Exploring Barrier of Intrapartum Care Maternal Satisfaction Among Mothers Who Gave Birth in Public Hospitals, South-West Shoa Zone, Ethiopia, 2022, Pure Qualitative Study

Introduction: intrapartum care satisfaction is the assumption of mother satisfaction contentment with oneself, the physical setting of the birth unit, and the standard of care. Dissatisfied moms who didn`t receive good intrapartum care services have an impact on the choice of delivery location and can help uncover discrepancies between expected and actual health care services. This study sought to investigate maternal satisfaction barriers related to intrapartum care.

 Objectives: To explore barrier of intrapartum care maternal satisfaction among mothers who gave birth in public hospitals, South-west Shoa Zone, Oromia region, Ethiopia, 2022. 

Methods:A qualitative study was carried out among 28 mothers from April 15 – May 20, 2022. Purposive sampling technique was used to select mothers for face–to–face in-depth interviews. Qualitative data were analyzed thematically by transcribing recorded audio and notes taken during the interviews manually. 

Results: Ten sub-themes were formed based on similarities of mothers` opinions. Then, the sub-theme was merged together, and four main themes were formed. The main themes were inadequate care given by health care providers, inadequate information and counseling given by health care provider, lack of Cleanliness and availability of infrastructure in the health facility and lack of laboratory test, drugs and medical supply. 

Conclusion and Recommendation: The barrier of intrapartum care maternal satisfaction were inadequate care given by health care providers, inadequate information and counseling given by health care provider, lack of Cleanliness and availability of infrastructure in the health facility and lack of laboratory test, drugs and medical supply. Health Facility (Hospitals) managers should work hard on availing drugs and laboratory tests cleanliness of delivery ward, and provide linen and night cloth for women who came for labour and delivery.

Maternal satisfaction is the term used to describe a mother's happiness when she compares the services, she received from a healthcare facility to what she had anticipated. The ability of the services to live up to expectations is a critical consideration when choosing a healthcare facility, ensuring that patients follow through on appointments, and continuing their treatment [1]. Users' happiness with intrapartum care is a multifaceted notion that encompasses their level of satisfaction, the physical layout of the delivery ward, and the quality of care provided. The most often cited standard for assessing the caliber of reproductive services is women's contentment during childbirth. Intrapartum care happiness the use of services and the belief that care outcomes meet mothers' expectations are closely related to maternal satisfaction [2]. 

Mothers' satisfaction serves as a proxy for the effectiveness and quality of treatment provided by the health care systems, with the overall satisfaction of clients being significantly influenced by the quality of professional care [3]. Over 830 women worldwide passed away in less than a day due to issues with the pregnancy and delivery process; low- and middle-income nations account for 94% of all maternal deaths [4]. In Sustainable Development Goal 3, States have committed to decreasing the maternal mortality ratio (from currently 216) to less than 70 per 100,000 live births between 2015 and 2030. Therefore, addressing current levels of maternal and neonatal mortality in low and middle-income countries is a global priority by 2030 [5]. In Sub-Saharan Africa, where estimates of severe maternal morbidity range up to 108 per 1,000 live births, the burden of the condition are the highest [6]. Maternal mortality is high in-home delivery [7]. Utilization of healthcare services and the belief that the services provided met clients' expectations are directly related to women's satisfaction [8].

The research  done in Nepal, and Malaysia showed that 89.88%  and vaginal birth 68.7%, and cesarean section 79.2% of women were satisfied with childbirth care  respectively [8, 9]. Maternal satisfaction among women who gave birth in African nations was 78.54%, 94%, and 92.54% in Egypt, Ghana,and Mozambique respectively  [10–12]. However, in Ethiopia, the magnitude of moms who were happy with child bearing care ranged from 19% to 87.2% [13–18]. Long waiting time, improper availability of drugs and supplies, disrespectful care, not keeping privacy, poor cleanliness of health facility, poor communication, bad healthcare professional behavior, unplanned pregnancy, and complicated feto-maternal birth outcome were barriers that have negative impacts on maternal satisfaction with intrapartum care [1,11,19–22]. Mothers who denied the friendly approaching behavior of the Health care provider during childbirth choose  traditional birth attendance [23, 24]. Women who were not satisfied with the quality of care during labour and delivery were prefer their future childbirth in-home [25]. The dissatisfaction of mothers with childbirth services was an essential barrier to women seeking institutional delivery [26, 27]. 

Maternal satisfaction with childbirth provides crucial and cost-effective feedback for further increases institutional childbearing services [8].When a mother is satisfied with her intrapartum care, there are both immediate and long-term benefits to her health, as well as later adoption and the institution's recommendation to her neighbors and relatives [3].

