Factors affecting utilization and satisfaction of maternal health care services among mothers of neonates in Paropakar maternity and women’s hospital

INTRODUCTION

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period so maternal service utilization is crucial on determining women overall health status. Antenatal care and skilled health attendance at delivery are essential for eliminating every preventable maternal death. The WHO recommends that pregnant women should have four antenatal visits. First at fourth, sixth, eighth and ninth months respectively.^1,2

According to the fact sheet published by WHO, globally 2.6 million children died in the first month of life. ³ In Nepal, the Maternal mortality ratio (MMR) is 239 maternal deaths per 1,00,000 live births. Although different indicators of maternal health in Nepal had shown few improvements, but a lot of challenges on maternal health still remains.^4,5

The objective of this study was to describe the factors associated with utilization and satisfaction of maternal health care services among mothers having neonates in Paropakar maternity and women’s hospital.

METHODS

A hospital based quantitative cross-sectional study was conducted from September 2018 to April 2019 among 210 recently delivered mothers (15-49 years) who had normal delivery in Thapathali maternity and women’s hospital of Kathmandu district. The sample size (N) was calculated using the formula-

Where, N= sample size; Z= 1.96 for CI of 95%; P= prevalence of antenatal care during all specified months in Central Development Region (51%).⁴

e= margin of error= 7%.

The calculated sample size was 196. By adding non-response rate of 7%, the final sample size for the study was 210. Recently delivered woman having normal delivery in Thapathali maternity hospital were included in the study. Women having cesarean delivery, severely ill and mentally depressed women were excluded.

A set of structured questions and Interviews was done and simple random sampling was used as sampling technique. The names of the respondents were collected from the register book of the ward. Confidentiality was maintained throughout the study.

The quantitative data were presented on descriptive statistics using percentage and table by using statistical data analysis techniques (SPSS 16.0). The relation between dependent and independent variables were shown by using chi-square test. P value less than 0.05 was considered as statistically significant throughout the analysis in this study.

RESULTS

Socio-demographic characteristics of respondents

Table 1 shows socio-demographic characteristics of respondents where, majority (82.9%) of the women having normal delivery in hospital were above 20 years of age where 56.7% were married before or at the age of 20 years and two-third of the women (66.2%) age at pregnancy was after 20 years. Ninety-five (45.2%) of the respondents taken under study were Janajati. Almost two-third (62.4%) were from joint family where the majority (86.7%) had two or less than two children. Nearly, three-fourth (72.4%) of the respondents were housewives, and more than three-fourth (78.6%) household income was less than NRs. 10,000.

Utilization of antenatal care service

Table 1 shows, utilization of antenatal care service, where of total respondents, time taken to reach the hospital for 81.4% was one hour or less. Similarly, two-third (66.7%) had completed 4 or more ANC visits and 47.6% completed it as per protocol. Nearly three-fourth of the respondents visited public health facility (74.8%) for ANC service and almost nine in ten were assisted by trained health professionals. Majority (91.9%) of the respondents were suggested by their husband/family members to have ANC checkup and more than three quarters of 78.6% were influenced by mass media for utilization of ANC and institutional delivery service. Almost two-third (63.3%) knew about maternal health services.

Satisfaction on maternal health service of hospital

Table 3 shows satisfaction on maternal health service of hospital, which was self-administered questionnaires having 5 category approaches to scaling responses of satisfaction and is based on Likert scale. Majority of neutral responses were observed for satisfaction on staff behavior (36.7%), counseling service (41%), staffs and patients communication (45.7%), and consultation time (41.9%). Most of the respondents were satisfied with doctors’ availability (41.9%), staff availability (44.3%), and privacy maintenance (47.1%). Similarly, dissatisfaction was observed for cleanliness 99 (47.1%), availability of medicine and other medical products 96 (45.7%) and status of infrastructure 110 (52.4%).

Factors affecting utilization of antenatal care service

Respondents’ age at marriage and age at 1st pregnancy was not statistically significant. Educational status of a women was not statistically significantly however, literate women were 2.327 times more likely to visit ANC as per protocol than illiterate women (OR=2.327, 95% CI=0.789-6.856, p=0.126). Respondents whose ethnicity was Dalit were significantly associated with ANC as per protocol (OR=0.294, 95% CI=0.126-0.685, p=0.005).

Hindu and Buddhist respondents were 4.197 and 3.325 times respectively more likely to visit ANC as per protocol than Christian respondents. Similarly, income of respondents more than or equals to NRs 10,000 were 2.125 times more likely to be visit ANC as per protocol (OR=2.125, 95% CI=1.065-4.241, p=0.032) than income less than NRs 10,000 which was found to be statistically significant. Education level and family type of the respondents were not statistically significant with ANC visits.

