Client perceived quality of the postnatal care provided by public sector specialized care institutions following a normal vaginal delivery in Sri Lanka: a cross sectional study

Curative health sector in Sri Lanka is comprised of three levels: primary, secondary and tertiary. Primary health services provide the field and the first contact care, while the secondary and tertiary level institutions provide specialized services under the guidance of specialist health professionals. Thus, in the institutions providing specialized Maternal and Newborn Health (MNH) care, both routine basic care and comprehensive care for emergencies and complications are provided through a team of trained health care providers.

Of the 330,898 deliveries that that took place in government hospitals in 2014, the highest proportion (12.6%) took place in Colombo district [12]. It is worthwhile to note that Colombo district also reports the lowest rate of vaginal deliveries, which was 55.1% in year 2017 [16]. This may be attributed to the fact that the two main referral institutions for pregnant mothers are situated in this district.

The six state sector health care institutions providing specialized MNH care in Colombo account for 98.4% of the total deliveries [17]. These six institutions include three base hospitals (secondary level), one teaching hospital (tertiary level) and two special hospitals specialized to provide women’s’ health services only. Altogether, there are 17 wards providing specialized MNH services in these six institutions.

The study population consisted of mothers who had been discharged following a normal vaginal delivery. Mothers who had complications and the mothers with newborns who had complications following a normal delivery were excluded from the study as their care would deviate from the regular postnatal care, which was the focus of the study. A sample of 1300 mothers was deemed necessary to detect the significant associations of client perceptions.

Mothers were selected from all 17 wards. Number of mothers selected from each ward was proportionate to the number of NVDs in the first quarter of 2016 in that ward. Consecutive sampling technique was used to select eligible mothers in each ward.

A thorough literature survey was conducted to identify a suitable instrument to assess client perceptions of institutional postnatal care in Sri Lanka. Though a number of instruments were available for assessment of client satisfaction, instruments assessing client perceived quality of postnatal care were scarce. The possibility of using the instrument used by van Duong et al., to evaluate the client perceived quality of maternity services in rural Vietnam [11] was assessed by an expert panel consisting of three public health specialists. According to the experts, several items in this instrument were not relevant to the institutional postnatal care provision in Sri Lanka. Therefore a new instrument - The Client Perceived Quality of Institutional Postnatal Care (CPQIPNC) questionnaire- was developed by the Principal Investigator (PI), for data collection. It had a total of 23 items divided into three domains: technical care and information, interpersonal care and ward facilities and cleanliness. Each item was rated on a five-point Likert scale, from one to five, and had five statements: “very poor”, “poor”, “neutral”, “good” and “very good”. The scores ranged from one for “very poor” ratings, to five for “very good” ratings. Therefore, the total obtainable score ranged from 23 to 115 (Additional file 1). It was validated by conducting an exploratory and confirmatory factor analysis and had an internal consistency and test retest reliability of 0.94 [18]. In addition, socio demographic information from the mother and information on receipt of services by the mother and the baby that are stipulated in the National guidelines on maternal care [19] were also collected using interviewer administered questionnaires (Additional files 2 and 3).

Interviews were conducted in a pre-identified place in the ward with adequate privacy after all the discharge procedures were completed for each selected mother. As discharges are done twice daily at 12 noon and at 5.00 pm, two interview sessions were done daily, approximately at these times.

Data collection was conducted by six trained pre-intern medical officers via an interviewer administered questionnaire after obtaining the informed written consent from the eligible mothers. Data collectors were supervised by the PI throughout the study and 2% of all questionnaires completed by each data collector was re-administered by the PI to ensure reliability of data collection. Inter-rater reliability was assessed by computing Intraclass correlation coefficient (ICC) for data collectors’ results and PI’s results. The cut off was set at 0.7 [20]. The ICC obtained by data collectors ranged between 0.96–0.99, indicating a satisfactory inter-rater reliability.

Data analysis was conducted by SPSS version 21. Descriptive statistics were used to describe the basic information of the study sample, services received by them during the postnatal period and their perceived quality.