With its quick infrastructure development, greater access to healthcare providers, higher budget allocation, and improved financial management, Ethiopia has made impressive strides toward expanding its health care services. Only 50% of women, meanwhile, gave delivery in a hospital. Up until now, keeping the service's quality high and making improvements has been quite difficult. Consequently, delivering top-notch healthcare has emerged as a crucial transformation imperative [28].

The majority of studies in Ethiopia conducted on intrapartum care maternal satisfaction were done by using quantitative research approach via a cross-sectional study design. Therefore, using only quantitative study does not assess factors. This study was exploring barrier of maternal feelings and expectations toward intrapartum care. Therefore, this study was aimed to explore barrier of intrapartum care maternal satisfaction in public hospitals in the South West Shoa Zone, Ethiopia.

Study area, study period and study design

The study was conducted at public hospitals in South West Shoa Zone, Oromia region, Ethiopia. Southwest Shoa Zone is found to the south of Addis Ababa. South West Shoa Zone is bordered on the south by the Southern nation and nationality people region, on the north by West Shoa Zone and Addis Ababa city, on the west-by-West Shoa Zone, and on the east-by-East Shoa Zone. Southwest Shoa Zone comprised five government hospitals named Tullu Bollo General Hospital, Waliso General Hospital, Ameya Primary Hospital, Bantu Primary Hospital, and Leman Primary Hospital, and one non-government hospital called Lukas Catholic Hospital which is found in Waliso, the capital city of the South West Shoa Zone. The study was conducted from April 15 – May 20, 2022. A qualitative phenomenological study design was employed by using in-depth interviews (IDIs) to explore barrier intrapartum care maternal satisfaction. 

Population

Mothers who gave birth by C/S, SVD, and assist instrumental delivery, mothers who came from both urban and rural, and those who were primiparous and multiparous, and their current pregnancy was planned and unplanned, interviewed at the time of health care provider decide to discharge, but before leaving the hospital.

Eligibility Criteria

Inclusion Criteria

Moms who gave birth, and were discharged from the hospitals by health care providers were included in qualitative study.

Exclusion Criteria

Mothers who were critically ill and unable to communicate face-to-face interviews and in-depth interviews at the time of data collection were happy for health facility services were excluded from the study. Mothers who were referred to another hospital and mothers who gave stillbirth not complain health facility services were excluded from the study

Sample Size Determination and Sampling procedure

Sample size was determined after ideas of mothers were got saturated, with guiding and propping question and twenty-eight mothers who gave birth in four hospitals were included in the study. Purposive sampling technique was used to select moms for IDI based on mothers’ willingness to participate in IDI.

Data Collection instrument and Technique

Data was collected by using a semi-structured interview guide with probing questions linked to maternal satisfaction aspects. During the in-depth interview, voice recorded and notes were taken. The questionnaires contain 4 guiding questions and 13 probing questions.

Face-to-face interviews were used to gather data, and three master's degree holders in health who are proficient in the local tongue conducted IDIs. An audio tape recorder, field notes, and an interview guide were used to gather data. The duration of the interviews varied from 25 to 45 minutes, depending on the participants' perceived levels of saturation. The responders were able to complete the IDIs in a convenient, quiet, and private setting. The exact responses of every participant were captured on an audio cassette, and the data were transcribed and translated exactly from that recording. Four master's-level health workers who are proficient in the local languages.

Data Quality Control (Assurance)

To maintain uniformity, the semi-structured interview guide was first developed in English, translated into Afan-Oromo, the local tongue, and then back into English. Lastly, data was gathered using the Afan Oromo version of the interview guide. The data collectors received one days of training on the study's goal, data collection techniques, and ethical issues prior to beginning actual data collection. The interviewers employed tape recording and note taking regarding each guiding question and probing question during the interviews. The IDIs were conducted in a salient and private setting at the health facilities.  Experts in qualitative research assessed and checked the interview instructions and questions and verified that the tools' content was valid. Prior to the instruments being used for real data collection, they were pretested among 8 moms who gave birth at Holeta Primary Hospital.

Data Processing and Analysis

Qualitative data were analyzed thematically by transcribing recorded audio and notes taken during the Interviews. The recorded audio was first transcribed word by word into Afan Oromo, and then translated into English by the language translator. The transcribed data into English was coded manually (color-coded) with similar ideas with the same code. Then, the narrated qualitative information was organized and categorized according to their similar ideas to form sub-themes. Sub-themes emerged together to form the main themes. Then, the study participant's comment was written in quotes. Ideas related to the objective of the study and commonly indicated by study participants were taken and written in quotes. The result was presented using text, tables, and charts. 