Incentives given for ANC visit was not statistically significant with ANC visit as per protocol. Similarly, family members/husband suggestion for utilization of ANC (OR=4.715, 95% CI=1.313-16.933, p value=0.017), ANC assisted by Trained health professionals (OR=23.360, 95% CI=3.079-177.225, p value=0.002), impact of mass media on the utilization of ANC (OR=14.261, 95% CI=4.881-41.670, p value<0.001) and time taken to reach health facility within or less than 1 hour (OR=2.763, 95% CI=1.293-5.903, p value<0.009) were significantly associated with ANC as per protocol.

Note: *-Multiple responses.

Note: *Significant at <0.05.

DISCUSSION

In this study, utilization of maternal health service was measured by ANC visits as per protocol which was 49.8%. According to Nepal demographic health survey 2016, 58.8% of a women had ANC during all specified months.⁴

This study shows that women whose age at 1st pregnancy was above 20 years were 1.386 times and whose ethnicity and religion was Brahmin/Chettri and Hindu were 1.2 and 4.1 times more likely to visit ANC as per protocol, similar findings was observed in study carried out by A. Sunil shows that women whose age at first child born was above 20 were 1.5 times more likely to have at least 4 ANC visits.⁷

According to this study, literate women were 2.3 times more likely to utilize ANC service, similarly study carried out by Kidist et al in Holeta town of Central Ethiopia shows that women with some education were more than two times more likely to attend ANC (OR=2.645, 95% CI=1.078 6.487, p=0.034)) as compared with those who had no education.⁸ Respondents who had impact of mass media for utilization of ANC were 14 times more likely to visit ANC as per protocol than those who were not impacted. The findings of the study were comparable with a study conducted by Deo et al in Eastern Nepal which shows that respondents who were exposed to mass media for utilization of ANC service were 3.5 times more likely to have four or more ANC visits than the women who were not exposed to media information regarding maternal health care (OR=3.5, 95% CI=1.2-10.1).⁶

Women who were within hour distance to the health facility were 2.7 times more likely to use ANC services as per protocol which was supported by a study done in Rural Chitwan, Nepal by Shah et al which shows that, women living within one hour’s distance from a birthing facility were more likely to utilize maternal health service than women living further away (OR=2.15, 95% CI=1.26-3.69, p=0.005). Similarly, high percentage (72.4%) of the women in the study were housewives but women engaged in Job (service or trade) were 1.2 times and those who were labor were 1.6 times more likely to utilize ANC as per protocol. The findings of this study is similar to other studies done by Buna et al and Dhimal et al which shows most (53%) and (80.4%) of the respondents under study were housewives. Also, study conducted in Nepal by Sunil et al shows that women whose occupation is manual labor (57.7%) have utilized ANC services 4 or more times and the logistic regression analyses result shows that women who are in service or trade related occupation are 2.43 times more likely (95% CI=1.761-3.368) to use ANC services 4 or more times than those women who are not working.^7,9-11

According to this study, women who knew about ANC Checkup were 6.5 times more likely to visit ANC as per protocol than women who didn’t knew about it and was statistically significant. A similar finding had been reported in a study done by Amentie et al in Assosa District, West Ethiopia and in Southern Ethiopia by Wakgari et al shows that women who were knowledgeable about ANC service were 1.96 and 16.35 times more likely to utilize ANC service than women who were not knowledgeable on ANC services (AOR=1.96, 95%; CI=1.04-3.68) (OR=16.35, 95% CI=6.07-44.04, p value<0.000].^12,13

Respondents who were suggested by family members/husband for ANC check-up were 4.7 times more likely to utilize ANC as per protocol (OR=4.715, 95% CI=1.313-16.933, p value=0.017) than those who were not and was also statistically significant.

Similarly, a study carried out by Kidist et al in Holeta town of Central Ethiopia shows that utilization of ANC was almost nine times more likely for women reported their husband’s approval for ANC was found to be statistically significant. (OR=8.99, 95% CI=3.706 21.855, p value=0.000).⁸

Regarding statements related to health institutions, most (41.9%) of the respondents were satisfied with the doctor’s availability in hospital. The result of study conducted in Rural Bengal by Das et al showed that more percentage of the respondents (73.94%) had a satisfactory level of satisfaction regarding the availability of doctors in that institution.¹⁴

Furthermore, the study shows that higher percentage (47.1%) of the respondents were satisfied with privacy maintained at hospital and most (41%) of the respondents were had neutral repsonses towards counseling service of the hospital, about 45.7% of the respondents were dissatisfied with the availability of all medicines and other medical products. Similar findings were observed in a study done by Panth et al in a government hospital of Mid-Western Nepal shows a consistent result regarding privacy maintained, counseling service and availability of all necessary medicines and supplies where most 47.2%, 53.4% and 44.4% were satisfied with privacy maintained, counseling service and availability of all necessary medicines and supplies.¹⁵

Higher percentages (52.4%) were not satisfied with status of hospital infrastructure followed by 27.1% having neutral response. A study done by Taghavi et al in Northwest Iran shows that higher percentage of the respondents (42.4%) were satisfied with physical infrastructure of health facilities followed by 31.3% of respondents having neutral response, whereas only 3.3% of the respondents were dissatisfied with the physical infrastructure of health facilities.¹⁶

The limitation of this study was that it was only confined to mothers visiting Paropakar maternity and women’s hospital, so it might not predict to mothers from different health service seeking settings.

