Women’s satisfaction with maternal care services in Georgia

Highlights

• •Women are satisfied with the maternal care as basic services are assured.
• •Satisfaction of women does not indicate efficient use of resources.
• •Those who pay out-of-pocket are overall less satisfied.

Abstract

Introduction

Patient satisfaction is a key indicator of health care quality. We investigated women’s satisfaction with antenatal, natal and immediate postnatal care, as well as the association between women’s satisfaction with the care they received and background characteristics.

Methods

We conducted a survey in the capital and two regions of Georgia. 400 women, who gave birth to healthy babies during the preceding twelve months before the date of data collection, were the target population. Women’s opinion about the organization of maternal care (tangibility, availability, accessibility) and process characteristics (responsiveness, reliability, empathy, communication and courtesy) were measured. Women satisfaction with antenatal, natal and postnatal services was also measured.

Results

Women’s satisfaction with antenatal, natal, and immediate postnatal services was high. The respondents’ perception about the tangibility of maternity houses was quite positive, more than three quarters of the respondents agreed or strongly agreed with the statements that maternity houses/units were attractive and medical equipment was up to date. Regression analysis on satisfaction with antenatal, natal, and immediate postnatal showed that those who paid for services were less satisfied than those who did not pay. Women in urban areas were more satisfied with antenatal and natal services than in rural areas. High educated women were less satisfied than women with the lowest education level.

Conclusions

In general, women are satisfied with maternal care in Georgia. The high level of satisfaction can be due to the improvement in structural factors of maternal health care such as tangibility, availability, and accessibility.

1. Introduction

Consumer’ satisfaction with healthcare services is predictive of their decisions regarding choice of health care plans [1], [2] and treatment outcomes [3]. The patient characteristics associate with general patient satisfaction including demographic factors, socioeconomic status [4], [5] and general health status. Also, satisfaction is influenced by the manner in which health care is delivered, such as type of health care setting [6], [7] and characteristics of the medical provider [8], [9].

Measuring consumer satisfaction is an essential part of the assessment of health care services in terms of service quality, access, and health care system responsiveness [10], [11]. Client satisfaction becomes noticeable as the patients are involved actively in the decision-making process and in the achievement of good health outcomes [12], [13]. Satisfaction is the of the most frequently reported outcome measures for quality of care [14] and enhanced satisfaction is a goal for improvement in health care [15]. Women’s satisfaction with maternal care services such as care during childbirth has become increasingly important to healthcare providers, administrators, and policymakers [16], [17]. Some studies show that women’s satisfaction with childbirth is related to the health and well-being of the mother and her baby. While dissatisfaction is associated with poorer postnatal psychological adjustment, a higher rate of abortions, preference for a caesarean section, more negative feelings towards the infant, and breast-feeding problems [14], [18], [19].

Satisfaction with maternal care services is also strongly influenced and shaped by socio-demographic characteristics of women (the level of education, age, marital status, and economic status), the number of personal factors (values, attitudes, the threshold of pain, health literacy, and personal support), as well as perceived control and expectations formed on the basis of previous experiences and outcomes of previous pregnancies and births [14], [18], [19], [20], [21]. It is unusual for a woman to feel completely satisfied with every aspect of maternal care. More likely she will rank the quality of her care as satisfactory, but when asked to reflect on her experience she can often share what she liked and disliked [22]. In the qualitative study was done in Georgia during the focus group discussion mother highlighted some issues related to financial and quality aspects of maternal care [23] but maternal satisfaction with health services not studied yet in the country and needs further research.

Concepts and approaches to measuring maternal satisfaction differ among researchers. A common approach is to measure clients’ satisfaction indirectly through assessing their expectations and perceptions of health service quality. Due to the limits of health outcomes to measure service quality, often healthcare structure and process features are assessed as indirect indicators of quality [24], [25]. Combination of direct and indirect measurement of satisfaction is evidenced for investigating interrelationships among clients’ perception of service quality, utility value, clients’ satisfaction, and their ultimate reactions to health care [26].

As the World Health Organization recommends monitoring and evaluating maternal satisfaction in health care sectors - to improve the quality and efficiency of health care during pregnancy, childbirth, and the puerperium [27], according to recommendations countries implement various tools to assess women’s satisfaction with maternal care services.