Ethical Approval

An ethical clearance letter was obtained from Salale University College of Health Science Ethical Review committee. Official letters of cooperation were obtained from Oromia Regional Health Bureau. 

Qualitative study results

A total of 28 mothers who gave birth in public hospitals, South West Shoa (Tullu Bollo General Hospital, Ameya Primary Hospital, Leman Primary Hospital, and Bantu Primary Hospital) participated in in-depth interviews. The results of the qualitative study showed that among 28 mothers, the age of mothers ranged from 18-39 years old. Half of the women 14(50%) who participated in IDI were living in urban areas. Concerning the mode of delivery 13(46.2%) of mothers gave birth through SVD. More than half, 15 (53.57%) of respondents had a history of childbirth. Three-fourths, 21(75%) of mothers planned their current pregnancy (see table 1).

Table 1: Socio-demographic and obstetrics characteristics of mothers Participated in a qualitative study among mothers who gave birth in public hospitals, South West Shoa, Ethiopia, 2022

Key, TBGH = Tullu Bollo General Hospital, APH= Ameya Primary Hospital, BPH=Bantu Primary Hospital, LPH= Leman Primary Hospital, MP= Mother participant 

The finding of the qualitative study revealed that the barrier to intrapartum care maternal satisfaction was identified by using interview guide questions with probing. Ten sub-themes were formed based on similarities of mothers` opinions. Then, the sub-theme was merged together, and four main themes were formed (see table 2).

Table 2: Themes of qualitative study analysis of intrapartum care maternal satisfaction among mothers who gave birth in public hospitals, South West Shoa Zone, Ethiopia, 2022

Theme 1: Inadequate care given by health care providers

In this study barrier to intrapartum care maternal satisfaction was identified by the qualitative study. Mothers who participate in IDI pointed out that there were some factors that affect the level of satisfaction of mothers during labour and delivery. 

 Labouring mothers were dissatisfied when health care providers didn`t stay with them and laboured along during intrapartum. This was supported by the result from IDI:

“…The midwives didn`t stay with me, they didn't come quickly when I called them. I laboured for a long time (one and half days), the way I gave birth was very disgusting [dissatisfied]” (MP2, 28 years old). “Health caregivers’ didn`t stay with me, they didn`t give me care when I wanted, they decided to give birth via surgical operation [cesarean section] after I laboured for a long time, and I got tired [long labour duration] …” (MP19, 28 years old).

In addition, the respondents were dissatisfied with the care given by health care providers during childbearing service. Women who were not allowed their family and husband to stay with them, not received a warm welcome, and delay to be seen by health care providers at the time of admission were not satisfied with intrapartum care. The following were some of the mothers’ sentiments: 

“…I didn`t get treatment [care] as soon as I arrived. They [caregivers] refused my husband to be with me, I felt very bad at that time….” (MP12, 21 years old).  “…the midwives didn't allow my family to be with me, they made me stay alone. So I had laboured badly [laboured alone] …” (MP17, 19 years old)

Women's ideas reflected the bad manner of health care providers was a barrier that made mothers dissatisfied with intrapartum care. This was explained by:

 “… I wouldn’t say I liked the way she [midwife] served me. She came and looks me only when I cried and screamed, sheshouted at me saying what made you like this?” (MP3, 22 years old). “The manner of health professionals is not good, how they yell at labouring mother…” (MP11, 19 years old).

Moreover, some women were not happy with the services they received regarding managing labour pain and got complications during labour and delivery. Participants narrated:

“…They [health care providers] didn’t give me anything when labour suffered me, they simply look me. Finally, my reproductive organ [perineal] was lacerated when I gave birth …” (MP24, 27 years old). “... They [midwife] gave me a bed and assessed my labour, leaving me alone, they didn`t manage my labour pain. When I give birth my baby couldn`t breathe, and also, I was bleeding a lot…” (MP17, 19 years old)

Theme 2: Lack of information and counseling given by health care provider

The finding of the present qualitative study showed that the respondents were dissatisfied with the counsel given during labour and delivery by health care providers. The following were some of the women`s ideas: 

“...Midwives didn`t tell me how to lie in the left position, how to keep myself clean, how to breastfeed newborn.  I didn’t think the service I received is very good [women didn`t happy with care] …” (MP8, 18 years old). “...Midwives didn`t counsel me the advantage of lying in left position during labour, how to breastfeed my newborn, and advantage of first milk for the newborn. I am not happy with their counseling.” (MP22, 23 years old).