CONCLUSION

The study reveals that out of 210 respondents, 100 (47.6%) respondents visited ANC as per protocol while, 110 (52.4%) visited ANC but not as per protocol, still every respondent had at least one ANC visit during her pregnancy, where most of them visited public health facilities. Ethnicity, religion, monthly income, support from husband/family were factors supporting to utilize the antenatal care services.

ACKNOWLEDGEMENTS

We would like to thank Ms. Anuska Karki, Mr. Amol Pachhaldangiya and Mr. Niskar Sharma, Ms. Alina Koirala, IRC of Paropakar maternity and women’s hospital and to all respondents.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. WHO. Maternal health, 2020. Available at: https://www.who.int/health-topics/maternal-health. Accessed on 01 September 2021.
2. 2. WHO. What is the efficacy/effectiveness of antenatal care and the financial and organizational implications?, 2020. Available at: https://www.euro.who.int/data/assets/pdf_file/0007/74662/E82996.pdf. Accessed on 01 September 2021.
3. 3. WHO. Newborns: reducing mortality, 2019. Available at: https://www.who.int/news-room/factsheets/detail/newborns-reducing-mortality. Accessed on 01 September 2021.
4. 4. Ministry of Health. 4. Nepal Demographic and Health Survey 2016, 2017. Available at: https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf. Accessed on 01 September 2021.
5. 5. Bhusal CK, Bhattara S, Bhaskar R. Maternal health in Nepal: progress, Challenges and opportunities. Int J Med Heal Res. 2015;1:68-73.
6. 6. Deo KK, Paudel YR, Khatri RB, Bhaskar RK, Paudel R, Mehata S, Wagle RR. Barriers to Utilization of Antenatal Care Services in Eastern Nepal. Front Public Health. 2015;3:197.
7. 7. Acharya SK. Demographic and Socio-economic Factors Affecting Antenatal Care Services Utilization in Nepal. J Devpt Admin Stud. 2018;24(1):71-87.
8. 8. Birmeta K, Dibaba Y, Woldeyohannes D. Determinants of maternal health care utilization in Holeta town, central Ethiopia. BMC Health Serv Res. 2013;13(1).
9. 9. Shrestha B, Prasad PD, Shrestha N, Dhimal B. Client’s Satisfaction on Maternity Services at Paropakar Maternity and Women’s Hospital, Kathmandu. J Health Allied Sci. 2010;1(1):56-9.
10. 10. Bhandari B, Pokhrel B, Bhatta B, Karn R, Pokhrel A, Jha N. Utilization of maternal health care services in Belbari VDC of Eastern Region of Nepal. J Nobel Med Coll. 2012;1(1):53-8.
11. 11. Habte F, Demissie M. Magnitude and factors associated with institutional delivery service utilization among childbearing mothers in Cheha district, Gurage zone, SNNPR, Ethiopia: a community based cross sectional study. BMC Preg Childbirth. 2015;15(1):299.
12. 12. Amentie M, Abera M, Abdulahi M. Utilization of Antenatal Care Services and Influencing Factors among Women of Child Bearing Age in Assosa District, Benishangul Gumuz Regional State, West Ethiopia. Global J Med Res. 2015;15(2):9-17.
13. 13. Dulla D, Daka D, Wakgari N. Antenatal Care Utilization and Its Associated Factors among Pregnant Women in Boricha District, Southern Ethiopia. Diver Equality in Health Care. 2017;14(2):76-84.
14. 14. Pal R, Das P, Basu M, Tikadar T, Biswas G, Mridha P. Client satisfaction on maternal and child health services in rural Bengal. Indian J Community Med. 2010;35(4):478.
15. 15. Panth A, Kafle P. Maternal Satisfaction on Delivery Service among Postnatal Mothers in a Government Hospital, Mid-Western Nepal. Obstetr Gynecol Int. 2018;2018:1-11.
16. 16. Taghavi S, Ghojazadeh M, Aghdash SA, Alikhah H, Bakhtiarzadeh K, Azami A, et al. Assessment of mothers’ satisfaction with the care of maternal care in Specialized Educational-Medical Centers in obstetrics and gynecological disease in Northwest, Iran. J Anal Res Clin Med. 2015;3(2):77-86.