Mothers' satisfaction with referral hospital delivery service in Amhara Region, Ethiopia

One of the Millennium Development Goals (MDG5) is to reduce the maternal mortality ratio by 3/4 between 1990 and 2015. Pregnancy and childbirth claim the lives of an estimated half a million of women globally each year [1]. More than half of these deaths occur in Africa [1]. Ethiopia is one of the countries that have highest maternal mortality rates (MMR) in the world which is estimated to be 673/100,000 live births [2]. Part of this mortality is attributed to poor delivery care [3].

The Ethiopian government and international organizations are working for making hospital delivery services accessible and usable for all pregnant women but still the proportion of births attended by a skilled birth attendant is about 18.4% [4] in 2009 which was much lower than the average level in developing countries in general (59%), Sub-Saharan regions (44%), and very far from MDG target of 90% coverage [1, 3]. The reasons forwarded by researchers for the higher maternal mortality, and lower coverage of skilled delivery in Ethiopia include mothers' unhappy health institutional delivery experience [3, 5].

In Ethiopia, dire health institutional delivery experience limits women's ability to seek care for subsequent pregnancies [3, 5]. A midterm assessment of the third Ethiopian Health Sector Development Program (HSDP III) also identified poor quality skilled birth attendance as one of the critical bottlenecks for improving the lower utilization of hospital delivery [5]. Many studies have been conducted on quality of maternity care with hospital and health centers in Ethiopia [6, 7]. These studies suggest that the quality of maternity care in Ethiopia is poor. This includes not only the quality of clinical care but also gender sensitivity, preservation of dignity and cultural sensitivity [5, 7]. These factors together with the community level factors explain the extremely low utilization of health services for delivery [3, 6, 7].

Satisfaction is a meaningful output indicator of quality health care [8‐10]. Various studies have reported that satisfied service users are more likely to utilize health services, comply with services and follow ups, and continue with the health care [11‐14]. Satisfaction with childbirth experience is important to the woman, infant's health and well-being, and mother-infant relationship. Studies reported that a mother's positive perception of birth experience has been linked to positive feelings toward her infant and adaptation to the mothering role [15‐17].

A community based study conducted in Kenya among women who delivered in health facilities showed that over half (56%) of women are satisfied with delivery care [11].

Despite having many studies done elsewhere, there is paucity of data concerning mother's satisfaction with childbirth services in referral hospitals in Ethiopia. Hence, this study was conducted to show Ethiopian case at referral level in Amhara region of Ethiopia.

This paper presents a study that estimated the level of mothers' satisfaction with referral hospitals' maternity care in Amhara Region of Ethiopia. The overall proportion of mothers who were satisfied with delivery care in this study was 61.9%. This percentage is very low compared to other studies in developing countries - 92.5% in Côte d'Ivoire [18] but it is comparable to a study in Nairobi, Kenya-56% [11] and greater than a study in Sri Lanka 48% [12]. This variation may be because of a real difference in quality of services provided, expectation of mothers or the type of health facilities. Studies conducted in Canada [19], Kenya [11] and Sir Lanka [12] suggest that services dealing with referred patients or complicated deliveries yield less satisfaction.

In this study delivering mothers satisfactions was predicted by wanted status of the pregnancy, immediate maternal condition after delivery, waiting time before seen by a health worker, perception about the waiting area for mothers and relatives, health professionals measure taken to assure privacy during maternal examinations, and service cost paid. This finding is consistent with other studies in Africa [11, 12, 18].

Mothers who wanted their pregnancy were more likely to be satisfied than mothers who did not. Similar finding was reported in Kenya by Bazent and her colleagues [11]. The study also showed that mothers without complication were more likely to be satisfied than mothers with complication. Women who experience no complications may be happy that they survived and this may result satisfaction with care [11].

In studies conducted in Oromia and Afar Regions of Ethiopia, mothers were complaining payment for service, inadequate privacy and unfriendly attitude of care providers [7, 20]. Similarly, in this study the researchers found privacy and cost incurred for service to be associated with mothers' dissatisfaction. Mothers who reported privacy during physical examination were more satisfied than those who perceived absence of privacy. This reflects there is privacy breach which should be improved. The mothers' level of satisfaction was also related to the amount of money paid for service as mothers who paid less than or equal to157 ETB were more satisfied than those who paid greater than157 ETB. This might be due to the low socio economic status of the mothers or/and mothers may have paid unexpected costs such as cost for travel and charge for supplies.

Our finding showed that nearly two-thirds of all women were very likely to recommend the delivery care facility to friends and family. Though this suggests that the hospitals are providing an acceptable quality of care, there is room for substantial improvement at University of Gondar Teaching and Referral Hospital.

The findings of this study had limitations. First, data are restricted to delivery experience to referral hospital thereby limiting generalization to the overall health facility experience of childbirth by women. Second, potential response biases often present in patient satisfaction studies related to social desirability. We tried to minimize this bias by interviewing mothers in a separate room by trained nurses who are not affiliated with the facilities studied.

The overall satisfaction of hospital delivery services in this study is found to be suboptimal. The study strongly suggests that more could be done to assure that services provided are more patient centered.

This study also revealed several constraints in the provision of delivery care services which can be implied as areas of possible improvement, including poor maintenance of clients' privacy, longer waiting time, and unavailability of waiting areas.