Women’s satisfaction and its’ associated factors on institutional delivery services provided by public health facilities of Tanahun district, Nepal

Background Institutional delivery is one of the important strategies to reduce the maternal related risk at the time of delivery. Satisfaction of women on labor and delivery care services has good inuence on their health and results in subsequent utilization of health services. This study was focused to assess women’s satisfaction and its’ associated factors with institution delivery services in public health institutions. Methods Cross- sectional study was conducted among 169 participants from June 2018 to November 2018 among women (having under one year children) residing in Tanahun district. Simple random sampling, face to face interview and semi structured interview schedule was used for the collection of data. Data were entered in Epi-Data and analyzed by SPSS. Ethical approval was obtained from Institutional Review Committee at Pokhara University and maintained during the process of research. Results The age of the participants were between 16 to 40 years with median age 25 years (IQR = 7 Years). Most (93.5%) of the participants were Hindu. Majority of the participants (57.4%) and their husbands (60.4%) had secondary level education. Almost all pregnancies (99.4%) are planned and normal delivery was most common (77.5%). The study shows that 55% of the women performed delivery in public health facilities. The study states high satisfaction score in health status of women after delivery (4.8) and lowest in availability of visitor's bed (2.99). Women's satisfaction and religion was seen to be signicantly associated. Conclusion participants health


Background
Satisfaction is stated as a pleasant feeling that you get when women receive facilities they wanted, or when they have done something they wanted to do. [1] Satisfaction of women is a subjective and dynamic perception of the extent to which health care facility you expect to receive. It is not important whether the women are right or wrong, but what is important is how the women feel. [2,3] Satisfaction among pregnant women who were attending in health institution delivery is important measures to measure the quality of health care. The World Health Organization (WHO) emphasizes ensuring patient satisfaction as a means of secondary prevention of maternal mortality since satis ed women may be more likely to adhere to health providers' recommendations. [4] Satisfaction on maternity care is a multidimensional construct embracing satisfaction with self and with the physical environment of delivery room and quality of care [5] . Quality of care is an important but often neglected issue in safe motherhood programs. Quality of care can be considered from the provider or user's perspective, and is differentiated into observed and perceived quality. Lack of quality health services results in the negligence on health services. The mother's assessment of quality is central because emotional, cultural and respectful supports are needed during labor and the delivery process. [6] Women's satisfaction is one of the most frequently reported outcome measures of quality of care [3] Satisfaction of women on labor and delivery care services has good in uence on her health and results in subsequent utilization of health services. Thus knowledge about women satisfaction on labor and delivery care can increase the utilization of services. [7] Several barriers are seen for the utilizing of institutional delivery services. The major factors are sociodemographic factors, maternal health factors, household factors and service related factors. [8][9][10][11] Some studies states that strategies like user-fee exemption for delivery and associated to enhance access, barriers still exist as universal coverage remains elusive. In some studies household headship, education, maternal age, and socioeconomic status were also signi cantly associated with place of delivery. [12] Major three types of delay are seen for receiving institutional delivery services. They are delay in seeking care, delay in reaching care and delay in receiving care. Poor birth preparedness, knowledge on institution delivery, family in uence on decision, geographical inaccessibility, and unmet needs of care in CEONC and fear of hospital setting [13] are common factors related to rst delay. Late and poor-quality referral, transport not available and inadequate decisions by husband/relatives have been associated with the second type of delay. Lack of supplies and staff, poor quality of care and multiple delays due to second referrals have been reported in the literature as part of the third type of delay. [14][15][16] Many of the women get suffer from the maternal related health issue during pregnancy and childbirth. In 2015, about 3, 03,000 women died due to maternal related cause. Among them 99% of the death are occurred in low and middle and low income country. More than 90% of all births bene tted from the presence of a trained midwife, doctor or nurse in middle and high income countries but, only less than half of all births in several low-income and lower-middle-income countries were assisted by such skilled health personnel. [17] The South East Asia Region alone accounts for approximately one-third of the global maternal and child deaths annually. [18] Nepal government has introduced institutional delivery services as demand sided intervention. There has been increased in number of birthing center in the different district of the country. Nepal has committed to achieve 70% of all deliveries at institution by 2020 for achieving SDG target in 2030. Institutional delivery has been increased in all region expect state number two. [19] Maternal morbidity and mortality highly decreases by safe delivery and skilled birth attendant at every birth. Improving maternal health and decreasing maternal mortality is the strategies for increasing emphasis on women's satisfaction with care in order to improve women's adherence to the service. [7] Women's satisfaction is an element representative of quality of care. Therefore the most powerful prediction for measuring women's satisfaction on governmental health services was provider's behavior towards the patients, particularly respect and politeness. [20] Maternal morbidity and mortality is highly decreased by safe delivery and skilled birth attendant at every birth which indicates women satisfaction with the services was the major factor for improving maternal health. One on the three strategies for reducing maternal mortality is taken as a maternal satisfaction. [7] A satis ed women will recommend center's services expressing their satisfaction to four or ve peoples, while a dissatis ed women on the other hand will complain to twenty or more. [21] Different factors are associated with the satisfaction of mother at institution delivery services. [22] It is also essential to identify the factors involved in dissatisfaction, if a good health care system is sought. [21] Most of the women were satis ed with receiving health care facility, providers skill, politeness of the staff waiting involvement in decision making, cleanliness and information received by them. [22] More waiting time and less consultation time are seen as the problem in the satisfaction among women. [20] Almost all the study related to maternal satisfaction were based on hospital that have create a fear to women to tell about bad side of the services. [23] Patient satisfaction has been increasing as the important outcome for health care delivery and increasing studies in the developing countries. Most studies are focused on low and middle income countries. Among them Nepal is one of the developing countries which has low institution delivery rate. So it becomes an important issue in the public health. Mainly women are not satis ed on health related services. Since Nepal is mountainous country, topographical variation can be seen as the barriers for receiving health services. Most of the people have low income. So government has provided these services free of cost. Instead of free institution delivery services the status of the institutional delivery is very low in the district. The study also attempts to describe the socio economic condition and its impact on institutional delivery services. The study mainly aims to nd out the level of satisfaction among women who have taken institutional delivery services. There may be number of researches in this issue. So, it would be relevant to explore the women's satisfaction and its' associated factors at institution delivery services provided by public health institutions of Tanahun district.

