 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 dissatisfied with intrapartum care.
Women who did not receive adequate back massage were six times more likely (AOR = 6.43) to be dissatisfied than the ones who felt they did receive adequate back massage (Table
From the fourth indicator (communication patterns of health care providers), women who reported that the staff did not ask for permission before any procedure were more likely (AOR = 2.39) to be dissatisfied 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 dissatisfied with intrapartum care. Women reporting that the staff did not use a language that they could easily understand were at higher odds (AOR = 8.72) to be dissatisfied to those who said they did. Women who reported that the staff did not greet them with a smile and give a warm welcome, staff not showing a genuine interest in their well-being, staff 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
Overall, only 20.8% (
Worldwide, available findings 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 [
Studies indicate that satisfaction with the physical environment is a significant predictor of women’s overall satisfaction and positive experience of labour and delivery services [
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.
There has been growing evidence that events such as operative births, long and painful labour, inadequate pain relief, and increased obstetric interventions can adversely affect satisfaction with intrapartum care [
Studies have reported that support from the health care providers during labour tends to improve childbirth outcomes and women’s satisfaction [
Interpersonal processes including perceived empathy, perceived technical competency, nonverbal communication, and patient enablement are believed to significantly influence patient satisfaction [
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 [
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 [
Previous studies have suggested that many of the standard elements of quality of care have less effect on return behavior, whereas time and attention paid to health care users were the strongest predictors of returning to a health institution [
The proportion of mothers who were satisfied 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. This information will help in planning and implementing appropriate strategies to assist women have a positive birth experience.
Ethical approval for this study was granted by Asmara College of Health Sciences research ethical approval committee.
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.
The authors declare that they do not have any conflicts of interest.
The authors are grateful to all the women who participated in this study and shared their experiences, thoughts, and feelings in the interviews.