Delivery service satisfaction and associated factors among mothers who gave birth at West Shewa Zone public hospitals, Ethiopia

Objective: This study assessed mothers satisfaction towards delivery Services and its associated factors at public Hospitals found in West Shewa Zone, Ethiopia, from March 1 to April 15/2018. Result : This study nding showed that the overall satisfaction level of mothers towards delivery service was 82.1%. Those Mother’s who planned their pregnancy were 4.93 times more satised with delivery service than those who did not planned (AOR: 4.93; 95% CI: 2.172-11.208). The odds of satisfaction for women who had pain management were 1.56 times higher than those who did not. Moreover, Gestational age at birth for pre-term and full term [(AOR: 0.027; 95% CI: 0.003-0.254), (AOR: 0.067; 95 % CI: 0.011-0.401)], means of transportation (use of Ambulance) (AOR: 3.785; 95% CI: 1.24-11.51) and stay in hospital (AOR: 0.10, 95% CI 0.01, 0.93) were the signicant predictors of mother’s satisfaction with delivery service at the study area. Therefore notable attention should be given to those factors as they may inuence the future utilization of service.


Introduction
Sub-Saharan Africa countries are characterized by high maternal mortality ratio and lowest coverage of births attended by skilled health care provider [1]. Ethiopia is also one of the Sub-Saharan African countries(SSA) with high maternal mortality ratio of 412 per 100,000 live births and 19,000 maternal deaths annually [2].This is due to delays in seeking health service, in reaching the health facility and in receiving timely and effective intervention after reaching the health facility [3].
Worldwide, 63.1% of births were attended by a skilled health care provider. Almost all births were attended by skilled health care professionals in developed countries. In Africa and Asia, only 46.5% and 60.8%, respectively, of women gave birth with the help of a skilled attendant [4]. In Ethiopia, only about 28% of deliveries were attended by a skilled birth attendants and only about 26% of delivery was institutional. On contrary, home delivery was 73% which is still high. Similarly, in Oromia region (Ethiopia) Home delivery accounts 81% while institutional deliveries was only about 19% [1,5,6].
Low utilization of delivery service at health facility was mainly related to maternal satisfaction during delivery services [7,8]. That's why WHO emphasizes ensuring client satisfaction as a means of secondary prevention of maternal mortality, since satis ed women are more likely to adhere to health care providers recommendations and utilization [9].
Maternal satisfaction with hospital care during delivery plays a role in utilization of maternal health services [14]. It improves client friendliness, cultural sensitivity of institution based delivery and postpartum care [15].Women who were satis ed with delivery care have better self-esteem and con dence, faster in establishing a maternal-neonatal bond, and more likely to breastfeed their infant [16,17].
Studies had shown that, women who were dissatis ed with their delivery experiences were more prone to develop a fear of delivery, postnatal depressive symptoms, face di culties in breastfeeding and in performing self-care and their new born [18,19]. Furthermore, it may also resulted with poorer postnatal psychological adjustment, a higher rate of future abortions, preference for a caesarean section, more negative feelings towards the infant and breast-feeding problems [20].
In Ethiopia few studies were conducted, meanwhile all studies were quantitative which prevent mothers from expressing their deepest feeling about delivery service they had provided. Therefore using both quantitative and qualitative methods, this study aimed to assess the current status of mother's satisfaction towards delivery services and its associated factor at the study area. Sample size determination and Sampling procedures All randomly selected mothers who gave birth in selected Hospitals during the study period were included in the study. Single population proportion formula was used to get nal sample size of 390, at 95% con dence level, 5% marginal error, 10% non-response rate, 1.5 design effect and 19% level of satisfaction taken from previous study [17]. Moreover, for in-depth interview, ten participants (6 mothers who gave births and 4 family members) were selected purposively from selected hospitals.

Data collection methods
For Quantitative part: Data were collected using a pre tested Interviewer administered structured questionnaire. The questionnaire were adapted by reviewing related studies and presented using a 5-scale or likert scale measurements (1-very dissatis ed, 2-dissatis ed, 3-neutral, 4-satis ed and 5-very satis ed).
Questions were prepared originally in English language and then translated to local language for easy management, then translated back to English to maintain the quality and consistency of information. The overall level mother's satisfaction was calculated from 20 items of satisfaction questions; which reported a good internal consistency (Cronbach s alpha = 0.76).
For qualitative part: In-depth interview was employed on mothers who gave birth at selected hospital and their family or supporter during the study period. However, those mothers who participated in quantitative study were excluded from participating in interviews.

