Maternal satisfaction on delivery care services and associated factors among mothers who gave birth in the University of Gondar teaching and referral hospital, northwest Ethiopia

Maternal satisfaction on delivery services is an important indicator for assessment of the quality of care. Quality of delivery care increases the likelihood of timely and appropriate treatment and good outcomes. The use of delivery services and outcomes are the result not only of the provision of care but also of women’s experience of that care. Therefore, investigating women’s experience or satisfaction on delivery care is of paramount importance to enhance the services utilization. An institution-based cross-sectional study design was used. Data were collected using structured and pretested questionnaire from 403 mothers who were recruited by simple random sampling technique. Multivariable binary logistic regression analysis was used to identify variables associated with maternal satisfaction on delivery services on the basis of adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value less than 0.05.


Introduction
Maternal satisfaction on delivery services is an important indicator for assessment of the quality of care. Quality of delivery care increases the likelihood of timely and appropriate treatment and good outcomes. The use of delivery services and outcomes are the result not only of the provision of care but also of women's experience of that care. Therefore, investigating women's experience or satisfaction on delivery care is of paramount importance to enhance the services utilization.

Methods
An institution-based cross-sectional study design was used. Data were collected using structured and pretested questionnaire from 403 mothers who were recruited by simple random sampling technique. Multivariable binary logistic regression analysis was used to identify variables associated with maternal satisfaction on delivery services on the basis of adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value less than 0.05.

Results
The current study found that the overall satisfaction of mothers on delivery services was found to be 65.5%. Specifically, 78.2%, 65.5%, 64.3%, 49.9% and 44.7% of the mothers who gave birth at the University of Gondar teaching and referral hospital were satisfied on physicians' communication, healthcare services, physicians' attitude, privacy and sanitation condition of the health institution respectively. Maternal satisfaction was statistically associated with maternal education (diploma and above education) AOR = 0.29, 95% CI = (0. 13

Conclusion
This study revealed that the overall satisfaction of mothers on delivery service was found to be suboptimal. Physicians' communication, healthcare services and physicians' attitude were areas where the highest proportion of mothers satisfied. On the other hand, the highest proportion of mothers was dissatisfied on sanitation condition. Educational status, ANC follow-up and waiting time were found to be statistically associated with maternal satisfaction on delivery services.

Background
Maternal satisfaction on delivery services is an important indicator for assessment of the quality of care. Quality of delivery care is the degree to which maternal health services for individuals and populations increases the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes. The use of services and outcomes are the result not only of the provision of care but also of women's experience of that care(1).
The quality of maternity care received by mothers in developing countries is often reported as poor. Poor quality of maternity care leads to maternal and child death.
Globally, about 800 women die from pregnancy or labor related complications every day.
In 2010, around 287,000 women died during pregnancy and childbirth (2). The maternal mortality is reported to be 14 times higher in developing regions than the developed(3).
Sub-Saharan Africa alone accounted for 62% of global maternal deaths. Maternal mortality in the Sub-Saharan Africa region is reaching 686 per 100,000 live births (2).
The lifetime risk of maternal death in industrialized countries is 1 in 4,000 vs. 1 in 51 in countries classified as 'least developed' (4).
Ethiopia is one of ten countries sharing 58% of the global maternal deaths reported in 2013(3) and has an maternal mortality rate of 412 per 100,000 live births (5). According to Ethiopian demographic and health surveys (EDHS) 2016, institutional delivery was 26% which is low. One possible reason for this low institutional delivery might include unhappy health institutional delivery experience for the mother that limits their ability to utilize the service in subsequent pregnancies. Factors might include low ANC coverage, gender sensitivity, preservation of dignity, and cultural sensitivity(6-10).
Ensuring client satisfaction is an important means of secondary prevention of mortality.
Satisfied patients are more likely to utilize health services, comply with medical treatment, and continue to interact with healthcare providers (11). When patients are satisfied, medical management and outcomes are enhanced. Patient satisfaction is a measure of the quality of care and is indispensable for the assessment of quality and the design and management of healthcare systems (12)(13)(14). Assessing client satisfaction with respect to service delivery and the healthcare facilities might help guide the development and improvement of service delivery. This institution-based crosssectional study was, therefore, conducted to assess level of satisfaction on delivery care services among mothers who gave birth at the University of Gondar teaching and referral hospital.