Women who were not informed about the result of their examination, labour progress, and fetus condition were very dissatisfied with childbearing services. The following were some of their sentiments: 

“… Health care providers didn`t tell me the progress of my labour and the condition of my fetus, they just checked me and left me alone without any advice.” (MP16, 23 years old).  “The health care providers did not tell me the results of my tests [laboratory test], my labour progress, and the condition of my newborn. I was very sick at the end of the delivery. I was dissatisfied with their care...” (MP14, 33 years old).  “...Midwives didn`t tells me the result of my laboratory test, they simply bring, and attached in a medical folder. Doctors also didn’t tell me the progress of my labour; they simply examined me and go away. After that, I didn`t feel well. …” (MP25, 28 years old). “As soon as I arrived the delivery ward. First midwives assessed my labour, then they told me saying your labour was inadequate let we consult the doctor. Then, the doctor came and assessed my labour, and simply he got out. He didn`t tell me about my labour. After that, I didn`t feels better…” (MP28, 32 years old).

Theme 3: Lack of Cleanliness and availability of infrastructure of the health facility

This study revealed that women who didn`t get unclean bathroom, toilet, delivery and labor room were unhappy with services received during childbirth. 

Additionally, women who didn`t get a clean toilet, clean delivery ward, and linen were less satisfied with intrapartum care. This was narrated: 

“… The toilet has no water and it was dirty, not cleaned that day, the room is also not clean, and had a bad smell and was soaked with blood, that delivery room is so disgusting.  Some beds of mom’s don`t have linen and night cloth, and mothers who came empty-handed were exposed to cold. Some linen was soaked with blood and not changed for mother …” (MP5, 39 years old).  “The midwife gave me a bed. The bed has no linen and night cloth [blanket]. I was labouring on a bare bed. The delivery room was clean, but after a little while, it got dirty.  The cleaners didn't clean it again and again. The toilet is a little unclean…” (MP4, 26 years old). “…The bed that mothers gave birth on isn't particularly tidy. It is not constantly cleaned. I don't like the smells in the delivery room, even after they transport me there. Why this place isn’t kept tidy?” (MP25, 28 years old). “I get really dirty when I use the bathroom during labor. The hospital's bathing facilities should not be used. It gets dull to use the bed because it isn't cleaned frequently enough. In case it's better for upcoming moms…” (MP28, 32 years old). “…I arrived at this hospital as soon as my labor began. I was subsequently brought to the labor room, but I was unable to sleep there because of the unpleasant odor. Nothing changed when they moved me to the delivery and postpartum room later. It's good if it gets better.” (MP8, 18 years old).

Theme 4: lack of laboratory test, drugs and medical supply

The result from the in-depth interviews of mothers indicates that drugs and medical supply shortage were the factors for barriers intrapartum caremothers’ satisfaction. The major moms stated that:

“…. They sent my husband to buy drugs and water [distilled water] from outside, he got and bought distilled water, but he didn’t get drugs from this town and sent another person to Waliso town, this drug was also not available at Waliso town, then left it came back.” (MP22, 23 years old). “…Health caregivers sent my sister to the pharmacy to buy drugs, but the pharmacy has no nothing, then she went private pharmacy and bought the prescribed drugs. How do mothers come for delivery served in this hospital?” (MP18, 18 years old).

Furthermore, moms who didn’t get sent laboratory requests in the health facility disliked the service the hospital provided for mothers who came with labour. This was evident by:

 “…The doctor decided and told me that you give birth through C/S. Then, the midwife sent my blood to the laboratory for the test, but there was no reagent in the hospital. So, my blood was tested at a private clinic.” (MP28, 32 years old). “…The midwife sent my urine and blood to the lab [laboratory], but only urine test was available in the hospital at that time…” (MP6, 27 years old).

Moms’ satisfaction with intrapartum care service is an important outcome measure for the quality of care and provision of services. This study aimed to explore barrier of intrapartum care maternal satisfaction at public hospitals, South West Shoa. The qualitative study found that a mother who was normal after the newborn was delivered was more likely satisfied with intrapartum care. It is similar to a study conducted in Nekemte Specialized Hospital in Western Ethiopia(1). This is due to the fact that women who experience complications may be unhappy and they consider they served with good attention which may end in dissatisfaction.  The other probable justification might be due to moms with complications blame the care of the health facility and give a negative response. The other reason could be mothers who got complications during intrapartum may believe that it is the fault of the healthcare workers who attended her or the hospital in general, resulting in reduced trust to deliver at a health facility ends with unhappy. The present study revealed that mothers whose labour persists along were more likely dissatisfied with intrapartum care compared with moms whose labour persisted short hours. This was similar to the previous study conducted in Eastern Ethiopia [29], and  Nekemte Specialized Hospital in Western Ethiopia [1]. This may be due to the fact that laboring for a longer period of time can wear a woman out and subject her to repeated obstetric procedures like vaginal examinations and labour pain [30], and as time passes, tension about the birth's outcome may also increase, leading to a decrease in maternal satisfaction [31].