Data analysis procedures
Quantitative data analysis: Collected data were cleaned, coded and entered to Epi-data version 3.1 and exported to SPSS version 20 windows for further analysis. Bivariate and multivariable logistic regression was performed. Independent variables with p-value < 0.2 in bivariate logistic regression were included for multivariable logistic regression. Variables were considered as statistically signi cant if p-value < 0.05 in multivariable logistic regression.
Qualitative data analysis: Collected data were transcribed and translated exactly from local language to English. The manual transcription and thematic content analysis was conducted. Then identi ed themes were triangulated with quantitative part to determine differences and similarities in the perspectives of the mother's satisfaction on delivery service.

Results
Socio-demographic characteristics of the respondents A total of 390 mothers were participated in this study making 100%response rate. The mean age of the respondents was 26.92 ±5.10SD. About 322(82.6%) of delivery were planned, about 123 (59.9%) mothers came to hospitals using Ambulance whereas 297(76.3%) of them waited care provider for <15 minutes (Table  1).
However, the ndings of this study is higher than the studies done in western Nepal, Northern Jordan, Kenya, Felege Hiwot Referral hospital (Ethiopia) and St.paulose hospital (Ethiopia) which were 67.8%, 64%, 56%, 74.9% and 19% respectively [8,[10][11][12]18]. This variation may be due to difference back ground of the study participants, satisfaction measurement tools used, study time difference, method of analysis. On the other hand, this nding is lower than studies conducted in west India (86%) and Kenya (96%) [27,28]. This discrepancy may be due to cultural difference and difference in quality of service provided at this study area.
This study revealed variables like: gestational age at birth, duration of stay, mode of transportation (use of free Ambulance), fetal outcome, status of pregnancy and pain managements were predictor's of delivery service satisfaction among study participants. This nding is consistent with other studies conducted at different part of Ethiopia [10,12,28,29]. Likewise, Mothers who gave birth at preterm and full term were less satis ed than those who gave birth at post term (AOR: 0.027, 95% CI: 0.003-0.25), AOR: 0.067, 95% CI: 0.01-0.40) respectively. However, this nding was found in contrast with the nding from a Nepal study [10]. The reason may be due to difference in expectation of mothers and cultural difference.
Additionally duration of stay in hospital was other predictor of delivery service satisfaction. Mothers who stayed in hospitals for 48-72 hours were less satis ed compared to those who stayed >72 hours (AOR:0.107,95% CI: 0.01-0.93).This nding was in contrast with studies conducted at Nepal and St Paul's hospital [10,12]. The possible reason could be mother's perception of getting a better care through longer stay in hospitals.
The other important predictor of delivery service satisfaction was means of transportation. Mothers who came to hospital during their labor by free Ambulance were 3.785 times more likely to be satis ed than those who used other means of transportation like by cart, on foot by shoulder (AOR:3.785,95% CI: 1.24 -11.51). It is supported by qualitative study. "…The existence of ambulance was unforgettable for its contribution in my arrival very quickly…". Nevertheless, means of transportation was not statically associated with maternal satisfaction with delivery service [24] .The possible reason may due to different in topography of the study area and accessibility of Hospitals and awareness of study participant on use of ambulance.
Regarding the status of mothers pregnancy, mothers who planned their pregnancy were 4.93 times more satis ed with delivery care than those who did not planned (AOR: 4.93, 95% CI; 2. 17-11.20) .This nding is similar with studies conducted at Kenya, Amhara region referral hospitals and Jimma zone, Ethiopia [11,29,30].This may due to having planned pregnancy may be associated with better psychological preparation for the delivery service.
Lastly pain management was signi cantly associated with delivery service satisfaction. These mothers who get medication for pain management were 4.5 times more likely to be satis ed as compared to who did not (AOR: 4.782; 95% CI: 1.98 -10.52). This result is in line with studies conducted elsewhere [25,29,31], as well as supported by qualitative result which states "When they were stitching up the episiotomy site they gave me anti-pain and I felt much better." Similarly another mother reported "I cannot tolerate its pain and I shouted to them if anything is their which can reduce it. Then they gave me one injection and I became better." In this study variables like: income, residence, ethnicity, ANC follow up and Educational status of the respondents were not signi cantly associated with delivery service satisfaction as it was explained in previous studies [8,12,25,27].
Limitation of the study The nature of the study does not allow the study to establish causal relationship between the different independent variables and the dependent variable. was explained to the study participants and written informed consent was obtained prior to participation in the study. Privacy and con dentiality of collected information was ensured.

Consent to publish
Not applicable Availability of data and materials All data that support the ndings of this study is available from the corresponding author upon request.