Methods
Community based cross-sectional analytical study was conducted among 169 participants from June 2018 to November 2018 among women (having under one children) residing in Tanahun district which is located in Gandaki Province of Nepal. Simple random sampling technique was used. Face to face interview was the data collection technique. Semi structured interview schedule was used as a tool for assessing satisfaction on institutional delivery services. Pre-testing was conducted and necessary modi cation was made in questionnaire. Data were entered in Epic-Data (Version 3.1) and analyzed by SPSS 20.The data was analyzed in terms of frequency (percentage), mean (S.D) or median(IQR) as per necessary. Info-graphics was created and interpreted as per the need. Ethical approval was obtained from Institutional Review Committee, Pokhara University. Participants who involved in this research were provided with the information in relation to the topic.

Demographic Characteristics of Participants
Majority 71.6% (121) were age between 20-29 years. The median age of the participant was 25 years (IQR=7 years). Similarly majority of the participants follow Hinduism (93.5%) and lived in joint family (60.9%). Most of them 57.4% had secondary level education and only 3.6% were illiterate. Most of the women, 85.2% were housewife while remaining 14.8% (25) had some kind of work such as business job and daily wages.

Reproductive Health related Characteristics of Participants
Majority of the women, 62.1%were above 20 years. Similarly, most of the women, 62.7% were between 20-26 years during rst pregnancy. Most of the participants (56.83%) were primiparous while remaining 43.16%. Among primiparous, most of them 67.1% had less than 14 hours labor time while 32.9 %. In case of multiparous 63.3% noticed less than 8 hours labor. Regarding the decision on service delivery point mostly husband 50.3% followed by wife/self (45.6%) were involved.

