Assessment of Maternal Satisfaction and Associated Factors among Parturients Who Underwent Cesarean Delivery under Spinal Anesthesia at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2019

Background Spinal anesthesia is the most common anesthetic technique for cesarean delivery. Patient satisfaction is a subjective and complicated concept, involving physical, emotional, psychological, social, and cultural factors. Regular evaluation of maternal satisfaction related to anesthesia service is an important parameter to the required changes and expansion of high-quality care services. We aimed to assess maternal satisfaction and associated factors among parturients who underwent cesarean delivery under spinal anesthesia. Methods Institutional-based cross-sectional study was conducted from February to May 2019. A total of 383 parturients were enrolled to assess maternal satisfaction using a 5-point Likert scale. Both bivariable and multivariable logistic regression analyses were done. Variables of p value ≤0.2 in the bivariable analysis were a candidate for multivariable logistic regression. A p value <0.05 was considered as significantly associated with maternal satisfaction at 95% CI. Results This study revealed that 315 (82.3%) of the parturients were satisfied. Single spinal prick attempts (AOR = 2.08, 95% CI = 1.05–4.11), successful spinal block (AOR = 7.17, 95% CI = 3.33–15.43), less incidence of postdural puncture headache (AOR = 2.36, 95% CI = 1.33–4.20), and prophylactic antiemetic use (AOR = 0.35, 95% CI = 0.19–0.66) were positively associated with maternal satisfaction. Conclusions The overall maternal satisfaction receiving spinal anesthesia was considerably low. Single spinal prink attempts, successful spinal block, and less incidence of postural puncture headache can increase maternal satisfaction. Therefore, effective perioperative management, skillful techniques, and using the small-gauge Quincke spinal needle (25–27 gauge) may increase the maternal satisfaction and quality of spinal anesthesia management.


Background
Spinal anesthesia is a safe anesthetic technique for cesarean delivery which gained worldwide acceptance since the introduction to clinical practice [1,2]. It has good quality of analgesia and avoids general anesthesia-related maternal morbidity and mortality, decreased risk of gastric aspiration, avoids exposure of anesthetic depressant drugs to the neonate, less incidence of deep venous thrombosis, and decreases blood loss during surgery [2][3][4]. In addition, it has favorable effects on bonding the mother to the newborn [5].
Rate of cesarean delivery has been raising all over the world with a rate of 13-39% [6]. e overall institutional rate of the national population-based cesarean delivery in Ethiopia was 15-18%, which reaches 46% in the private sectors, among which maternal indications accounted for 66%, and others were fetal indications [7].
During preoperative anesthetic evaluation, it is important to explain the procedure, side effects, and possible complications of SA to parturients and obtain informed consent, and this process may improve retention of information and increase maternal satisfaction [8][9][10]. In addition, emotional support before spinal anesthesia for cesarean delivery helps to decrease preoperative anxiety and increase maternal satisfaction [11,12].
A study done in South Africa concludes that integrating preanesthesia explanations, counseling during labor, and the use of adequate medications to reduce discomfort, pain, and shivering may increase maternal satisfaction with spinal anesthesia for CD [13].
Studies done in Australia and Kenya on obstetrics surgeries revealed that parturients being illiterate, multiparous, and absence of comorbidities significantly increase maternal satisfaction [14,15]. In addition, a similar study conducted in Canada showed that being young age, good coordination, and absence of complications were the most influential factors in determining parturient satisfaction [16].
Although spinal anesthesia provides excellent anesthesia and analgesia that improve patients' satisfaction, fewer patients (18-20%) still experience some degree of pain and discomfort during the procedure [10], with possible cause of differences in patients' perception of pain, previous experience, race, ethnicity, and experience of the anesthetist [19].
Nowadays, determining the level of client's satisfaction and identifying factors that can affect the level of satisfaction on the health system are the part and parcel of every institution. In University of Gondar Comprehensive Specialized Hospital, a large number of cesarean deliveries are performed every year based on the maternal and fetal indication; however, there was no study related to the level of maternal satisfaction regarding to anesthesia service. erefore, this institutional-based cross-sectional study was designed to assess the level of maternal satisfaction and identify factors that can affect the maternal satisfaction after receiving spinal anesthesia for cesarean delivery.