Study design and period
An institution based cross-sectional study design was used to assess level of maternal satisfaction on delivery care service and associated factors among mothers who gave birth in University of Gondar teaching and referral hospital during September 2017.

Sample size determination and sampling procedures
Sample size was determined using single population proportion formula with the following assumptions: maternal satisfaction on labor and delivery care services in referral hospitals = 61.9% (15), 95% confidence interval, 5% marigion of error and 15% nonresponse rate.
The estimated sample size was thus 418 women. Simple random sampling technique was used to select the study subject using the registeration book as a sampling frame.

Data collection procedure
Data were collected using structured and pretested questionnaire (see supplementary file). Data were collected by final year medical students. Trainng on techniques of face to face interview and research ethics was given to data collectors. The interview were done when the mothers were about to be discharged from the labor and delivery wards.

Measurment of outcome variable
Mothers' satisfaction on labor and delivery care services, the primary outcome variable of this study was measured using a five scale (very dissatisfied, dissatisfied, neutral, satisfied, and very satisfied) assessment tool. Point 1 was given for very dissatisfied, 2 for dissatisfied, 3 for neutral, 4 for satisfied and 5 for very satisfied. The answer of each question was summed-up and dvided by the total number of questions and then multiplied by 100 to determine level of satisfaction. Accordingly, mothers' satisfaction was taken as 'satisfied' if mothers scored 75% and above points and 'dissatisfied' if they scored less than 75% (15, 16).

Data analysis
Data were entered to Epi-Infor version seven and exported to statistical package for social sciences (SPSS) version twenty for analysis. Descriptive statistics, like mean, standard deviation, frequency, and percent were analysed for most variables. Univariable binary logistic regression analysis was used to select variables for the multivariable binary logistic regression analysis on the basis of a p-value less than 0.2. Variables having a pvalue less than 0.2 by the univariable analysis were further analysed by multivariable binary logistic regression to control confounding and finally variables associated with mothers' satisfaction were identified on the basis of AOR with 95% CI and a p -value less than 0.05.

Sociodemographic characterstics of participants
A total of 403 postnatal mothers participated in this study with 96.4% response rate.
Among these mothers, 274 (68%) were from urban. Two hundred seven (51.4%) of the mothers were aged between 25 and 34 years. The mean age was 28 years (+6 SD). Almost all, 388 (96.3%) of the mothers were engaged at the time of the survey. Three hundred thirty-nine (84.1%) mothers were at least can read and write. Ninety-five(23.6%) mothers were housewife by their occupation. Eighty-five (21.1%) of the mothers were from a family of greater than five members. Twenty-three (5.7%) of the mothers gave more than five births (Table 1).

ANC related information
The majority, 383 (95%) of mothers knew about ANC and 373 (92.6%) of the mothers had access to ANC care services. Three hundred seventy-two (92.3%) of the mothers who gave birth were at ANC follow-up for the current pregnancy. Two hundred nineteen (58.9%) of the mother who had ANC follow-up for the current pregnancy got the services from University of Gondar teaching and referral hospital and 206 (55.4%) of the mothers reported that each visit took more than twenty minutes. One hundred fifty-five (41.7%) of the mothers followed more than four times ( Table 2).

Labor and delivery related services
The vast majority, 318 (85%) of the mothers deliverd their previous baby through spontaneous vaginal delivery (SVD) and 230 (57.1%) of the mothers reported that they gave birth at hospitals for their previous pregnancy. Two hundred ten (52.1%) mothers came to hospital by their own plan. Two hundred fifteen (53.3%) of the mothers reported that they waited for 10 or below minutes to get services. Three hundred eighty-seven (96%) of the mothers were seen by doctors during delivery and the labor of 381 (94.5%) mothers lasted more than 3 hours. Three hundred eighty(94.3%) mothers gave alive birth and 76 (18.9%) of the new borne babies were under weight (Table 3).

