Delivery Health Service Satisfaction of Mothers and Fear of COVID-19: Implications for Maternal and Child Health in Pakistan

High maternal and neonatal mortality rates in developing regions like Pakistan are linked to low rates of institutional deliveries. One way to improve rates of institutional deliveries is through improving institutional delivery service satisfaction in mothers. The aim of this research is to identify which factors inuence delivery service satisfaction in mothers during the era of COVID-19 and to identify socio-demographic characteristics of mothers associated with greater fear of catching COVID-19 during institutional deliveries. A total of 190 women who had delivered a baby between May 2020 and June 2020 were sampled from two private and two public hospitals of Lahore which gave permission for data collection. Results reveal that majority women at 74.7% are afraid of contracting COVID-19, specically women: delivering at public hospitals, who are illiterate or semi-literate, with more than 4 children, with low household income, and who are unemployed. Four multiple regression models were used to identify factors related to higher satisfaction in delivery services, including: (i) pre-delivery care (explanatory power of R 2 = 0.651), (ii) during delivery care (R 2 = 0.716), (iii) after delivery care for mother (R 2 = 0.525), and (iv) after delivery care for newborn (R 2 = 0.780). Based on our ndings we recommend improved regulation of delivery services, especially at public hospitals, increased protection for disadvantaged women groups, and improved service quality by healthcare providers.

(National Institute of Population Studies, 2013). One of the major reasons for lower delivery service care, as discussed above, includes lower institutional deliveries, but also the lack of training of healthcare providers found at hospitals of developing countries (Simkhada, Teijlingen, Porter, & Simkhada, 2008).
Healthcare providers have been found not to be held accountable for their delivering services to mothers and newborns (Mathole, Lindmark, Majoko, & Ahlberg, 2004), and some research also suggests that providers may exhibit negative attitudes and abuse (Mousa & Turingan, 2019). It is argued that one means of improving this culture of fear and resistance to institutional deliveries is to improve the services of care for mothers who do deliver at institutions (Colombara et al., 2016). This would help improve word of mouth promotion for institutional deliveries and build trust for institutional healthcare providers and staff (Khowaja et al., 2018).
Both the public and private hospitals of Punjab are bound by the provincial regulatory authority, Punjab Healthcare Commission (PHC), which is an independent health regulatory body. The PHC is mandated to ensure that all healthcare establishments adhere to the Minimum Service Delivery Standards (MSDS) while offering maternal and child health services (Punjab Healthcare Commission, 2020). The MSDS have been developed by the PHC and comprise a set of indicators that cover the entire spectrum of healthcare service delivery and care services for obstetric patients, including clinical and managerial aspects for maternal and newborn health.

Aim of study
One way to improve rates of institutional deliveries is through improving institutional delivery service satisfaction in mothers. This is especially pertinent as in the era of pandemics a traditional society like Pakistani might revert to home deliveries if they fear contracting COVID-19 from unsafe institutions. The aim of this study was to: (i) identify demographic variables associated with fear of contracting COVID-19 during institutional deliveries and (ii) ascertain factors for delivery service satisfaction in women opting for institutional deliveries during coronavirus pandemic, speci cally with respect to: a. pre-delivery care, b.
during delivery care, and c. after delivery care for mother and newborn.

Methods
Ethics approval for this study was taken from the Institutional Review Board of Forman Christian College University. No names were asked from participants. All con dentiality and anonymity was maintained of women participants. No hospital names have been reported due to lack of permission. Women were provided a number for free counseling services by a trained clinical psychologist, if needed, as survey included questions related to fear.

Sampling Selection criteria
Only women who had delivered a baby at public or private hospitals of Lahore during the COVID-19 pandemic were invited to be part of this study. Both public and private hospitals from Category-I Hospitals (Punjab Healthcare Commission, 2020) were considered eligible for sampling, in order to provide homogeneity for data analysis and conclusions from ndings. Category-I hospitals are de ned as hospitals with at least 50 in-patient beds.

