Mehata et al. BMC Pregnancy and Childbirth (2017) 17:319 DOI 10.1186/s12884-017-1532-0
RESEARCH ARTICLE
Open Access
Factors determining satisfaction among facility-based maternity clients in Nepal Suresh Mehata1*, Yuba Raj Paudel1, Maureen Dariang1, Krishna Kumar Aryal2, Susan Paudel3, Ranju Mehta3, Stuart King1 and Sarah Barnett4
Abstract Background: With an increasing number of institutional deliveries, the Nepalese health system faces a challenge to ensure a quality of service provision. This paper aims to identify the determinants of client satisfaction with maternity care in Nepal using data from a nationally representative health facility survey. Methods: A total of 447 exit interviews, with women who had either recently delivered or who had experienced obstetric complications, were conducted across 13 districts in Nepal (87% in hospitals, 8% in Primary Health Care Centres (PHCCs), and 5% in Sub/Health Posts(S/HPs). Client satisfaction was measured using an eight item scale that covered accessibility, interpersonal communication, physical environment, technical aspect of care and decision making. A client satisfaction index was computed using ordinal principal component analysis. A multivariate probit model was used to assess the net effect of explanatory variables on client satisfaction. Results: Longer waiting times and overcrowding increased the likelihood of dissatisfaction. Having an opportunity to ask questions was positively associated with client satisfaction. Respondents from hill districts and rural areas were more likely to be satisfied in comparison to respondents from mountain, terai and urban areas. Sociodemographic factors (age, parity, caste/ethnicity, education, and ecological zone) and supply side factors (the time taken to reach a facility, type of facility, payment for services, and unknown heath worker or anyone entering the delivery room) were not statistically associated with satisfaction. Conclusions: The findings suggest client satisfaction with the quality of maternity services in Nepal could be improved by reducing waiting times and overcrowding, and giving the mothers adequate time to ask questions. If clients are more satisfied they are more likely to use the facility again/recommend to a friend. Keywords: Quality of care, Client satisfaction, Maternity care, Utilisation, Nepal
Backgroud Satisfaction with maternity care is a multidimensional construct embracing satisfaction with self (personal control), and with the physical environment of delivery room and quality of care [1]. Aspects of care that may influence client satisfaction include: provider attitude, provider competence, outcome, physical environment, continuity of care, access, information, cost, bureaucracy and attention to psychosocial problems. Quality of care may not always be linearly associated with the level of satisfaction as perceived by the clients [2], however, client satisfaction is * Correspondence: [email protected] 1 Nepal Health Sector Support Program, Ministry of Health and Population, Ramshaha Path, GPO Box: 7830, Kathmandu 44600, Nepal Full list of author information is available at the end of the article
an important determinant of utilization of health services and the choice of health facility [3], it is important to know clients’ views and experiences while designing health programmes [4]. Client satisfaction also impacts the viability and sustainability of health care services, and is an important input for regular monitoring and quality improvement in health care delivery systems. Hospital-based maternity care has contributed towards the reduction in maternal and neonatal mortality and morbidity in developing countries [5, 6]. With the increasing rates of institutional deliveries, poor countries are now facing a challenge to ensure good quality maternity care [7]. Access to and availability of institutional delivery care alone is not enough to achieve the desired goals in maternal and child health, it is also the quality of care that saves
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mehata et al. BMC Pregnancy and Childbirth (2017) 17:319
lives of mothers and newborns. Although client satisfaction is not directly addressed in the Nepal Health Policy 1991 [8], the Nepal Health Sector Programme-2 (NHSP-2: 2010–2015), includes client satisfaction as an essential component of health service delivery [9]. The newly released National Health Policy aims to develop an accountable health system that includes a mechanism to collect client complaints/feedback [10]. Several studies have described the determinants of clients’ satisfaction with maternity care in other countries [2, 11–14]. Women who are treated with respect, courtesy and dignity, and have trusting relationships with their care providers are more likely to be satisfied [15]. Lack of involvement in decision making and inadequate information about their care are associated with dissatisfaction [16]. Older people more commonly report satisfaction with maternity care [12–14, 17]. Compared to the service tracking survey 2012 (STS 2012), which showed 90% of clients satisfied/very satisfied) [18], STS 2013 showed a slightly lower satisfaction (86%) to maternity services [19]. Similarly, slightly higher percentage of maternity clients (4%) mentioned not willing to visit the facility again in STS 2013 [19] compared to STS 2012(3%) [18]. The two studies cited above (STS 2012 and STS 2013) have only looked into the percentage of clients satisfied but have not explored the determinants. This study will be helpful to address the knowledge gap regarding determinants of maternity clients satisfaction in the Nepalese context and similar settings.