Study Participants and Data Collection Procedure.
After obtaining written informed consent, all parturients who underwent CD under spinal anesthesia during the study period were enrolled in the study. Parturients who had communication problems due to different reasons including neurologic, psychiatric ill parturients, multiple pregnancies, parturients with functional incapacitated systemic illness, headache prior to cesarean delivery, or conversion from spinal to general anesthesia during surgery were excluded from the study.
Rapid preoperative assessment and explanation regarding the techniques of anesthesia, possible side effects, and its management were provided by the assigned anesthetist to the parturient in emergency cesarean delivery. However, in elective cesarean delivery, detailed preoperative assessment and explanations about the techniques of anesthesia, possible side effects, and its management were provided. Besides, question and answer regarding all aspects of anesthesia-related service from the patient was also entertained since the anesthetist and the parturients had adequate time to address and cover all concerns.
In emergency cesarean delivery, intravenous catheter was inserted before arrival at the operating theater, and 10 ml/kg of crystalloids was preloaded. Patients were then placed in the sitting position at the operating table, and a standard integrated monitor was attached. Spinal anesthesia was performed by using a 21-25 G Quincke needle via the L3-4 or L4-5 interspace following 1% lidocaine infiltration. Anesthesia was provided with 10-12.5 mg isobaric bupivacaine of 0.5% with ±10 μg intrathecal fentanyl. Intraoperative management, such as management of nausea and vomiting, heat loss, fluid status, and blood pressure, was at the discretion of each anesthetist.
Data were collected by two junior anesthetists who had not been responsible to manage parturients during the study period. Data were collected through chart review, direct observation, and pretested semistructure questionnaires. Data were collected at two phases: during intraoperative period and 24 hours after delivery. e semistructured questionnaire was developed based on different studies. e questionnaire included two sections: the first section focused on sociodemographic variables, maternal and newborn-related factors, and intraoperative anesthesia-related factors, and the second section contained two parts; postoperative anesthesia-related factors, patient experience, and items of patients' satisfaction were assessed by using a 5-point Likert scale.
e five-point Likert scale was adapted from the Leiden perioperative care patient satisfaction questionnaire (LPPSq) and dichotomized as satisfied and dissatisfied based on the demarcation threshold formula. is scale was applied for sub and overall maternal satisfaction, so based on the formula, patients who scored less than 54 points out of 90 were considered as not satisfied whereas 54 and above were considered as satisfied. Leiden perioperative care patient satisfaction questionnaire (LPPSq) was a valid and reliable assessment tool to assess perioperative patient satisfaction [16].

Independent Variables.
Maternal and newborn-related factors such as ASA status, history of comorbidity, anesthesia history, parity, pregnancy, indication, urgency of surgery, sex of the newborn, weight of the newborn, APGAR score, status of the newborn, and gestational age were considered as the independent variables. Intraoperative anesthesia-related factors included spinal prick attempt, block height ≤T4, needle prick pain, paraesthesia, surgical pain, surgical duration, difficult to breathe, hypotension, light headedness, bradycardia, intraoperative nausea/vomiting, shivering, failed block, antiemetics, and sedatives or analgesics. Postoperative anesthesia-related factors consisting of PDPH, shivering, PONV, lower back pain, pain with 2 hours immediately after operation were independent variables of this study.

Operational Definitions
Maternal satisfaction: parturients were considered to be satisfied who scored greater than or equal to the cutpoint based on the demarcation threshold formula [20][21][22]: demarcation threshold formula � (total highest score − total lowest score) 2 +(total lowest score). (1) A failed block: the need to repeat spinal anesthesia or intravenous analgesic drug was required to proceed with the surgical procedure. Needle prick pain: it is defined as sudden and sharp pain accompanying needle puncture. Paraesthesia is defined as uncomfortable pain accompanying needle. Hypotension: a decrease in mean arterial pressure 20% from baseline, and bradycardia is defined as a decrease in heart rate 20% from baseline. Postdural puncture headache (PDPH): frontal and/or occipital headache that appears after lumbar puncture, which worsens within 15 minutes of assuming the upright position and improves within 30 minutes of resuming the recumbent position.

