Maternal satisfaction among mothers delivering at public health facilities in India: a narrative review

INTRODUCTION

The sustainable development goals (SDG) target is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. For 2017 to 2019, maternal mortality ratio (MMR) estimate for India is 103.¹ India looks all set to achieve the SDG target. Ministry of Health and family welfare has taken many initiatives to address the maternal mortality viz. Janani Suraksha Yojna (JSY), Janani Shishu Suraksha Karyakram (JSSK), Surakshit Matritav Abhiyaan (SUMAN) and many more. These initiatives by the government have increased the availability of the services as well as incentivizing the use has led to increase in the institutionalization of childbirths.

It is also a well-accepted truth that only the availability and its use does not endure that quality service are being provided. Satisfaction is considered as an important indicator of quality of the services offered. Maternal satisfaction reflects the quality of services offered by the public health facilities.²

Evaluation of satisfaction of mothers with child birth services is an important aspect to explore the perception of mothers regarding the quality of the available services. Women who are satisfied with their childbirth experiences tend to have a better self-esteem and an improved maternal neonatal bonding and also are more likely to breast feed the newborn. Several factors influence the satisfaction of the mothers regarding child birth services. It may include their expectations of the child birth experience their fear of labor pains. Maternal satisfaction is also seen to be influenced by the outcome of the labor process.³

In order to ensure the availability of basic and emergency obstetric care services round the clock 24×7 primary health care’s (PHC's) have been operationalized. Type B PHC's that are conducting more than 20 deliveries in a month are being operationalized to function for 24×7 hours. Perspective of the service users is an important indicator of quality of services provided at the center therefore assessment of maternal satisfaction of the mothers delivering at public health facilities is very important. Ministry of Health and Family Welfare also has emphasized on client centered provision of services.⁴

Pregnancy and childbirth are perceived to be a natural process and women in the ancient times have delivered at home. Almost 50% of the maternal deaths occur during labor and within 48 hours after birth. Institutionalizing child birth through incentivizing them by initiatives like JSY have made immense contribution in increasing the rate of institutional deliveries to almost 85-90%. Increase in the awareness and incentives have led to increased utilization of the services but it does not guarantee the quality of services.⁵

A community based cross sectional survey to explore the women’s expectations influencing her choice to deliver at public health facilities. This study concluded that availability of medicine and supply and her perception of possible health benefits and availability of good care influences her decision to opt for delivering at public health facilities. They observed that women with higher age, education and income were more inclined to have antenatal checkups. Regular assessment of the maternal satisfaction should be an integral part of quality improvement initiative.⁶

Considering an important maternal health concern researcher undertook this narrative review to highlight level of maternal satisfaction among mothers delivering at public health facilities in India, determinants of maternal satisfaction with childbirth services and recommend interventions that can improve maternal satisfaction.

METHODS

The narrative review summarizes the maternal satisfaction with childbirth services at public health facilities and its determinants. Authors browsed pub med and Google Scholar using keywords maternal satisfaction, determinants, public health facilities, primary health centers, maternal and newborn services, childbirth services. Reference list of all selected articles was also searched for relevant articles. Research studies quantitative/qualitative published in English and available in full text exploring maternal satisfaction with childbirth services in public health services were included in this review. 26 articles were retrieved. 12 duplicate articles from these were removed and rest 14 articles were screened and further 4 more articles were removed. A total of 10 articles were included in this narrative review. All these articles were thoroughly read and evaluated. This review is arranged under the subheading’s maternal satisfaction, determinants of maternal satisfaction and recommendations to improve maternal satisfaction.

RESULTS

Maternal satisfaction with child birth services

Patient centered services provide respectful care that is responsive to the needs of the individual's and in congruence with their values. Services that are tailored to the individual needs of the mother are satisfying to them and motivate optimum utilization of the services.

A cross sectional survey conducted by Jha et al exploring the satisfaction with childbirth services in public health facilities including 2 district hospitals and 15 community health centers among postnatal women in Chhattisgarh concluded that most of the women (68.7%) were satisfied with overall childbirth services received. Mothers reported least level of satisfaction regarding the process around meeting their neonates. interaction with care providers, provision of privacy, being free of fear of childbirth and monetary incentive had a positive influence on overall satisfaction of mothers.³

A descriptive study conducted by Pricila et al to assess the satisfaction of antenatal mothers with the care provided by nurse-midwives in an urban health center in South India concluded that majority (95%) of mothers were satisfied with the antenatal care whereas only a few (31.8%) were satisfied with family planning health advice.⁷

A community based cross-sectional study carried out among mothers delivered at 24×7 PHCs of a district in Western India by Misra et al concluded that majority of the mothers (89%) were satisfied with the behavior of the staff, cleanliness at PHC (92%) and obstetric care services (87%). A very important point was highlighted by the researchers that very few mothers (14%) were observed for more than 24 hours after a normal delivery therefore they recommended that the postnatal stay needs to be extended for at least 48 hours.⁴