Survey
The survey (Appendix A) comprised of 39 questions from a standardized tool by the UK National Health Services (NHS) Survey 2017 (Henderson & Redshaw, 2017). The scale covered the following domains: 1. Registration and admission services; 2. Birthing and delivery services; and 3. Post-delivery services. Some modi cations for regional relevancy were made and questions related to COVID-19 were added to the survey. Likert scale items ranged from 1-5 ('Not at all', 'Not really', 'Somewhat', 'Very much', 'All the time'). The Cronbach alpha results showed high internal validity of the survey: (i) Pre-delivery care was measured by 6 items, and had a Cronbach alpha of 0.870; (ii) Care during delivery was measured with 12 items which, and had a Cronbach alpha of 0.955; and (iii) Care after birth was measured with 7 variables, and had a Cronbach alpha of 0.870. The survey was translated in Urdu, the local language, by the rst two authors, who are uent in both languages.

Data collection
The second and fourth authors are medical doctors currently working in Lahore. They were able to gain permission to collect data from two public sector and two private sector hospitals. Data was collected between May 15 th 2020 to June 13 th 2020 by the rst four authors of the study. The face to face method of data collection was used, so if the mother was illiterate or busy with the baby, the data collector was present for assistance in reading of questions and survey completion. Women were asked permission to participate in the study and if they were not alone, they were asked for a free time for the data collector to come back for survey completion. Women respondents were communicated an informed cover letter, in both English and Urdu, about the research objectives and the option to withdraw from the study at any time while answering questions.
Data collectors adorned PPE kit while collecting data and if the woman respondent was not wearing a mask, they were provided one, to ensure safety of interviewer and interviewee. On average the sampled public sector hospitals have 50-70 women delivering daily and the private hospitals have 10-15 women delivering daily. The four data collectors spent one month collecting data from each hospital respectively and were able to spend two-four hours a day on average requesting interviews from a self-assigned daily target of 10 women a day. In total 100 women were sampled from the two public sector hospitals and 90 women were sampled from the private hospitals. The response was low, at 15.8%, with only 190 women being sampled, despite request from 1,200 women who had delivered. We were unable to continue sampling due to revocation of permission to continue collecting data from the hospitals due to increased protocols for COVID-19 safety.

Data Analysis
Initially descriptive statistics and correlations between study variables were calculated. Next, t-tests were used to identify which socio-demographic characteristics of mothers were signi cantly associated with fear for self and child catching COVID-19 during institutional delivery. For t-test calculations sociodemographic variables were recoded into bivariate groups. Last multivariate regression analysis was performed to identify the predictors for four maternal and child health support areas of: (i) satisfaction with pre-delivery care services, (ii) satisfaction with care during delivery, (iii) satisfaction with maternal post-delivery care, and (iv) satisfaction with care for newborn.

Results
Socio-demographic characteristics of sample Table 1 presents the socio-demographic characteristics of the sample (N=190) and the chi square associations for women who are afraid of catching COVID-19 during institutional deliveries (n=142, 74.7%). Nearly all women lie between the ages of 20-39 years (94.2%) and are currently married (97.8%).
A signi cant number of women are illiterate (17.9%) or educated to 10 th grade secondary studies (25.8%).
Majority women have a household income between PKR 7,000-PKR 59,999/ USD 42.01-360.06 (68.9%) and have between 1-3 children (75.8%). Nearly all women are Muslims (95.3%) and unemployed housewives (73.2%). A near majority of women had C-sections, emergency or planned, (57.9%) and delivered at private hospitals (52.6%). Frequencies and percentages of other variables of study measuring delivery satisfaction in women have been presented in Appendix B. Most chi square associations for fear of catching COVID-19 show signi cance and helped determine which variables were included in the multiple regression analysis. [1] PKR to USD conversions, as at July 15 th 2020, at the rate of 1 USD to 166.634 PKR, from: https://usd.fxexchangerate.com/pkr/  Eight factors explained 71.6% of the variance in overall satisfaction with support during delivery (Table  4). Four variables show statistical signi cance in association with satisfaction with overall support during delivery: (i) comfortable position and movement (t= 5.06, P=0.000); (ii) con dence and trust in staff (t= 4.32, P=0.000); (iii) involved in decision-making (t= 3.55, P=0.000); and (iii) staff assistance in reasonable time (t= 2.07, P=0.040).  Seven factors explained 78.0% of the variance in satisfaction with care for newborn (Table 6). Four variables show statistical signi cance in association with satisfaction with care for newborn: (i) advice and support for breast feeding (t= 5.39, P=0.000); (ii) advice and support for child immunization (t= 3.29, P=0.001); (iii) advice for family planning and birth spacing (t= 2.38, P=0.018); and (iv) satisfaction with room hygiene and sanitation of room or ward (t= 1.98, P=0.048).