The aim of the study is to explore the women’s satisfaction with maternal care services namely to identify the key influences of clients’ satisfaction and utilization of the antenatal and natal; to detect the key factors influencing expected and perceived specific service quality as the predictors of clients’ satisfaction in, and to assess the relationships between perceived specific service quality and satisfaction level in the maternal healthcare system Georgia.

2. Methodology

We used a quantitative questionnaire study was conducted in September and November 2017, in the capital Tbilisi and in two regions of Georgia, namely Imereti and Adjara. These regions were selected because of the following reasons: 1) these are the biggest regions in Georgia [28]; 2) Previous qualitative study was done in these particular regions and for the triangulation of the results. The mothers who had birth during the last twelve months were the target population. We selected the target women in each location through the hospital/birth registry. We did this to enhance the possibility of selecting women who gave childbirth at different facilities rather than a single facility; thereby, to get data from women with diverse experience of maternal care delivery. In each region, two research assistants identified the target women.

Women who had a birth during the last twelve months were interviewed about were asked about seeking: 1) antenatal, 3) childbirth, and 4) postnatal care, about financial expenses related to maternity and the quality of care received; their overall satisfaction with the care received.

An interviewer-administered questionnaire was developed based on a literature review [29], [30], [31] and analysis of the waves of reproductive health survey was done in Georgia in 1999, 2000, and 2010 [32], [33], [34].

We prepared a semi-structural interview questionnaire in English, which was then translated into Georgian by the Principal Investigator. The questionnaire was pretested and adapted. The questionnaire was validated. Informed written consent was given by all respondents prior to each interview. The Principal Investigator acted as a study coordinator and monitored the fieldwork. The confidentiality of data was maintained. Ethical approval of the study was obtained from NCDC & PH of Georgia.

2.1. Sample size and sampling

A sample size of 384 was estimated using the published sampling table of [35] for an entire population with 95% confidence interval. A random sampling method was used to select the mothers from rural-urban settings. The ‘probability proportionate to size’ sampling method was used to estimate the study participants [36]. Total childbirths in Tbilisi, Imereti, and the Adjara region were 39 207 in 2016. In Tbilisi were 25 565 childbirths, among them 6 were home delivery and 25 559 hospital childbirth. In Imereti there were 7382 total childbirths, among them there were four home births. In Adjara region, in 2016 there were 6260 childbirths among them five birth happened at home [37]. Georgian birth registry was used for a random sampling of mothers who had childbirth during the last one year. A following number of mothers were sampled from Tbilisi (n = 251 each), a number of mothers were sampled from the Imereti, and Adjara regions were 72 and 61 respectively.

2.2. Data collection tools, techniques and quality control

An interviewer-administered questionnaire was developed containing mostly closed quantitative items. A few qualitative open-ended items also were included. The authors initially amended the tool through discussions and based on previous work related with maternal healthcare financing and quality of maternal care. Then a piloting was conducted with 12 mothers to confirm the instrument’s usability as well as skills of the research assistants. All closed items used five-point Likert scales (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree). No further adaptations were needed. The following were the key domains, variables, and items of the tool: direct measure of mothers’ satisfaction with antenatal; natal and postnatal services; the influence of mother’s expectations and choice of the private obstetrics/gynecologist; perceived specific service quality; Structure related variables and items: Tangibility: outlook of infrastructure, equipment, and records, and cleanliness; Availability: supply of drugs and diagnostic tests; Accessibility (financial): ability to pay the costs of consultancy, medicines, and diagnostics. Process related variables and items: Responsiveness: availability of doctor, and promptness of service delivery; Reliability: doctors’ skills, rationale of the advised drugs, and diagnostic tests; Empathy: doctors’ attentiveness to patients’ problems, concerns of clients’ financial situation, and mental supports; Communication: explanation of diagnosis, treatment plan, and prescription; Courtesy: respect to clients, and maintenance of privacy [34].

All research assistants were given intensive training on data collection focuses on reducing information bias and effective communication. Data was collected from the household of the mothers who had childbirth during the last one year. Informed consent was taken from all respondents. Confidentiality was maintained. Each interview took an average of 40 min. Two computer experts entered data and cross-checked each other’s work regularly; also the Principal Investigator checked a random sample. Data collected during September and December 2017.