Proportion of clients' satis ed
There were twenty four items to measure the opinion of the respondents. The lowest score (2.99) was obtained for availability of visitors bed and highest score (4.80) was obtained by condition of women after delivery. Most of the variables value was more than four but food services (3.91) was followed by the lowest value. 4.2 to 4.8 range score was obtained to the services provided by staff in public health centers. Infrastructure of the health institution obtained the value range from 4.1 to 4.6. Similarly, accessibility of the services had the score range value from .4.0 to 4.6.

Satisfaction on institution delivery services
According to the data obtained 55% (93) respondents were satis ed with institutional delivery services while 45% (76) respondents were not satis ed. Almost all the participant 99.4% (168) wanted to visit to hospital for next delivery and suggested others for institute delivery.
Association of socio-demographic factors with clients' satisfaction during delivery period  Table 4 represents the association between the socio-demographic variable and women's satisfaction in institution delivery services. Religion (χ 2 =6.084, df=1, p= 0.0024) was signi cantly associated with women's satisfaction.
Association of Reproductive Health related Characteristics with Client satisfaction during delivery period  Table 5 shows the association between reproductive health related characteristics with women's satisfaction. None of the variables were found statistically signi cant.
Association of Health Service related Characteristics with Women's Satisfaction during delivery period  Table 6 expresses association between health service related characteristics with women's satisfaction.
None of the variables were found statistically signi cant.

Satisfaction on Institution Delivery Services
According to survey (55%) of the participant were satis ed with institutional delivery services provided by public health centers. The level of satisfaction was 56% in Sri-Lanka, 51.9% in South Africa and 54.5% Kenya which were said to be similar studies of this research. In the similar case, the studies conducted in South Australia and Bangladesh, 86.1% and 92.3% women were satis ed respectively. [24] A study in Ethiopia states that 90.26% women were satis ed with institution delivery services. Similarly some other studies on Ethiopia state that 82.9% and 61.9% women were satis ed. [7] A study conducted in Nepal states that the overall satisfaction on institution delivery services was 45.1% while it was 58.1% in Kaski District. [25] According to STS Survey in 2012 the level of satisfaction among Nepalese women was 90%.
But STS survey stated 86% satisfaction on their survey in 2013. [5] The difference in level of satisfaction in other studies and ours could be because of study setting difference, more availability of health service facilities in different countries and could also because of methodological difference in which researcher used factor analysis to set the cutoff point for satisfaction.
Satisfaction was seen to be strongly correlated with the politeness and experience of staff as well as the health facilities that they received. A study in Nepal showed that clients were satis ed with care received at the facility (86%), provider's skills (85%), politeness of staff (83%), waiting time (80%), involvement in decision making (77%), cleanliness (70%), information received (69%), and assured con dentiality (67%).
[22] The proportion of mothers who were satis ed with delivery care was nearly four-fth (79,1 %).
satisfaction levels for cleanliness was (35%), presence of relatives or family to support women during child birth was (65.3%) the client and emotional support during child birth. [26] A study revealed that support for institutional delivery by mother-in-law and husband is associated with institutional delivery. [27] Another study states that that two-third of the clients were satis ed or very satis ed with privacy in the facilities. [22] Women who were treated with respect, courtesy and dignity and had trusting relationship with their care providers were more likely to be satis ed. [5] Socio-demographic variables with Satisfaction In this study, religion is considered as one of the variables associated with satisfaction in delivery services. But in other studies there was association between age group and education with overall satisfaction which was statistically signi cant. [28] This study states that women who were 25 years and above, were more satis ed but the case was not found same to women whose age ranging from 20 to 34 years . This is to say, they were less satis ed with the care they received compared to women whose age from 35 to 49 years. [29] A study in Chitwan shows Age [30] , parity and education were associated with the institution delivery services while this study didn't show any association. [31] The difference in sociodemographic characters of the participants in other studies and our studies could be due to the variation in geographical status, standard of living, level of education, religion and status of family.
Reproductive health variables with satisfaction.
A study in Nepal states that one-third of Nepali women get married before 16 while 57% become pregnant at their adolescent but this study expresses that around two-third women get married after age twenty and more than seventh-tenth planned rst baby after 20 years. [32] With changing time period, increase in health education, restriction by government law and provision of education to girls could be reason for delay marriage which can further increases in decision making ability of female which ultimately reduces the pregnancy before the age of 20 years. A study conducted in public health facilities of Kenya states that more than half (51.7%) were multiparous where as in this study 35% were multiparous. A tri-nation study states that decision regarding utilization of birthing facilities is often made by the husband or his family members rather than by the parturient woman [13] where as another study of eastern Nepal showed that slightly more than half of the of decision for delivery point were made by mother and her spouse which is also considered as supporting details to this study. [33] The reason behind this could be because of the patriarchal nature of society, where the nal decision are mostly made by the husbands or elder persons of the household regarding delivery point. A study conducted in eastern Nepal showed that almost all (92.5%) pregnancies were planned which supports our study. [33] Increase level of education of our participants (female) and theirs husbands might be one of the reason for high planned pregnancy.