Sample Size, Sampling Technique, and Data
Analysis. e sample size was determined using the single population proportion formula: where n � the desired sample size, Z � 1.96 (corresponds to the 95% confidence level), p � population proportion (50%, 0.5), and q which is 1 − p, 1-0.5 � 0.5. ε � degree of accuracy (marginal error is 5% (0.05)); then, the sample size is Data were checked for completeness, inconsistencies, and then coded and entered using EPI data version 4.4. en, the data were cleaned and analyzed using SPSS version 23. Descriptive statistics were computed to determine frequencies and summary statistics (mean, standard deviation, median, IQR, and percentage). Data were presented using tables and graphs. All variables with p ≤ 0.2 in the bivariable logistic regression analysis were included in the final model of multivariable logistic regression analysis in order to control all possible confounders. Multicollinearity was checked to see the linear correlation among the independent variables by using the standard error. Variables with a standard error >0.2 were dropped from the multivariable logistic regression analysis. Model fitness was checked with the Hosmer-Lemeshow test. Adjusted odds ratio with 95% CI was estimated to identify the factors associated with adherence status using multivariable logistic regression analysis. Level of statistical significance was declared at p value <0.05.

Sociodemographic Characteristics.
A total of 383 parturients were enrolled in this study. e mean age and standard deviation of parturients was 27.7 ± 4.9 years. e median and interquartile range of BMI of parturients was 25 (23-27 kg/m 2 ) ( Table 1).
Previous cesarean section was the most common indication of cesarean delivery (22.2%) followed by non-reassuring the fetal heart rate pattern (17.0%) (Figure 1).

Determinants of Maternal Satisfaction after Spinal
Anesthesia. e major reasons to refuse SA for the same surgical procedures again in the future were surgical pain, afraid of being awake during the procedure, side effects, and unknown reasons, 27 (5.2%), 13 (3.3%), 11 (2.9%), and 6 (1.6%), respectively. Spinal prick attempts, failed block, PDPH, and antiemetic prophylaxis were factors associated with maternal satisfaction after spinal anesthesia in multivariable logistic regression. e odds of a parturient with single spinal prick attempts (AOR � 2.08, 95% CI � 1.05-4.11, p value � 0.035) were 2 times more likely satisfied than those with multiple attempts. e odds of parturients who have successful spinal block (AOR � 7.17, 95% CI � 3.33-15.43, p value < 0.001) were 7 times more likely to have satisfaction than those who got a failed block. e odds of less incidence in postdural puncture headache (AOR � 2.36, 95% CI � 1.33-4.20, p value � 0.009) were 2 times more likely to have satisfied than their counterparts. e chance of taking prophylactic antiemetics (AOR � 0.35, 95% CI � 0.19-0.66, p value � 0.001) decreased the level of satisfaction by 65% than women who were not taking antiemetic prophylaxis (Table 5).