Methods Data source and sampling
This study is the secondary analysis of the survey data obtained as part STS 2013 conducted by the Ministry of Health (MoH), Nepal. The survey incorporated a facility questionnaire, and maternity and outpatient exit interviews. The primary objective of the survey was to provide national estimates for key reproductive, maternal, neonatal and child health indicators related to service availability, readiness and distribution of public (not private) sector of Nepal. Nepal consists of 75 districts divided into three ecological zones (mountain, hill, and terai), or five administrative regions. For the purposes of the study design these ecological zones and administrative regions were amalgamated to form 13 sub-regions. The survey used a twostage sampling design. In the first stage, one district was randomly selected from each of 13 sub-regions and these districts were the Primary Sampling Units (PSUs). This resulted in three districts being selected from the mountain region, five from the hill region, and five from the terai region, which are considered as strata for this study. In the second stage, the facilities were selected within each of the 13 districts. The higher the level of facility, the greater the probability of being selected: all public hospitals (17) and
Page 2 of 10
primary health care centres (PHCCs) (39) from the selected districts were included and an Equal Probability Sampling Method (EPSEM) was used to select health posts (HPs) (100/208) and sub-health posts (SHPs) (68/ 490). All maternity clients from PHCCs, HPs and SHPs attending the course of 2 days, and up to five clients per hospital, were interviewed. More details on the methodology are presented in the STS 2013 final report [20]. A total of 447 women who delivered at the facility or sought care for intra-partum complications were interviewed across the 13 districts (87% in hospitals, 8% in PHCCs, and 5% in S/HPs.). All clients who participated in exit interviews had received inpatient services. The smaller percentage of interviews at lower level facilities reflected the lower caseload. Data collection and quality assurance
Data collection was performed from July to August 2013. A total of 43 enumerators and 13 field supervisors were recruited for data collection. All of the field researchers had some experience of research/data collection, and had an academic background in health sciences (public health, nursing, medicine, sociology). A Training Manual, Survey Field Manual, and Data Entry Manual were produced and used across the training period, data collection period, and data entry period, respectively to maintain quality and consistency in the work. Enumerators received 5 days of training. Supervision and monitoring visits from the Government of Nepal and Nepal Health Sector Support Programme (NHSSP) were carried out to identify and rectify any problems. During supervisory visits, some cases of noncompliance to survey manuals were observed. Feedback was provided during data collection and was also circulated to all of the district supervisors by telephone. Field teams could contact the central support team by mobile phone whenever necessary. During fieldwork, all completed questionnaires were checked by the supervisors in the district before sending them to the central office for data entry. Feedback was provided to the enumerators during data collection. Data cleaning, coding and entry
Before data entry, consistency checks and content cleaning were carried out and outliers in continuous variables were checked. Any suspect data were cross-checked against hard copies of completed questionnaires. The database was developed in CSPro 5.0 and pre-tested before data entry started. Measures Client satisfaction
Client satisfaction was measured by an eight-item instrument. The items covered key dimensions of client satisfaction: accessibility (one question), interpersonal
Mehata et al. BMC Pregnancy and Childbirth (2017) 17:319
communication (two questions), physical environment (two questions), clinical care (two questions) and decision making (one question). The responses were marked using a five-point Likert scale [21]: (1) very dissatisfied, (2) dissatisfied, (3) Neutral, (4) satisfied and (5) very satisfied. Different client satisfaction surveys have focused on different elements of client satisfaction. The eight items used in this survey aim to measure the key elements of the client’s experience of maternity care [22] and had a high internal consistency (Cronbach’s alpha = 0.74). Similar questionnaires were used in the previous rounds of the STS, conducted in 2011 and 2012, [18, 23] although some minor modifications were made to the 2013 STS questionnaire compared to earlier surveys. The client satisfaction index was computed from the eight domains presented in Appendix, using