2.3. Statistical analysis

SPSS (version 21) was used for data processing and analysis. Means and standard deviations of all variables were computed. Data from the indirect and direct satisfaction self-explicated ranking are analyzed using descriptive statistics. Based on the value of the modes of attribute ranks, a general ranking is made. This ranking shows how important the attributes are to respondents in relative terms. Also, we also applied logistic regression analysis to examine the associations between each dependent variable and the set of independent variables, namely age, ethnicity, educational status, employment, residence, religion, and socioeconomic status. Depending on the nature of the dependent variable, the multinominal analysis was performed using the backward selection technique. Nagelkerke R² was calculated for each regression model.

3. Results

A total of 400 women were interviewed. The socio-demographic characteristics of the study participants are presented in Table 1. The age groups 25–29 and 30–34 years constitute 66.3% of the sample. In total, 94% of the sample is Georgians. Additionally, 79% are highly educated (belonging either to the group of college education or university) and nearly half of the sample are housewives. Nearly half of the study participants belonged to the two lowest income groups (monthly income 200 GEL to 900 GEL or lower than 200 GEL).

Table 1.

Socio-demographic characteristics of study participants (N = 400).

Socio-demographic characteristics	n (%)
Age range
18–24 years old	81 (20.2%)
25–29 years old	157 (39.2%)
30–34 years old	108 (27.0%)
35–39 years old	47 (11.8%)
40–44 years old	7 (1.8%)
Ethnicity
Georgian	376 (94.0%)
Armenian	12 (3.0%)
Azeri	8 (2.0%)
Russian	4 (1.0%)
Place of residence
Urban	124 (31.0%)
Rural	276 (69.0%)
Religion
Christian	386 (96.5%)
Islam	14 (3.5%)
Educational level
Grade 1–4	0 (0%)
Grade 5–9	4 (1.0%)
Grade 10–12	80 (20.0%)
College (technical education)	76 (19.0%)
University	240 (60.0%)
Employment status
Housewife	191 (47.7%)
Own business	10 (2.5%)
Student	33 (8.3%)
Day-labor	10 (2.5%)
Public job	53 (13.3%)
Private job	103(25.7%)
Household monthly income
<200 Gel	19 (4.8%)
200–<900 Gel	175 (43.7%)
900–1500 Gel	116 (29.0%)
>1500 Gel	90 (22.5%)
Family receives social benefits
Yes	22 (5.5%)
No	378 (94.5%)

Table 2 shows the use of maternal care. In total, 99.5% of women received antenatal care and only 0.5% did not visit the medical doctors during the antenatal period. Also, 90.3% of the study participants received antenatal care either at a women’s consultation center or a city maternity house. Nearly 85% received more than 8 antenatal visits. In 98.9% of the cases, the antenatal care providers were obstetrician, and 70.8% of the participants paid for the antenatal care visits. All participants had childbirth by a skilled birth attendant in one of the maternity houses. Having only a midwife present during childbirth was reported by 2.8% of the participants. Immediate postnatal care as well as natal and antenatal care for the absolute majority of cases was provided by the obstetrician. In total, 80.5% of the mothers in our study paid for childbirth services and for immediate postnatal care services (Table 2).

Table 2.

Utilization of antenatal, natal and immediate postnatal services by the study participants.^*