Mothers' satisfaction on delivery care service
Mothers' satisfaction on delivery care services was measured using 31 questions  Table 4 shows factors associated with mothers' level of satisfaction on delivery services.

Factors associated with mothers' level of satisfaction on delivery services
Level of maternal education, ANC follow-up in the current pregnancy, waiting time, qualification of care providers, duration of labor, and pregnancy outcomes were selected to the multivariable binary logistic regression analysis by the univariable binary logistic regression analysis. Maternal satisfaction on delivery was statistically associated with level of maternal education, ANC follow-up in the current pregnancy, and waiting time.
This study revealed that literate mothers were more dissatisfied than illiterate mothers.
The odds of satisfaction was 71% less among mothers whose education level was diploma The current study depicted that waiting time was associated with maternal satisfaction on delivery services. Mothers who waited for 10 and/or below minutes were 1.85 times more likely to be satisfied compared with mothers who waited for more than 10 minutes to get services [AOR =1.85, 95% CI = (1.19, 2.88)].

Discussion
The present study determined the level of maternal satisfaction on delivery services at the University of Gondar teaching and referral hospital, northwest Ethiopia. The overall satisfaction level of mothers was found to be 65.5% (95% CI = 60.1, 70.2%). The current level of satisfaction was in line with the reports of other similar studies in Amhara region (61.9%) (15) and South Ethiopia (67.9%) (17). The level of maternal satisfaction reported in this study was lower than the findings of other similar studies in Debremarkos (81.7%) (16), Assela (80.7%) (18), Bure (88%) (19), Bahir Dar(74.9 %) (20), Hawassa (87.7%)(21), Wolayta zone(82.9%) (22), Arba Minch(90.2%) (23) and Nepal(89.88%) (24). The Current level of maternal satisfaction was also higher than the findings of other studies in Iran (59.5 %) (25) and Sri Lanka(29.6%) (26). The difference in level of maternal satisfaction across studies might be due to variation in health institutions quality and healthcare providers competency, behavior and approach.
This study showed that education status of mothers was found to be significantly associated with maternal satisfaction on delivery care rervices. Mothers who attended formal education were dissatisfied. Other similar studies also reported the inverse relation of satisfaction and educational status of mothers (18, 19, 21, 23). The probable reason might be due to the fact that educated mothers expect and demand better healthcare service quality. Moreover, educated mothers might know service quality standards and might compare the services they received with the standards(24).
This institution-based cross-sectional study depicted that maternal satisfaction on delivery services was significantly associated with ANC follow-up which is inline with the findings of other studies (15, 18, 23, 27). ANC follow-up might give mothers a continuum of care from the ante-natal to the post-partum period which will grant mothers all the necessary information about birth preparedness and information related to the current pregnancy(28).
This study found that waiting time to get healthcare service was the other statistically significant variable with maternal satisfaction. Mothers who waited shorter time to get service were more satisfied. This finding is also supported by other studies (15, 18, 23). This might be due to the fact that providing healthcare services with no delay can prevent complication due to prolonged pain and clients boringness (29, 30).

Conclusions
This study revealed that the overall satisfaction of mothers on delivery service was found Gondar. There were no risks due to participation in this research. The collected data were used only for this research purpose. Verbal informed consent was obtained from the mothers. The information collected from participants kept with complete confidentiality.
Privacy was maintained during the interview.

Consent for publication
This manuscript does not contain any individual person's data.

Availability of data and material
Data will be made available upon requesting the primary author.

Competing Interest
None of the authors have any competing interests in the manuscript.

Funding information
This study had no any special fund. However, the University of Gondar had covered questionnaire duplication fee.

Authors' contribution
AF, AM, AD, AA, AB, AB and AA participated during conception of the research issue, development of a research proposal and data collection. ZA supervise the data collection process and wrote various parts of the research report. ZG analyzed the data and prepared the manuscript. All the authors read and approved the final manuscript.

28.
World Health Organization (WHO     Level of satisfaction of mothers who gave birth at University of Gondar teaching and referral hospital during September 2017on healthcare services, physicians' communication, physicians' attitude, privacy and sanitation