the ordinal Principal Component Analysis (PCA) [24], since the variables were measured in the ordinal scale. A previous study has shown the agreement between observed satisfaction and predicted satisfaction using PCA [25]. A spearman correlations of the predicted overall satisfaction level was assessed with the observed satisfaction domains in this study and presented in Appendix. To conduct bivariate and multivariate analysis the five point Likert scale was dichotomized: scores of four or five were counted as satisfied whereas one to three were counted as a not satisfied. The rationale behind the dichotomization was to yield a simple outcome variable which allows for complex tests of predictors. Explanatory variables
Individual characteristics (mother’s age, education and caste/ethnicity), cluster characteristics (ecological zone and place of residence), access to health facilities (reaching and waiting time), facility type, clinical care (mode of delivery and breastfed within an hour), advice and information (danger signs for mothers and newborns, exclusive breast feeding, comfort with the sex of the provider, family planning and being given the opportunity to ask questions), overcrowding within maternity departments, and the cost of care. Waiting time in this article refers to the duration of time between arriving at the facility and the first check-up by a service provider. Data analysis
Data analysis took into account the selection of districts within the strata defined by the ecological zones (mountain, hill and terai) and acknowledged the weighting of the data, the approximate stratification, and the clustering (health facilities asPSUs) while computing statistical tests, using the survey functions of STATA 12 SE Version. To assess the determinants of clients’ satisfaction, the chi-square test was used for bivariate analysis and multivariate probit model was used to assess the net effect of
Page 3 of 10
explanatory variables on outcome variable. Findings are reported as significant where the p-value is
RESEARCH ARTICLE
Open Access
Factors determining satisfaction among facility-based maternity clients in Nepal Suresh Mehata1*, Yuba Raj Paudel1, Maureen Dariang1, Krishna Kumar Aryal2, Susan Paudel3, Ranju Mehta3, Stuart King1 and Sarah Barnett4
Abstract Background: With an increasing number of institutional deliveries, the Nepalese health system faces a challenge to ensure a quality of service provision. This paper aims to identify the determinants of client satisfaction with maternity care in Nepal using data from a nationally representative health facility survey. Methods: A total of 447 exit interviews, with women who had either recently delivered or who had experienced obstetric complications, were conducted across 13 districts in Nepal (87% in hospitals, 8% in Primary Health Care Centres (PHCCs), and 5% in Sub/Health Posts(S/HPs). Client satisfaction was measured using an eight item scale that covered accessibility, interpersonal communication, physical environment, technical aspect of care and decision making. A client satisfaction index was computed using ordinal principal component analysis. A multivariate probit model was used to assess the net effect of explanatory variables on client satisfaction. Results: Longer waiting times and overcrowding increased the likelihood of dissatisfaction. Having an opportunity to ask questions was positively associated with client satisfaction. Respondents from hill districts and rural areas were more likely to be satisfied in comparison to respondents from mountain, terai and urban areas. Sociodemographic factors (age, parity, caste/ethnicity, education, and ecological zone) and supply side factors (the time taken to reach a facility, type of facility, payment for services, and unknown heath worker or anyone entering the delivery room) were not statistically associated with satisfaction. Conclusions: The findings suggest client satisfaction with the quality of maternity services in Nepal could be improved by reducing waiting times and overcrowding, and giving the mothers adequate time to ask questions. If clients are more satisfied they are more likely to use the facility again/recommend to a friend. Keywords: Quality of care, Client satisfaction, Maternity care, Utilisation, Nepal
Backgroud Satisfaction with maternity care is a multidimensional construct embracing satisfaction with self (personal control), and with the physical environment of delivery room and quality of care [1]. Aspects of care that may influence client satisfaction include: provider attitude, provider competence, outcome, physical environment, continuity of care, access, information, cost, bureaucracy and attention to psychosocial problems. Quality of care may not always be linearly associated with the level of satisfaction as perceived by the clients [2], however, client satisfaction is * Correspondence: [email protected] 1 Nepal Health Sector Support Program, Ministry of Health and Population, Ramshaha Path, GPO Box: 7830, Kathmandu 44600, Nepal Full list of author information is available at the end of the article