Utilization variables	n (%)
Received antenatal care, N = 400
No	2 (0.2%)
Yes	398 (99.8%)
Average number of antenatal visits ≥ 8, N = 400
No	60 (15.0%)
Yes	340 (85.0%)
Type of antenatal care facility, N = 400
None	2 (0.5%)
Women's consultation center	150 (37.3%)
Regional maternity house	16 (4.0%)
City maternity house	211 (53.0%)
Referral hospital	21 (5.2%)
Who provided most antenatal care, N = 400
None	2 (0.5%)
Midwife	1 (0.3%)
Family physician	1 (0.3%)
Obstetrician/gynecologist	396 (98.9%)
Antenatal complications, N = 400
No	317 (79.2%)
Yes	83 (20.8%)
Hospitalized due to complication, N = 400
No	376 (94.0%)
Yes	24 (6.0%)
Out-of-pocket payments for antenatal care, N = 400
No	116 (29.2%)
Yes	284 (70.8%)
Place of childbirth, N = 400
Home	0 (0%)
Primary level facility	20 (5.0%)
Secondary level facility	308 (77.0%)
Tertiary level facility	72 (18.0%)
Mode of childbirth, N = 400
Caesarean Section	179 (44.8%)
Vaginal childbirth	221 (55.2%)
Childbirth provider, N = 400
Midwife	11 (2.8%)
Obstetrician	389 (97.2%)
Immediate postnatal care provider, N = 400
Midwife	1 (0.3%)
Nurse	186 (46.4%)
Obstetrician	213 (53.3%)
Out-of-pocket payments natal and immediate postnatal care, N = 400
No	78 (19.5%)
Yes	322 (80.5%)

^*N varies due to missing data.

In general, we find that women are satisfied with maternal care services. Most respondents agreed with the statement that the condition of the medical facilities and medical equipment is good. They also generally agreed that the facility was clean and the prescriptions were clear. Most of the respondents agreed with the statement that common and specific diagnostic tests, necessary specialized care, and medicines were available and the service costs were affordable. Only a few of the participants strongly disagreed or disagreed with the statement that consultation fee (4.3% and 3.8% respectively), cost of medicines (8.3% and 6.3% respectively), diagnostics (5.3% and 8.5% respectively) and cost for transport (2.0% and 8.3% respectively) were not affordable for them.

In total, 56.8% of the participants agreed with the statement that the waiting time was acceptable for them (average waiting time was 20 min). However, 17.8% strongly disagreed and 8.8% disagreed with the same statement. Of all participants, 66.2% mentioned that antenatal caregivers considered their financial ability, but 23% kept neutral regarding this statement. The majority of the respondents (83.6%) agreed that the antenatal caregiver was respectful. They also agreed that information related to a healthy lifestyle was clearly explained. Our findings show that the majority of the respondents agreed or strongly agreed that they will recommend others their physician (93.4%) and they will recommend others the facilities they used (82%).

Women’s perception about the tangibility of maternity houses was quite high, 77.8% agreed or strongly agreed with the statements that maternity houses/units were attractive and 75.7% agreed or strongly agreed with the statements that medical equipment was updated. Most women in the study agreed or strongly agreed that common diagnostic tests (79.9%) and specific diagnostic tests (70.5%) were available in most cases. In total, 78% of women agreed or strongly agreed with that statement that the fees for childbirth care were affordable. More than 90% of the respondents agreed or strongly agreed that the decision of the care provider about the method of childbirth was correct. Of all participants, 63.7% agreed and 7.5% strongly agreed with the statement that the caregivers consider their financial ability. Most respondents agreed with statements about communication and courtesy of the caregivers during childbirth.

We found that satisfaction with childbirth care and immediate postnatal care was also very high. Participants were satisfied with the adequacy of childbirth care and immediate postnatal care. More than 90% of them agreed or strongly agreed that they will recommend their care provider to others. For the maternal care facility, this share was 87.4%.

Ordinal logistic regression was performed to study factors associated with satisfaction with maternal care services in Georgia. The analysis contains the following explanatory variables: age, education, employment status, place of living, ethnic background, religion, monthly income, antenatal care complication, and payments for maternal care. A statistically significant level of p < 0.05 was used in the analysis.

Regarding antenatal care, we found that younger age groups less often agreed with the statement that maternity care facility buildings and environment were attractive. The younger age groups also less often agreed that common diagnostic tests were available compared to the reference age group (40–44 years). Age group 25–29 years respondents less often agreed that pregnancy-related complications were explained to them clearly, while, the 30–34 years old respondents more often agreed with the same statement compared to the reference age group. The latter age groups more often agreed that privacy was well-maintained. Regarding childbirth and postnatal care we found that younger age groups more often agreed that specialized diagnostic tests were available during childbirth as well as immediate postnatal care compared to the reference group of 40–44 years old. At the same time, younger age groups more often agreed with the statement that physicians consider their financial ability during the natal and immediate postnatal period compared to the reference group.