A binomial logistic regression analysis was carried out to determine the associations of client perceptions, as most of the statistical assumptions were met for binomial regression analysis.

The total score obtained by each participant for the CPQIPNC questionnaire was taken as the dependent variable and was dichotomized into low and high client perceived quality, based on the median value of the total score. Identification of the independent variables was accomplished by reviewing previous literature and expert opinion. The variables included socio demographic factors, pregnancy related factors, institutional factors and services received during the current hospital stay.

Information on independent variables were gathered during interviews of the mothers using questionnaires developed by the PI. They were transformed into categorical variables for further analysis. The independent variables to be included in the analysis were determined by a bivariate analysis. The variables with less than 10 counts in one category were excluded from the analysis. The significance level for selection was taken as p < 0.25 [21]. Using the variables selected, a backward stepwise binomial logistic regression was conducted to assess the significant correlates. Goodness of fit of the regression model was assessed by the regression diagnostics (overall percentage of the predictions that were correctly classified by observed outcomes, The Omnibus test, Cox and Snell Square test, Negelkerke R Square test, Hosmer and Lameshow test).

Necessary administrative clearances were obtained and the ethical clearance for the study was obtained from the ethics Review Committee, faculty of Medicine, University of Colombo, Sri Lanka.

Age ranged from 16 to 46 years, while most mothers belonged to the 20–35 years age group (n = 1074, 84.9%). More than three fourths have obtained an educational qualification above year 11 (n = 1029, 81.3%). A clear majority of the study sample (n = 958, 75.7%) was unemployed. Average monthly income showed a wide variation, ranging from Sri Lankan Rupees 3000.00 (17 USD) to 350,000.00 (2000 USD). Close to half of the study sample were primi mothers (n = 525, 41.5%) (Table 1).

Services recommended in the national guidelines to be delivered during the postnatal period following a NVD were received by most of the participants. Majority have initiated breast feeding within 1 h after delivery (n = 1184, 93.6%) as recommended, and 99.4% mothers have exclusively breast fed while in the postnatal ward. The technique of breast feeding has been assessed by a health care worker for majority of mothers (n = 1249, 98.7%) and corrected where necessary. Least frequently received service was the opportunity to practice kangaroo mother care (KMC) (n = 970, 76.7%).

Inquiry was made into the services provided to the mother and the newborn at discharge. All the mothers and 99.8% (n = 1263) of the babies have been examined by a medical officer at discharge, and over 95% of the examinees were informed about their examination findings (1235 participants were informed about their examination findings and 1256 were given information following examination of the baby). Privacy has been ensured during 99% of the examinations by covering the examination area (n = 1254).

All mothers have received health advices regarding the postnatal period. The main sources of information were nursing officers and midwives (n = 1195, 94.5% and n = 190, 86.2% respectively). Medical officers have provided health advices to only 750 mothers in the study sample (59.3%) (Table 2).

The total obtainable score of CQIPNC ranged from 23 to 115. The obtainable scores for technical care and information domain, interpersonal care domain and ward facilities and cleanliness domain ranged between 9 - 45, 7–35, and 7–35 respectively.

The total score obtained for the CQIPNC questionnaire in the study ranged from 48 to 115. The median score obtained by the participants for the questionnaire was 108, which was 93.9% of the total obtainable score (IQR- 96-114). Technical care and information domain had a median score of 43 (IQR = 38–45). Interpersonal care domain and ward facilities and cleanliness domain had median scores of 33 (IQR = 30–35) and 32 (IQR = 28–35) respectively (Table 3).

Over 90% of the mothers have rated care as ‘good’ or ‘very good’ for all the items included in interpersonal care domain and the technical care and information domain. The ratings reduced somewhat for the items in the ward facilities and cleanliness domain. Only 81.1% have rated the cleanliness of the toilets in the ward as ‘good’ or ‘very good’. The ‘good’ or ‘very good’ ratings percentages for the space and the facilities available were 88.0 and 88.8% respectively (Table 4).