an important determinant of utilization of health services and the choice of health facility [3], it is important to know clients’ views and experiences while designing health programmes [4]. Client satisfaction also impacts the viability and sustainability of health care services, and is an important input for regular monitoring and quality improvement in health care delivery systems. Hospital-based maternity care has contributed towards the reduction in maternal and neonatal mortality and morbidity in developing countries [5, 6]. With the increasing rates of institutional deliveries, poor countries are now facing a challenge to ensure good quality maternity care [7]. Access to and availability of institutional delivery care alone is not enough to achieve the desired goals in maternal and child health, it is also the quality of care that saves
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mehata et al. BMC Pregnancy and Childbirth (2017) 17:319
lives of mothers and newborns. Although client satisfaction is not directly addressed in the Nepal Health Policy 1991 [8], the Nepal Health Sector Programme-2 (NHSP-2: 2010–2015), includes client satisfaction as an essential component of health service delivery [9]. The newly released National Health Policy aims to develop an accountable health system that includes a mechanism to collect client complaints/feedback [10]. Several studies have described the determinants of clients’ satisfaction with maternity care in other countries [2, 11–14]. Women who are treated with respect, courtesy and dignity, and have trusting relationships with their care providers are more likely to be satisfied [15]. Lack of involvement in decision making and inadequate information about their care are associated with dissatisfaction [16]. Older people more commonly report satisfaction with maternity care [12–14, 17]. Compared to the service tracking survey 2012 (STS 2012), which showed 90% of clients satisfied/very satisfied) [18], STS 2013 showed a slightly lower satisfaction (86%) to maternity services [19]. Similarly, slightly higher percentage of maternity clients (4%) mentioned not willing to visit the facility again in STS 2013 [19] compared to STS 2012(3%) [18]. The two studies cited above (STS 2012 and STS 2013) have only looked into the percentage of clients satisfied but have not explored the determinants. This study will be helpful to address the knowledge gap regarding determinants of maternity clients satisfaction in the Nepalese context and similar settings.
Methods Data source and sampling
This study is the secondary analysis of the survey data obtained as part STS 2013 conducted by the Ministry of Health (MoH), Nepal. The survey incorporated a facility questionnaire, and maternity and outpatient exit interviews. The primary objective of the survey was to provide national estimates for key reproductive, maternal, neonatal and child health indicators related to service availability, readiness and distribution of public (not private) sector of Nepal. Nepal consists of 75 districts divided into three ecological zones (mountain, hill, and terai), or five administrative regions. For the purposes of the study design these ecological zones and administrative regions were amalgamated to form 13 sub-regions. The survey used a twostage sampling design. In the first stage, one district was randomly selected from each of 13 sub-regions and these districts were the Primary Sampling Units (PSUs). This resulted in three districts being selected from the mountain region, five from the hill region, and five from the terai region, which are considered as strata for this study. In the second stage, the facilities were selected within each of the 13 districts. The higher the level of facility, the greater the probability of being selected: all public hospitals (17) and
Page 2 of 10
primary health care centres (PHCCs) (39) from the selected districts were included and an Equal Probability Sampling Method (EPSEM) was used to select health posts (HPs) (100/208) and sub-health posts (SHPs) (68/ 490). All maternity clients from PHCCs, HPs and SHPs attending the course of 2 days, and up to five clients per hospital, were interviewed. More details on the methodology are presented in the STS 2013 final report [20]. A total of 447 women who delivered at the facility or sought care for intra-partum complications were interviewed across the 13 districts (87% in hospitals, 8% in PHCCs, and 5% in S/HPs.). All clients who participated in exit interviews had received inpatient services. The smaller percentage of interviews at lower level facilities reflected the lower caseload. Data collection and quality assurance