The study shows that the lowest educated groups more often agreed with the statements about tangibility than the reference group (university educated). They also more often agreed with the statement that common diagnostic tests and necessary medicines were available during antenatal care. The same education group also more often agreed that antenatal caregivers were professionally competent compared to the highest education group (the reference group). The participants in the lowest education group less often agreed with the statement that cost for medicine were affordable during antenatal care. At the same time, they also more often agreed that they will consider antenatal services which they utilized during the last pregnancy.

Compared to respondents in the rural areas, respondents living in urban areas, more often agreed with the statement of the tangibility of antenatal care providers and they were more positive about the same for natal and immediate postnatal care facilities. They also less often stated that waiting time was acceptable during antenatal visits. Our findings also show that in the urban areas, women more often agreed that the provider was timely available. Those who had antenatal complications more often agreed with the statement about the affordability of consultation fee for antenatal care, however, they less often agreed that the costs for medicines were affordable compared to women without complications.

According to our results women with an income from 200 to 900 Gel more often agreed with statements about the attractiveness of antenatal clinics and the condition of the medical equipment compared to women in the highest income group (the reference group). They were also more often positive about the availability of necessary clinical tests during antenatal care compared to the highest-income category. The lowest income group less often agreed with the statement “I felt secured to caregivers services and decisions” during antenatal care. They also less often agreed with the statement about the necessity of prescribed drugs. Compared with the highest income group, women in the income group 200–<900 Gel more often agreed with statements about communication. The lowest income group respondents also less often agreed with the statement that the cost of medicine was acceptable during childbirths and immediate postnatal. The income group 200–<900 Gel more often agreed than other income groups that the price for hospitalization was affordable when they received care in the maternal houses/units.

Compared to those who did not pay, the respondents who paid for the antenatal care less often agreed with the statements about tangibility. At the same time, they more often agreed that common diagnostic tests were available but not necessary medicines. They agreed less with the statement that the waiting time was acceptable. However, they more often agreed that they felt secure with caregivers and that the medicines prescribed during antenatal care, were needed. Those who paid, less often agreed that they felt respect but more often agreed that they felt privacy in the contact with the antenatal care providers.

According to the ordinal regression on the satisfaction with antenatal, natal, and immediate postnatal care, Georgian women and those who paid for maternal care services were less satisfied with antenatal care than those who did not pay. Also, women in urban areas were more often satisfied with antenatal, natal, and immediate postnatal care. Those who paid for services were less motivated to recommend the services to others compared to women who did not pay, but those with complications more often considered recommending their (postnatal) provider.

4. Discussion

We have investigated women’s opinions about maternal care quality and women’s satisfaction with maternal care in Georgia, as well as the association with women’s background characteristics. We discuss the key findings below.

We found that the utilization of antenatal care is nearly 99.8% and most of the participants were satisfied with antenatal care services. About 85% of the respondents received eight and more than eight antenatal care visits which are considerably more than the state- scheduled four visits. Based on other studies, the high satisfaction with antenatal services is associated with the women’s freedom of choice of provider of antenatal care, which has been ensured by the recent decree of the government of Georgia [38]. Although the State has implemented the antenatal care program to meet the pregnant women's needs and demands, these women often needed to pay extra service costs beyond the state coverage. In Georgia, the high number of antenatal visits is often not need-driven but the result of the providers’ interests in gaining extra income [25]. From 2018, the State increased the number of standard antenatal visits based on the latest recommendation of Word Health Organization [39]. Currently, the state provides eight free antenatal care visits which are consistent with our findings. This approach is implemented to meet pregnant women’s needs.

Our findings suggest that women in the lowest education group more often agree with the statements about the tangibility of maternal care as well as with the availability of common diagnostic tests and medicines than women with the highest education level. Some studies have shown that higher education is associated with higher demands and expectations which in turn are related to lower satisfaction [40], [31]. Our findings are consistent with those findings. Also, we found that younger women have a lower opinion of tangibility which is probably because compared with older women, the younger ones cannot remember large, damp, and cold health facilities from the Soviet period [41]. Older women may more positively evaluate the replacement of the huge Soviet hospital infrastructure with the privately-owned smaller, more attractive and modernized facilities, and see it as a positive effect of the health system reform [27]. The replacement of the hospital infrastructure was done through the total privatization of health facilities. Apparently, the change of the Soviet health infrastructure was a good decision, however due to total privatization and liberalization of the health market, the achieved progress was halted and replaced by stagnation especially in the rural part of the country. The lack of regulation and monitoring mechanisms further negatively affect the development of maternal care.