For this analysis, the scores obtained for the CPQIPNC were categorized into high perceived quality and low perceived quality, based on the median value obtained for the questionnaire. Thus scores below 108 were categorized as low perceived quality (n = 632), and scores equal to or above 108 were categorized as high perceived quality (n = 633). The bivariate analysis depicted that participant characteristics such as the age between 20 and 35 years (OR = 1.6, p = 0.06), husband’s occupation (OR = 1.2, p = 0.08), average monthly income (OR = 0.8, p = 0.13), the type of institution used by the mother (OR = 1.4, p = 0.004); services such as initiation of breast feeding within 1 h (2.2, p = 0.001), informing the mother after examination of the baby (OR = 1.9, p = 0.02), provision of adequate pain relief during episiotomy suture (OR = 2.2, P < 0.001), giving assistance to practice KMC in the labour room and the ward (OR = 1.4, p = 0.02), receiving health advices from doctors (OR = 2.6, p < 0.001) and midwives (OR = 3.2, p < 0.001), regular examination of the mother (OR = 2.0, p = 0.009), getting assistance to initiate breast feeding (OR = 1.9, p = 0.12) were significantly associated with high perceptions of quality of care.

Among these variables, only 20–35 age category (aOR = 1.8, p = 0.024), teaching and specialized hospitals category (1.6, p < 0.001), and services such as initiation of breast feeding within 1 h of delivery (2.1, p = 0.009), pain relief during suturing of the episiotomy (2.2, p < 0.001), Ability to practice KMC (1.4, p = 0.035), Receiving health advices by the doctors (2.1, p < 0.001) and PHMs (2.1, p < 0.001) were identified as significant correlates via the multivariate analysis (Table 5).

Client perceptions may be influenced by many factors besides actual service delivery. Studies have shown that apart from structure, process and outcomes of care, factors such as client characteristics, access to services, financial costs, socio economic and cultural factors may shape the way clients perceive the services [24].

Logistic regression revealed that apart from age, other socio demographic factors were not associated with mothers’ perceptions of the quality of care. Similar findings have been reported by Kambala et al. [32], where socio demographic factors were found to be related to perceived quality of antenatal care but not delivery or postnatal care. Further, literature report that socio demographic associations of client perceptions are not consistent across studies. In addition, most of these associations are non-modifiable, limiting their value in improving care to meet patients’ expectations [33].

Awareness on service related and facility related factors that may influence mothers’ perceptions on the other hand, plays a major role in improving care. The current study found that certain services, such as initiation of breast feeding within 1 h of delivery, pain relief during suturing of the episiotomy, ability to practice KMC, receiving health advices by the doctors and midwives were associated with higher ratings of quality of care provided to mothers and the babies. These services may help to create a favourable opinion of the postnatal care in the mother, leading to high perceived quality.

Initiation of breast feeding and skin to skin care immediately after the delivery promotes the bonding between mother and the newborn has been known to improve the maternal perceptions and satisfaction with care [34, 35]. Practice of Kangaroo Mother Care also improves bonding through skin to skin care, leading to positive perceptions about quality of care.

Experience of intense pain during labour by the mother has constantly been associated with negative perceptions about labour [36]. Therefore, it is reasonable to expect that mothers who received adequate pain relief during suture of episiotomy would perceive care more positively compared to mothers who did not, as demonstrated by the current study.

Previous studies have reported that mothers expect to receive adequate information on important aspects such as breast feeding, child-care and behaviour during the postnatal period [37]. Positive perceptions of care by the mothers who receive information as expected is evident in many literature on maternal satisfaction [24]. Consistently, the current study revealed that while all mothers have received health advices from either midwives, nurses or doctors, those who received advices from doctors and midwives have perceived care more positively than who did not.

In addition to these services, mothers who received services from teaching and specialized hospitals have rated the quality more favourably than the mothers in the base hospitals. “Good physical environment and efficient management” has been stated as significant predictors of positive assessment of care by mothers [24]. Teaching hospitals and specialized hospitals have better facilities and resources than base hospitals and is capable of better management and care than base hospitals. This is consistent with literature that higher-level institutions are associated with more positive maternal perceptions of care, possibly due to better facilities [28].