Data collection was performed from July to August 2013. A total of 43 enumerators and 13 field supervisors were recruited for data collection. All of the field researchers had some experience of research/data collection, and had an academic background in health sciences (public health, nursing, medicine, sociology). A Training Manual, Survey Field Manual, and Data Entry Manual were produced and used across the training period, data collection period, and data entry period, respectively to maintain quality and consistency in the work. Enumerators received 5 days of training. Supervision and monitoring visits from the Government of Nepal and Nepal Health Sector Support Programme (NHSSP) were carried out to identify and rectify any problems. During supervisory visits, some cases of noncompliance to survey manuals were observed. Feedback was provided during data collection and was also circulated to all of the district supervisors by telephone. Field teams could contact the central support team by mobile phone whenever necessary. During fieldwork, all completed questionnaires were checked by the supervisors in the district before sending them to the central office for data entry. Feedback was provided to the enumerators during data collection. Data cleaning, coding and entry
Before data entry, consistency checks and content cleaning were carried out and outliers in continuous variables were checked. Any suspect data were cross-checked against hard copies of completed questionnaires. The database was developed in CSPro 5.0 and pre-tested before data entry started. Measures Client satisfaction
Client satisfaction was measured by an eight-item instrument. The items covered key dimensions of client satisfaction: accessibility (one question), interpersonal
Mehata et al. BMC Pregnancy and Childbirth (2017) 17:319
communication (two questions), physical environment (two questions), clinical care (two questions) and decision making (one question). The responses were marked using a five-point Likert scale [21]: (1) very dissatisfied, (2) dissatisfied, (3) Neutral, (4) satisfied and (5) very satisfied. Different client satisfaction surveys have focused on different elements of client satisfaction. The eight items used in this survey aim to measure the key elements of the client’s experience of maternity care [22] and had a high internal consistency (Cronbach’s alpha = 0.74). Similar questionnaires were used in the previous rounds of the STS, conducted in 2011 and 2012, [18, 23] although some minor modifications were made to the 2013 STS questionnaire compared to earlier surveys. The client satisfaction index was computed from the eight domains presented in Appendix, using the ordinal Principal Component Analysis (PCA) [24], since the variables were measured in the ordinal scale. A previous study has shown the agreement between observed satisfaction and predicted satisfaction using PCA [25]. A spearman correlations of the predicted overall satisfaction level was assessed with the observed satisfaction domains in this study and presented in Appendix. To conduct bivariate and multivariate analysis the five point Likert scale was dichotomized: scores of four or five were counted as satisfied whereas one to three were counted as a not satisfied. The rationale behind the dichotomization was to yield a simple outcome variable which allows for complex tests of predictors. Explanatory variables
Individual characteristics (mother’s age, education and caste/ethnicity), cluster characteristics (ecological zone and place of residence), access to health facilities (reaching and waiting time), facility type, clinical care (mode of delivery and breastfed within an hour), advice and information (danger signs for mothers and newborns, exclusive breast feeding, comfort with the sex of the provider, family planning and being given the opportunity to ask questions), overcrowding within maternity departments, and the cost of care. Waiting time in this article refers to the duration of time between arriving at the facility and the first check-up by a service provider. Data analysis
Data analysis took into account the selection of districts within the strata defined by the ecological zones (mountain, hill and terai) and acknowledged the weighting of the data, the approximate stratification, and the clustering (health facilities asPSUs) while computing statistical tests, using the survey functions of STATA 12 SE Version. To assess the determinants of clients’ satisfaction, the chi-square test was used for bivariate analysis and multivariate probit model was used to assess the net effect of
Page 3 of 10
explanatory variables on outcome variable. Findings are reported as significant where the p-value is