Discussion
Majority of the sample indicate fearing COVID-19 during institutional deliveries in hospitals of Lahore. Recent literature also suggests that vulnerable populations like pregnant women are more at risk of catching COVID-19 and thus they face great stress and fear on being admitted in hospital for child delivery (Dashraath et al., 2020). On a positive note however, this has not deterred the respondents from choosing institutional deliveries. Our results imply that, women and their families, belonging to urban cities from the developing world, are more cognizant of and committed to safer delivery practices to secure maternal and child health. Our mean analysis results show signi cance of speci c sociodemographic characteristics with greater fear of catching COVID-19. Women from disadvantaged backgrounds of illiteracy, unemployment, and lesser household income have greater fear of contracting COVID-19 during institutional deliveries. This aligns with international literature in that women of more disadvantaged groups are at greater risk of catching infectious diseases (Bishwajit, Ide, & Ghosh, 2014), and also receiving less support from healthcare providers during pandemics ( Our ndings also show that married women with more than four children face greater fear of contracting COVID-19. Recent scholarship from Pakistan also con rms that married people and women have greater fear of catching COVID-19, as they have more to lose in terms of risk to children and aging parents (Mahmood, 2020). Having already raised children, these women are also more aware of the rami cations of contracting infections on the wellbeing of children. Our ndings also reveal that women delivering at public sector hospitals show greater fear of contracting COVID-19. This nding is not unusual as most developing countries have poor public sector quality standards, with low levels of delivery satisfaction in mothers (Peters, El-Saharty, Siadat, Janovsky, & Vujicic, 2009). Other local research also con rms that public sector hospitals in the country are known for lack of cleanliness, more waiting time, and unsatisfactory behavior of healthcare providers (Kanwal, Hameed, & Riaz, 2017).
With regard to multiple regression results, our rst model showing satisfaction with pre-delivery care services, shows signi cant associations with better services of staff and administration, greater involvement in decision-making of mother, and timely room registration and room admission. Our ndings align with other developing world literature that better hospital services at pre-delivery time improves satisfaction for mothers (Sayed, AbdElAal, Mohammed, Abbas, & Zahran, 2018). Model 1 also shows that satisfaction with pre-delivery care services is associated with lesser fear of contracting COVID-19. Results imply that women are more observant of safety protocols for COVID-19 at registration and admission. Hospitals with more visible manifestation for COVID-19 prevention must help to reduce fears in mothers at the outset, making their stay at the hospital a less anxious time. These visible signs for preventive safety include: sterilization at entrance, mandatory face masks, physical distancing between seating areas, frequent sanitation of institution and availability of hand sanitizers, and PPE kits for healthcare staff.
Our second regression model showing satisfaction with care during delivery, shows signi cant associations with comfortable delivery position and movement, con dence and trust with staff, involvement in decision-making, and staff assistance in reasonable amount of time. Our ndings align with the developing world literature suggesting that the most pertinent determinants of satisfaction of labouring women is healthcare provider's interpersonal behaviour in terms of courteousness, promptness, and non-abuse (Srivastava, Avan, Rajbangshi, & Bhattacharyya, 2015). It is also important to note that our ndings show that during delivery time, services of healthcare staff are more important for mothers than the fear of COVID-19. This maybe because during delivery mothers are more worried for the safe arrival of their child. This implies that the period during delivery is an extremely vulnerable time for women, and it is the healthcare staff that has to ensure hygiene and sanitation for mother and newborn in the delivery room.
Our third regression model showing satisfaction with maternal post-delivery care shows signi cant associations with greater provision of necessary information and explanations, private hospital deliveries, and lesser fear of catching COVID-19. Our ndings corroborate international results that post-delivery satisfaction is high of mothers when they are provided adequate information about postnatal care for self and newborn (Karkee, Lee, & Pokharel, 2014). Despite high poverty rates in women of the country and low health nancing (Hassan, 2014), of the 66% of women that do deliver at institutions, 44% opt to deliver at costly private centers compared to 22% at free or subsidized public centers (National Institute of Population Studies, 2017-18). Previous research from Pakistan suggests that mothers are happier with private hospitals compared to public ones due to better services, less shortages in staff and resources, and timely service (Ashraf, 2012). There is also the concern that women are known to face disrespect by staff and providers of public sector hospitals, thus in uencing their choice for private hospitals (Munawar et al., 2017). Research from other developing regions also corroborates our ndings that public sector hospitals are perceived to be providing inferior quality of maternity services in comparison with private sector hospitals (Baltussen & Ye, 2006). In addition, private sector hospitals perform better than public sector hospitals, as they are more patient oriented and maintain focus on interpersonal relations between the healthcare provider and patient (Hulton, Matthews, & Stones, 2007).
Our fourth and nal regression model showing satisfaction with care for newborn shows signi cant associations with greater advice and support for breast feeding, child immunization, and family planning and birth spacing. Satisfaction with care for newborn also showed satisfaction with room hygiene and sanitation of room or ward. International literature suggests that when mothers are provided improved services for newborn feeding, immunization, and birth spacing, it results in improved child development in early years (Bhutta, 2005;Lassi, Das, Salam, & Bhutta, 2014). Findings also revealed that mothers are more satis ed with care for newborn when the hygiene and sanitation in the room or ward post-delivery was adequate. Recent research also suggests that mothers are concerned about hygiene and sanitation and contracting COVID-19 after the baby is born and before it is taken home safely (Brooks, Weston, & Greenberg, 2020).
Limitations of this study include the small sample size, perception based responses, and inability to sample other cities. However the strength of this study include (i) gathering data from women across both private and public hospitals, (ii) identifying socio-demographic characteristics of women who are afraid of contracting COVID-19 during institutional deliveries, and (iii) determining factors that are associated with higher satisfaction in delivery services. Our ndings can help direct improved policy for hospitals during the age of infectious pandemics. Our study also has implications for other developing regions attempting to improve delivery services at hospital-level and also aiming to improve institutional delivery rates at national-level. Finally, this study's ndings would hold true not just after the coronavirus pandemic is over, but also when infectious disease burden is generally high, as is the case in developing regions of the world, especially Pakistan (Hyder & Morrow, 2000).

