Maternal satisfaction towards childbirth Service in Public Health Facilities at Adama town, Ethiopia

Background Maternal satisfaction towards childbirth service is related to the quality of care. Promotion of patient satisfaction is essential for preventing patient anxiety, promoting treatment adherence, preventing disease, and health promotion. This study was aimed at assessing the satisfaction and associated factors among mothers who visit public health facilities in Adama town for childbirth service. Methods An institution based cross-sectional study design was conducted at public health facilities in Adama town from June 01 to June 30, 2018. Four hundred seventy-seven mothers were selected using a systematic random sampling method. Bivariate and multivariate logistic regressions were conducted to identify predictors of maternal satisfaction towards childbirth service by considering p-value less than 0.05. Results The study revealed that 357 (74.8%) were satisfied with the services. Factors which showed a significant association with satisfaction were 25–34 age group (AOR; 2.026, 95%CI:1.056,3.887), no formal education (AOR;2.810, 95%CI;1.085,7.278), planned childbirth (AOR; 1.823,95%CI;1.024,3.246), wait time of less than 1 h (AOR;11.620,95%CI;3.619,37.309) and wait time of one to 2 h (AOR;19.620, 95%CI;2.349,68.500). Conclusion Three-quarters of the mothers were satisfied with childbirth services. Age, educational status, reason for visit and wait time were found to have a significant association with maternal satisfaction of childbirth services.


Introduction
Client satisfaction of childbirth services is related to the quality of care [1]. Satisfaction is a means of preventing maternal death related to the lack of adherence to health counseling [1,2]. Increasing satisfaction of services has long-term benefit for both the community and patients.
If high quality care is provided, the utilization of reproductive and sexual health services will increase [3,4].
Health service satisfaction is influenced by cultural beliefs, accessibility, socioeconomic status, affordability, health professionals' approach, cleanliness of wards, and waiting rooms [4].
The health of the whole community is directly linked to the health of reproductive age women. There is a relationship between maternal and neonatal health. The immunization status, childhood development, and survival are affected by maternal health status. Healthier women and children create a better society [5][6][7]. Therefore, effective basic antenatal care, skilled birth attendance, post-partum care, and treatment of complications is essential [8,9]. Therefore, to decrease the maternal and child mortality and morbidity, affordable, respectful and evidence-based care is necessary [10].
Satisfaction of services reflects expectations and the quality of health care received [11]. Every health professionals should work skillfully and practice with compassionate care [12,13].
The World Health Organization (WHO) recommends respectful, women-centered and evidence-based maternity practice, which improves birth outcomes. Furthermore, maintaining the highest standard of personal conduct, integrity, proper and effective communication with patients is an integral component of the health system. Therefore, incorporating these principles may improve outcomes [14,15].
In developing countries, still, less than 50% of the mothers are satisfied with the childbirth services [3]. In urban areas of Ethiopia, the institutional delivery rate is 79%. According to the Ethiopian Ministry of Health sector transformation plan, maternal and newborn health is a priority. Respect to patient's autonomy, dignity, feelings, and preferences is mandatory. To increase the institutional childbirth rate and promote the utilization of postnatal care, care should focus on maintaining client satisfaction [16].
Assessing satisfaction of childbirth services and health care facilities might help to guide the development and improvement of services; one way of doing this is by surveying patients who have used health services. This study tried to assess maternal satisfaction and associated factors in three public health facilities at Adama town. This information will be helpful for the health professional to improve the quality of service delivery. In addition, the study findings can help health policymakers and other sectors working on maternal health to standardize the existing interventions.

Study area, period and design
A cross-sectional study was conducted at Adama hospital and medical college, Adama health center and Geda health center in Adama, East Shewa Zone, Ethiopia. The study was conducted from June 01 to June 30, 2018.

Inclusion and exclusion criteria
All mothers who visited the public health hospital at Adama town for childbirth services were included, those who were critically ill were excluded.

Sample size and sampling procedure
The required sample size was determined by using a single population proportion formula with the following assumptions, 74.9% maternal satisfaction level [17] with 95% confidence interval and 4% margin of error. Adding of 10% non-response rate, the final sample size was 497.
One governmental hospital and two health centers were selected using a random sampling method, and then the sample was proportionally allocated among the health institutions. Systematic random sampling was used to select participants,. Every fourth delivering mother in the governmental hospital was included and every third delivering mother was selected in each health center.

Operational definition Satisfaction
Those who reported being satisfied with greater or equal to 75% of items were categorized as satisfied, while those who were satisfied in less than 75% of the items were categorized as unsatisfied [8-12, 17, 18].

Data collection instrument and procedure
The structured questionnaire was adapted from the Donabedian quality assessment framework [18] and presented using a 5-scale likert scale (1-very dissatisfied, 2dissatisfied, 3-neutral, 4-satisfied, and 5-very satisfied). The questionnaire was shown to be reliable in the study (Cronbach's α = 0.725). The questionnaire sought information on the socio-demographic characteristics, obstetrics history, service characteristics and satisfaction level (Additional file 2).
Data collection was carried out in the postpartum unit. Four midwifery nurses were recruited as data collectors. One supervisor monitored the data collection. Training was provided for the data collectors and the supervisor for 2 days by the principal investigator. The training included the study objective, the meaning of each question and interviewing technique.