Regarding the accessibility of antenatal care, we found that those who had antenatal complications more often agreed with statements about the affordability of the consultation fee during antenatal care but they more often disagreed with the statement that “the cost of required medicines was affordable”. Additional medicines are paid by out-of- pocket payments and this presents an extra burden for the pregnant women and their households. Out-of-pocket payments tend to be regressive [38], [39] and frequently include unexpected expenses, especially in case of pregnancy complications.

As mentioned above, we found that overall women in urban areas were more positive about the tangibility of maternal care and the availability of the provider than those in rural areas. This could be due to structural factors of the maternal health care settings. In spite of the fact that basic maternal care services are ensured in the entire country. The maternity services in rural areas do not always meet women’s expectations. That leads to inequality in maternal care. Furthermore, comprehensive maternal care services are concentrated in the big cities [26]. For example, out of a total of 89 maternity houses in the country, 23 are located in the capital Tbilisi [31]. Pregnant women most often utilize services from the regional antenatal and natal providers rather than from the nearby rural-based facilities. This is related to rural women’s higher direct and indirect costs. Moreover, many rural women start receiving antenatal care from rural facilities and often switch to providers in urban facilities which cause a breach of continuity of care. This finding is consistent with other studies that find that the absence of continuity of maternal care is related to mistrust between physicians and patients [27].

More than 80% of the respondents paid out of pocket for antenatal, natal, and immediate postnatal care. In spite of fact that the State covers antenatal care visits and all types of childbirth [31], [41], pregnant women are paying for additional antenatal services and extra personal comfort during natal and postnatal services. Other studies showed that an extra payment mostly related to “a personal doctor” [26]. Women are paying to take away the “fear” that services are unavailable and because of the “word of mouth” that they will get more than those who do not pay [41]. Our results regarding out-of-pocket payments are mixed. We find that women who paid are less positive about the tangibility of antenatal care as well as the availability of necessary medicines. However, they felt more secure with caregivers and felt privacy in contact with the antenatal care providers. Moreover, our findings suggest that women who pay are overall less satisfied with antenatal care. Pregnant women pay out-of-pocket to have continuity of care which is not ensured by the State programs. This “do-it-yourself” [41] approach adopted by mothers and their relatives in the country, helps them to address their needs during antenatal, natal and immediate postnatal period.

Our study has some limitations that need to be acknowledged. First, only women who gave birth to healthy babies during the preceding twelve months were included in the study. This means that complicated cases were not well represented in the survey. Second, the study provides limited information about ethnic minorities. Third, the study has a non-experimental cross-sectional nature and therefore, results should only be interpreted in terms of associations. However, this paper is the first to assess women’s satisfaction with maternity care services in Georgia, which makes the study relevant to health policy in Georgia.

5. Conclusions

Our survey is the first to investigate women’s satisfaction with maternal care services in Georgia. In particular, the study provides evidence on women’s satisfaction with antenatal, natal, and immediate postnatal services. Out of ten regions and the capital, the study was conducted in Tbilisi and two regions of Georgia. However, selected areas represent nearly three-fifths of the total population of the country. In the study participated only mothers with a good outcome of pregnancy.

Overall, women are satisfied with the maternal care in Georgia as basic maternal care services are assured in the entire country. However, this satisfaction of women does not indicate the efficient use of resources invested by the government through the private health sector. OPPs for the antenatal, natal and immediate post-natal care are significant. Our findings indicate that the high price does not ensure high quality of maternal care services. Pregnant women and their households are paying out of pocket to get the best available services in the country. At the same time, the study showed that those who pay out-of-pocket are overall less satisfied. That indicates that maternal care services are substandard and lead to an extra financial burden on pregnant women. We found that women in urban settings were more satisfied with antenatal and natal services than in rural areas. It can be due to the improvement in structural factors of maternal health care such as tangibility, availability, accessibility in the cities.

Declaration of Competing Interest

None.