Conclusion
Reducing maternal mortality and increasing rates of institutional deliveries has to become a targeted focus if Pakistan is to meet its Sustainable Development Goals. This is possible only by assessing delivery service satisfaction of women and building a culture of trust for institutional deliveries. The satisfaction levels and safety during childbirth would be communicated by women and their families, to encourage and improve institutional delivery rates. We have found that when women are provided better services and assured of safety from infection they have higher rates of satisfaction with delivery services.
Given that the time for delivery for women is usually uncertain and a time of anxiety, it would not be illogical to juxtapose time of delivery with time of pandemics. Both bring with them immense pressure to save lives, maintain hygiene, and uphold quality services in order to retain trust and con dence in healthcare institutions and healthcare providers. Thus any improvements made in delivery services in response to allaying fears of COVID-19 would help overall in maternal and neonatal health after the pandemic is over. We recommend urgent compliance by the PHC across hospitals and other health delivery centres for: (i) MSDS for maternal and newborn health services and (ii) preventive protocols for COVID-19.
To improve accountability, we recommend the linking of hospital licensing, practitioner licensing, and practitioner promotions with delivery satisfaction surveys of mothers. We recommend improvement in maternal health services of the public sector hospitals by taking into account perspective of women on the care they require and by factoring in their feedback about the healthcare they receive. Policy and regulation must also ensure availability of standardized maternal and newborn healthcare across both private and public hospitals for family planning, child immunization, and breast feeding. Special attention needs to be paid on training of staff on communications and improving interpersonal skillset, and timely attention and support for maternal and newborn care. We also recommend stricter protocols for disadvantaged women groups-de ned by lower literacy, lower household income, and unemployed status, as they are more vulnerable not just to contracting infectious diseases, but also receiving suboptimal services from healthcare providers. We must stay cognizant of the fact that most disadvantaged women, especially the ones seeking healthcare from the public sector, are unaware of what quality healthcare services entail, hence the satisfaction rates stated in this and similar studies should be interpreted with caution.

Declarations Con ict Of Interest
None Funding None

Declarations section: Competing interests
The authors declare no competing interests.
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