Data quality assurance
After completing training, data collection was piloted. During the data collection period, completeness, consistency, and accuracy of each questionnaire were reviewed.
Corrective measures were taken, when necessary by the research team, to ensure a common understanding of each question. A translator was also used in some interviews.

Data processing and analysis
All data was checked manually for completeness and then coded and entered using EpiData version 3.1. Data were exported to SPSS version 20. Chi-Square was used to test a significant difference of satisfaction level among mothers who delivered in the three public health facilities. Significance was determined by using crude and adjusted odds ratios with 95% confidence intervals. To assess the association between the dependent variables and independent variables, bivariate logistic regression was used. Then multivariable logistic regression was   Table 2).
Characteristics of the service delivered 461(96.6%) reported that the facility had no waiting area. Three hundred fifty-two (73.8%) had reported that the wait time was less than 1 h. Two hundred ninety-six (62.1%) received services from midwives. Two hundred eight-seven (60.2%) of them received services from male health professionals. Three hundred sixty-six (76.7%) and 393(82.4%) would like to use institutional delivery in the future and recommend institutional delivery to others, respectively ( Table 4).

Level of satisfaction of childbirth service
Of the respondents, 357 (74.8%) and 120 (25.2%) were satisfied and unsatisfied by the services, respectively (Fig. 1). Furthermore, a significant difference was observed regarding the level of satisfaction among mothers   (Table 6).

Discussion
In this study, 74.8% were satisfied with the care delivered during childbirth. This finding is similar to a study conducted in Bahir Dar, which stated that 74.9% of the mothers were satisfied with their care [17]. This is lower than a report from studies conducted in Northwest Ethiopia, Southwest Ethiopia, Oromia region, west Gojjam, mid-western Nepal, and Gamo Gofa which stated that 81.7, 79.1, 80.7, 88, 89.88, 90.2% of the mothers were satisfied, respectively [19][20][21][22][23][24]. On the other hand, the finding is higher than a report from studies conducted in Addis Ababa, Amhara region, Jimma zone, and Eritrea, which stated that 19, 61.9, 65.2, and 20.8% of mothers were satisfied, respectively [25][26][27][28]. The differences might be related to the quality of services delivered at various health institutions and differing expectations. Furthermore, differences might be related to the study settings, study period or type of health institution. Dissatisfaction might be related to the fact that most women in this study had an unwanted pregnancy. In addition, the majority of the health professionals were male; however, in developing countries, most women prefer to have a care provided by women [3]. In this study, having no formal education had a positive association with satisfaction towards childbirth services. This is supported by studies conducted in midwestern Nepal [23], Gamo Gofa [24], and Ethiopia [29]. The expectation of services may be related to levels of knowledge [30]. Knowledge of the mothers is influenced by educational status [31].
Admission for a planned delivery was positively associated with satisfaction of childbirth services.
Wait times of less than 1 h or one to 2 h were positively associated with satisfaction of childbirth services. Research in South Ethiopia [24], Gamo Gofa [20] and Kenya [32] showed that mothers with less hours of waiting time had an increased satisfaction towards the childbirth service.
Mothers aged 25-34 years were two times more likely to be satisfied with childbirth services compared to those aged 35 and older. This is supported by research conducted in Jimma zone [27] and Oromia region [21]. This finding is opposite to a report from a study conducted in Bahirdar, which showed that women aged 20 to 34 years were less likely to satisfy with the care received compared to women aged 35 to 49 years [18]. In this study, most of the mothers aged 25-34 years had a complication as compared to those aged 35 and above. This might create dissatisfaction among the mothers aged 25 to 34.
The strength of the study was the involvement of three health facilities. It also used standardized measurement scale. It has to be noted that the finding of this study mainly reflects the situation in Adama town. Therefore, the findings should be interpreted with caution. The  responses might be subject to social desirability bias. The factors expected to influence satisfaction of childbirth services may not be exhaustive.

Conclusion
Only three-quarters of the mothers were satisfied with the childbirth service. Age, educational status, reason for visit and wait time were found to have a significant association with the satisfaction services. This study was not able to address the perception of health professionals and this could be an area of future research. In addition, future qualitative and quantitative research could explore the mechanism required to promote the quality of childbirth services.

Supplementary information
Supplementary information accompanies this paper at https://doi.org/10. 1186/s12978-020-00911-0. Authors' contributions MT, DB, ROF and MSO conceptualized and designed the study, analyzed, interpreted the data, drafted the manuscript and critically reviewed the manuscript. All the authors read and approved the manuscript.

Funding
No funding.

Availability of data and materials
The data-sets used and analyzed during the current study are available from the corresponding author on reasonable request. *: Significant association at p-value < 0.05, **: Significant association at p-value < 0.001