Health services related variable with satisfaction
Generally, more than eight-tenth (82.9%) participants travelled for an hour according to the study conducted in Ethiopia while in this study around seventh-tenth (66.9%) had travelled less than an hour to reach to health institution. [26] This could be because of the topographical variation, transportation facilities, social beliefs and practices on delivering on urban health facilities rather than rural health facilities. A study in Pakistan states that public sector hospitals were more e cient in providing assurance to women which was consistent to our study. [34] This could be because the Nepal government is increasing number of birthing center and provide free delivery service with travelling cost. So, believe towards the government health centers is increasing day by day. Discipline of staff, cleanliness and regular visits of doctors is found in public sector hospital which increased the satisfaction of women which is similar to our study [34] The reason behind this could be due to the commitment of health staffs during the recruitment to provide quality services and also could be due to the individual nature of health service providers. A study in Northern Ethiopia states that having plan to deliver at health institution and laboring time of less than six hours were signi cantly and positively associated with maternal satisfaction on delivery service but there was no any association seen in our study among characteristics [23] .Only 40% of mothers were satis ed with the quality of the services as a study conducted in Nairobi [4] . A study states that women who received advice from health workers on danger signs for mothers had higher satisfaction which was similar to our study. This can be supported by practice in Nepal that, Female Community Health Volunteer (FCHV) are regularly involved in ground level to ensure the safety for the pregnant women. They promote safe motherhood, child health and other community based health issues and service delivery and also refer serious cases to health institution and motivate local people on healthy behavior. Women who had an opportunity to ask questions related to reproductive health to the health providers had higher satisfaction which shows consistency in our study. [5] This could be because of the provision of four ANC checkup for pregnant women in which they can ask maternal health related issues in four visit in health institution. Female staff like ANM and SBA are recruited in health institution so that every female can share their problem without hesitation. Another study states that incentives is not only for the utilization of institutional delivery services. It also states that incentives scheme increased the awareness in the community. [35] Conclusion According to the overall study majority of delivery service users were satis ed with institutional delivery services provided by public health facilities (centers). The level of satisfaction was seen higher in services for mother delivering in health centers and lower in availability of well managed visitor's bed in health facilities. Women using delivery services were more satis ed with infrastructure and health services.
Majority of the participant were satis ed with time provided by health worker, their response towards the participant, co-operation during delivery period along with politeness of health staff. Respondents were dissatis ed with cleanliness of toilets, labor room, and availability of well managed visitor bed as well as with food services at hospitals. The study shows that religion was signi cantly associated with women's satisfaction where as other socio-demographic factors were not associated with women's satisfaction towards delivery services at public health facilities. Similarly, reproductive health characteristics and health services characteristics were not associated with women's satisfaction.
Quality of service is directly associated with environment around the health institution so hygienic environment should be maintained to ensure clean and safe delivery services that will ultimately increase the satisfaction of clients. Satisfaction with services is also associated with how visitors are managed in health institution so based on the ndings of this study it is recommended that adequate number of visitor's bed along with their maintenance should be considered as an important factor in every health institution. Promoting free and quality delivery services through public health facilities is today's concern.
So concerned authorities are recommended for considering need of people in community and are requested to address those with new service delivery equipment's and infrastructure which may further increase their satisfaction towards services and institution.