Discussion
In the current study, a total of 383 CD parturients were enrolled with overall maternal satisfaction and willingness to  choose spinal anesthesia again in the same future surgeries which were 82.3% (95% CI � 78.3-85.9%) and 78.6% (95% CI � 81.5-88.5%), respectively. Our result was similar to a study done by Sadaghi M and his colleagues regarding maternal satisfaction of spinal anesthesia for elective cesarean section which showed that 83.8% of parturients were satisfied. Additionally, 78.5% parturients showed willingness to choose spinal anesthesia in the future surgeries [4]. Another study done by Rashad Siddiqi and Syed Asadullah revealed that the overall level of satisfaction among the parturients who underwent cesarean delivery under spinal anesthesia was 81.4% and 53.66% who would opt for spinal anesthesia in the future [10]. Furthermore, a study done by Morris Senghor and Everlyne Nyanchera regarding determinants of maternal satisfaction with spinal anesthesia for cesarian delivery showed that the overall satisfaction was 85% [23]. However, there are studies that showed levels of maternal satisfaction were higher than this study. A study done by Dharmalingam and Zainuddin in 2013 on maternal satisfaction following SA showed that overall satisfaction and willingness to take it in the future for similar procedures were 97% and 88.5%, respectively [17]. e variation might be explained by use of the 2-point Likert scale (satisfaction or dissatisfaction). Another randomized control trial also reported that the overall parturient satisfaction was 89.48 ± 9.31% with no statistical significance between spinal and epidural anesthesia [24]. e discrepancy might be explained with control of confounding factors and intervention for side effects in their study.
In this study, satisfaction with preanesthesia information about the procedure was 29.1%, which is relatively low compared with Dharmalingam and Ahmad Zainuddin (98%), Shisanya and Morema (36%), and Makoko et al. (67.1%) [13,17,23]. is low client satisfaction might be explained with the majority of CD done as emergency (84.1%) and they might be in labor pain that parturients could not concentrate on the preoperative explanation, which is also supported by Shisanya et al. who showed that labour pain has negative impact on satisfaction of parturients with preanesthesia information [23].
Among the demographic variables, educational status is one of the mentioned predictors of maternal satisfaction. A study done by Muneer et al. suggested that maternal satisfaction after spinal anesthesia is negatively associated with higher educational status [14].
is association has been explained by highly educated people have a tendency to extrovert their feelings, information-seeking behavior, and awareness of possible complications.
Studies suggested spinal prick attempt was an independent predictor for maternal satisfaction [2,25,26] which is similar to the current finding (AOR � 2.08, 95% CI � 1.05-4.11, p value � 0.035). In contrast to this, studies had shown that spinal prick attempts were not significantly associated with satisfaction [17,18]. ese discrepancies could be related due to the use of the 25 G Quincke needle only; however, in this study, we use the 21-25G Quincke spinal needle. Additionally, in the current study, the study area is an institutional hospital; hence, students and junior anesthetists with less skills and experiences may perform Studies which were conducted to determine patients' satisfaction after spinal anesthesia concluded that failed block (AOR � 2.28, 95% CI � 0.09-0.87) was the predictor of maternal satisfaction [17,18], which is similar to the current study (AOR � 7.17, 95% CI � 3.33-15.43, p value < 0.001). Multiple studies suggested needle prick pain is an independent predictor for maternal satisfaction after SA [13,18,25]. In the current study, even if needle prick pain had a higher frequency (191 (49.9%)), it is not significantly associated with maternal satisfaction. Our finding was parallel with the other study which showed that needle prick pain was not significantly associated with the level of maternal satisfaction [4].
Previous studies showed that postdural puncture headache was the predictor for maternal satisfaction following SA, and less incidence of PDPH was associated with higher level of satisfaction [2,4,17,18], which is similar to the current study (AOR � 2.36, 95% CI � 1.33-4.20, p value � 0.009); in contrast, a study done in Iran showed that PDPH was not associated with parturients' satisfaction [4]. Different findings might be explained by preoperative information retention regarding the risk-benefit of SA, and their study participants were only elective parturients. Additionally, postdural puncture headache remains a problem in client satisfaction after spinal anesthesia.
e current study showed that the absence of PDPH was two times more likely to have satisfaction with 95% CI � 1.33-4.20, p value � 0.003, which was similar to a study done by Siddiqi and his colleagues [17]. e reason for PDPH association with satisfaction might be explained by low preanesthesia information delivery about the possible side effects of the procedure. Another study conducted by Sindhvananda et al. revealed that postdural puncture headache, pruritus, and PONV were predictors of satisfaction [24]. Different findings regarding pruritus and PONV might be explained due to their usage of intrathecal morphine.
Studies documented that postoperative nausea and vomiting was an independent risk factor to determine satisfaction [2,17,24,27], which is in contrast to the current study; the reasons might be in the current study, out of total, 162 (42.3%) parturients were given prophylactic antiemetics and due to less use of intrathecal opioids.

Limitation of the Study.
is study was conducted in a single center, and there was inconsistent adequate supply of medical equipment in the study area which could not truly show the magnitude of the maternal satisfaction level. Additionally, this study did not show a causal relationship between dependent and explanatory variables, as well as using different sizes of the spinal needle can create bias.

Conclusion
e overall maternal satisfaction receiving spinal anesthesia was low as compared with Leiden perioperative care patient satisfaction. Single spinal prink attempts, successful spinal block, and less incidence of postdural puncture headache can increase maternal satisfaction following spinal anesthesia. erefore, effective perioperative management and skillful techniques may increase the quality of service and maternal satisfaction.