 Similarly, the finding of this study revealed that delay to give immediate care as soon as moms arrived at health facilities had a negative association with intrapartum care maternal satisfaction and moms who got services as soon as arrived at health facility were very unhappy with care provided to them .This was similar with study conducted in  Harari regional state, Ethiopia [29], and Nekemte Specialized Hospital in Western Ethiopia [1]. This might be as a result of providing delay care to labouring moms, which could influence their expectations and increases complications during labour and delivery, leading to maternal dissatisfaction. The results of current qualitative study indicated that inadequate care during childbearing was a major barrier that dissatisfies mothers. Mothers who were alone throughout labor, refused to allow their family to stay with them, did not receive a warm welcome, were treated disrespectfully, and did not receive labour pain management were unsatisfied with intrapartum care. This was similar with study conducted in Nepal [9]. This implies that exhaustion from labour pain, loneliness, and not getting what women expect from health facilities during labour and delivery make women more dissatisfied with intrapartum care.

Furthermore, in this study women who didn`t get adequate information and counsel were unhappy with intrapartum care. This was similar with study conducted in Asrade Zewude Memorial Primary Hospital in Bure, West Gojjam, and Ethiopia [20]. This implies that didn`t get adequate information and counsel would tension mothers about their birth outcome, mothers consider their results to have abnormal findings, and health care providers didn`t give attention to mothers who come for labour and delivery. Similarly, lack of cleanliness and inadequate infrastructure in the health facility was found that a major barrier to intrapartum care maternal satisfaction. Women who didn`t get clean toilets, clean delivery ward, linen, and night cloth during childbearing were more dissatisfied with intrapartum care. This was similar with study conducted in Nepal [9]. This implies that loss of what mothers expect from the health facilities, labouring in the not attractive environment, and fear of infection made mothers very dissatisfied with intrapartum care. In addition, unavailable prescribed drugs, and sent laboratory tests in the health facility were some barriers to maternal satisfaction with childbearing care. This was similar with study conducted in  Harari regional state, Ethiopia [29] and in Nepal [9].  This implies that women who didn`t get prescribed drugs and sent laboratory requests in the health facilities were exposed to additional expenses, and didn`t get treatment timely, this made moms dissatisfaction with intrapartum care.

The barrier of intrapartum care maternal satisfaction among mothers who gave birth in Public Hospital, South West Shoa were Inadequate Care given by health care providers, Inadequate information and counseling given by health care provider, Lack of Cleanliness and availability of infrastructure in the health facility and lack of laboratory test, drugs and medical supply. Therefore, Health Facility (Hospitals) managers should work hard on availing drugs and laboratory tests cleanliness of delivery ward, and provide linen and night cloth for women who came for labour and delivery. Strengthen compassionate, and respectful, care for labouring and delivery mothers and give adequate information and counseling on their results after examining and assessing, women who come for labour and delivery.

Conflict of Interest

Authors declare no conflict-of-interest respect to this study.

Funding

There is no fund 

Author contribution 

All the authors contributed to the proposal development, questionnaires, and data collecting process, analysis, and interpretation. 

Data curation by

Bacha Merga Chuko, Fikru Assefa Kibrat, Mitiku Yonas Gindaba, Mulugeta Feyisa, Fikadu Tolesa, Zufela Sime Gari, Mone Fikadu and Shambel Negese Marami

Format analysis

Bacha Merga Chuko, Mulugeta Feyisa, Fikadu Tolesa, Andualem Gazehegn and Shambel Negese Marami

Investigation

Bacha Merga Chuko, Fikru Assefa Kibrat, Zufela Sime Gari, and Shambel Negese Marami 

Methodology

Bacha Merga Chuko, Fikru Assefa Kibrat, Shambel Negese Marami, Mitiku Yonas Gindaba, Mulugeta Feyisa, Gebreyes Mengistu Geda, Mone Fikadu and Teka Fayera Terefa

Revise the manuscript

Bacha Merga Chuko, Fikru Assefa Kibrat, Shambel Negese Marami, Mitiku Yonas Gindaba, Mulugeta Feyisa, Zufela Sime Gari, and Shambel Negese Marami

Final version of the article was checked by all authors.

Consent

Informed consent was taken from every study participant before the actual data collection started.