A systematic review conducted by Srivastava A to identify determinants of women's satisfaction with maternal care in developing countries. All three domains of the Donabedian model of quality-of-care framework including the structure, process and outcome were found to influence maternal satisfaction with childbirth services. Infrastructure, sanitation, competent human resource and availability of medicines were the structural elements. Behaviour of the staff, provision of privacy and emotional support were the process elements. Health status of the mother and newborn were identified as the outcome elements. They concluded that developing countries should focus on the process of care and health care workers should be motivated to improve the interpersonal behavior.²

A qualitative study conducted by Bhattacharya et al to explore the service provider's and service receiver’s perspective of available maternity services at secondary level public health facilities in Uttar Pradesh. Major concerns reported by mothers were physical access, cleanliness, interpersonal behavior, information sharing and out of pocket expenditure.⁸

Das in their implementation study reported that higher patient satisfaction with delivery and antenatal care was associated with prompt response, reduced waiting time, cleanliness, availability of supplies, informed treatment and lowered expenses. Major determinants of maternal satisfaction were identified as readiness of the facility, reduced waiting time and counselling by health care providers.⁹

Bhattacharya in their qualitative study identified major themes of care prioritized by women included availability of competent human resource; availability of supplies, medicines and equipment; food; transportation services; proper sanitation; provision of privacy; good maternal and newborn outcome without any complications; interpersonal communication; decreased out of pocket expenses.⁵

Bhattacharya et al in their study to assess women's perception of good delivery care concluded that women undergoing delivery at health care facilities expect competent human resource, availability of drugs and supplies, transport facilities, no out of pocket expenditure, incentives, and timely care. Respectful behavior and clean labor room were also important factors identified by delivering women.¹⁰

Determinants

Identifying the determinants of maternal satisfaction helps to develop an insight into what are the factors that affect the maternal satisfaction with childbirth services and what are the expectations from the perspectives of the service receivers.

Interpersonal behavior has been identified as a very important determinant of maternal satisfaction. If the nurse midwives or staff in the public health facilities speaks politely to the mothers and greets them, they are more comfortable at the facilities. Other determinants of maternal satisfaction are waiting time, privacy during internal examination, perception of provider's competency, cleanliness, and preference for female providers. Though all the three components including the structure, process and outcome had an impact on the maternal satisfaction but the process of care dominated the determinants of maternal satisfaction.⁷

Recommendations/Interventions to promote maternal satisfaction by nurse midwives

Nurse midwives are the PHC providers in public health facilities.³ Nurse midwives and other staff including the doctors by being more respectful and welcoming to the mothers can change the perception of mothers towards public health facilities. Postnatal stay needs to be extended for at least 48 hours.⁴

Maintaining proper cleanliness and making adequate arrangements for provision of privacy, minimizing waiting time, involving mothers in decision making and allowing companion of choice during birth are some measures that can promote maternal satisfaction with childbirth at public health facilities.

DISCUSSION

This review attempts to develop an insight into level of maternal satisfaction and its determinants among mothers delivering at public health facilities in India. Maternal satisfaction is a very important indicator of quality of services; therefore, it is very important to assess the maternal satisfaction and its determinants. Majority of mothers in all studies were satisfied with the available services which could be because of the fact that at times the outcome of the delivery – healthy mother and newborn dominates the process of care. While understanding the determinants of maternal satisfaction it was observed that all 3 aspects of the Danabedian model of quality assurance including the structure, process and outcome have been found to affect the level of maternal satisfaction with childbirth services. Structural component included the availability of the infrastructure, accessibility, water, electricity, sanitation. Process component included the interpersonal interaction between the mother and the staff, provision of privacy, less waiting time. Outcome components included the positive pregnancy outcome in the form of a healthy baby and mother. The most important finding of this review was that the process component dominated the determinants of maternal satisfaction and interpersonal behavior was identified as the most important determinant of maternal satisfaction.^2-6

CONCLUSION

This review is useful in identifying the determinants of maternal satisfaction and can help in focusing on these areas while assessment of quality of care or take action to improve quality of care. Delivery of the patient centered services is a very important component and further research on exploring the maternal perspective of the quality of care received can prove to be an important step in improving quality of maternal and newborn services at public health facilities in India

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Ministry of Health and Family Welfare Government of India. Special Bulletin on Maternal Mortality in India 2014-16. SRS Bull. 2018;(91):1-3.
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3. 3. Jha P, Larsson M, Christensson K, Svanberg AS. Satisfaction with childbirth services provided in public health facilities: Results from a cross-sectional survey among postnatal women in Chhattisgarh, India. Glob Health Action. 2017;10(1).
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8. 8. Bhattacharyya S, Issac A, Rajbangshi P, Srivastava A, Avan BI. “Neither we are satisfied nor they”-users and provider’s perspective: A qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India. BMC Health Serv Res. 2015;15(1):1-13.
9. 9. Das MK, Arora NK, Dalpath SK, Kumar S, Kumar AP, Khanna A, et al. Improving quality of care for pregnancy, perinatal and newborn care at district and sub-district public health facilities in three districts of Haryana, India: An Implementation study. PLoS One. 2021;16:1-25.
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