December 2008 no white pages.indd SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL NOVEMBER 2008, VOLUME 8, ISSUE 3, P. 325-332 SULTAN QABOOS UNIVERSITY© SUBMITTED - 23TH FEBRUARY 2008 ACCEPTED - 29TH JUNE 2008 1Directorate of Health Services, Ministry of Health, Musandam Governorate, Oman; 2Eye & Ear Health Care, Non-Communicable Disease Control Section, Department of Non-Communicable Disease Control, Ministry of Health, Oman *To whom correspondence should be addressed. Email: rajshpp@omantel.net.om Satisfaction among Expectant Mothers with Antenatal Care Services in the Musandam Region of Oman *Mohammed Ghobashi,1 Rajiv Khandekar2 ABSTRACT Objectives: As client feedback is useful to improve health service delivery, assessments should be undertaken periodi- cally. This study aimed to determine the level of satisfaction among expectant mothers visiting health institutions for antenatal care services in the Ministry of Health, Musandam region of Oman in 2005. Methods: This was a cross sectional survey in a hospital set- up. Women registered in the antenatal clinics of different health institutions of Musandam region were interviewed. Arabic speaking investigators in six health institutions of Musandum region collected personal profiles, details of different antenatal services offered and responses regarding the satisfaction with these services. The number and percentage of responses were calculated to grade the level of satisfaction. Results: Eighty-three registered women who visited antenatal clinics in six health institutions were interviewed. The overall satisfaction for antenatal care was of excellent grade in 49 (59% - 95% confidence interval 48.5 - 69.6) participants. Sixty- seven (8%) women were happy with services at antenatal clinics mainly because of the attitude of the doctors and nursing staff. The leading causes of dissatisfaction were the laboratory services and overcrowding during morning hours. Conclusion: The women attending antenatal care services in Musandam were highly satisfied with the services offered; however, there was scope for further improvement. The Ministry of Health in consultation with the caregivers should focus on improving antenatal services. Key words: Antenatal care; Patient satisfaction; Oman مسندم في منطقة في الوالدة قبل ما من خدمات احلوامل رضى عمان سلطنة خانديكار راجيف ، غباشة محمد تهدف ــة الدراس هذه لذلك. دوري تقييم عمل كان من الضروري لذا الصحية، اخلدمات ــني تقدمي حتس في مفيد املراجع رأي أن أخذ امللخص: الهدف: مبا ــة دراس الطريقة: هذه .2005 ــنة س خالل ــندم مس منطقة في لوزارة الصحة الصحية للمراكز املراجعات عند احلوامل الرضى ــتوى مس الى معرفة ــتة س في يتقنون اللغة العربية باحثون جمع ــندم. مس منطقة في اتلفة املراجعات للمراكزالصحية احلوامل األمهات مقابلة طريق عن مقطعية والنسب ألجابات األرقام ــاب حس مت اخلدمات. عن تلك رضاهن ــتوى ومس لهن املقدمة باملراجعات واخلدمات املتعلقة املعلومات ــندم مبس صحية مراكز ــاركة 49 مش ــنوى الرضى ممتازا في مس كان ــندم. مبس صحية مراكز ــتة في س ــجلة مس امرأة وثمانني ثالث من املعلومات جمع النتائج: مت احلوامل. خالل فترة الصحية املراكز اخلدمات الصحية في لتقدمي ــرورا س أظهرن (81%) امرأة ــتون وس ــبع س .(69.6 - 48.5 %95 هي الثقة (%59 - فترة اخلالصة: أظهرت الصباح. ــاعات س خالل واالزدحام اتبرات خدمات هو الرضى لعدم ــي الرئيس ــبب الس كان واملمرضات. األطباء ملواقف احلمل، خاصة ــني لتحس مجال هناك لكن ــندم، منطقة مس في تلك املراكز قبل من املقدمة رضاهن باخلدمات باحلوامل اخلاصة الصحية للمراكز املراجعات ــاء النس احلوامل. للنساء اخلدمات حتسني على املراكزوالتركيز تلك في املعنيني الصحة استشارة وزارة على اخلدمات. تلك عمان. املرضى، رضى احلوامل، الكلمات: رعاية مفتاح C L I N I C A L A N D B A S I C R E S E A R C H Advances in Knowledge • Reviewing the client’s perspective should be an integral part of health programme management. • Client satisfaction related to antenatal care services in the Musandam region of Oman was very good. • Feedback of clients should be complemented by direct observations of process and resource evaluation. 326 M O H A M M E D G H O B A S H I A N D R A J I V K H A N D E K A R CLIENT SATISFACTION IS THE LITMUS TEST that enables health programmes to assess the impact of their services; hence, it is an in- tegral part of the ‘quality assurance process’ of health delivery.1 The satisfaction of female clients of antena- tal care services has been studied in the past in other countries.2-5 Dowswell et al.6 performed a meta-analy- sis in 2001 to review the work of different researchers on this subject and suggested that more information is still needed. Apart from a thesis of a PhD student,7 no such feedback has been obtained in the past in Oman. Our study focuses on a remote area of Oman, which has a predominantly Muslim health clientele. Analys- ing satisfaction levels with the free services offered in a remote region of a Middle Eastern country is a useful way to improve the services and can provide a model for others to follow. Musandam is the northern most region of Oman. As this region is surrounded by part of the United Arab Emirates, access to the rest of the regions of Oman is difficult. The Oman Ministry of Health (MoH) provides health services to the 28,378 residents of the region. There are three hospitals and three primary health centres.7 Qualified medical doc- tors and nursing staff provide antenatal care services to expectant mothers in these institutions. Staff mem- bers were trained in different countries like India, Egypt, Pakistan and Iraq and many of them do not speak Arabic. Obstetricians provide high quality ante- natal, natal and postnatal care at the regional hospital and one local hospital. The 6,136 women aged 15 to 49 years of age in Musandam could use these services. The health services charge US $ 2.5 as a case fee. The terrain is so difficult and diverse that the services are offered either by boats or helicopter in some areas of the region. Complicated cases are transported to the tertiary care unit situated nearly 500 kilometres away in Muscat. Ambulances for such critical cases have to travel over mountainous roads, thus imposing una- voidable but definite risks on the patients. The national coverage of antenatal services in Oman is more than 99%. Around 97.5% of the expect- ant mothers give birth in the institutions while the rest deliver at homes under the supervision of a trained nurse.8, 9 In 2005, the staff of the MoH Maternal and Child Health Care Program evaluated the satisfaction of ex- pectant mothers who visited the health institutes of Musandam region. The authors here present the out- come of this study and propose ways to improve the services. Following this study, the Mother and Child Health Program of Oman was encouraged to under- take similar surveys in other regions. M E T H O D S This was a cross-sectional study approved by the ethi- cal committee of the MoH of the Musandam region. As no biological product was taken solely for the pur- pose of research and the study was conducted within the health institutions as part of operational research to improve health care systems, we obtained verbal instead of written consent from the participants. The expectant mothers visiting health institutions of the region between 3 and 9 January 2005 were enrolled in the study. To represent nearly 423 annual deliveries taking place in the region, we selected a sample for our study. We assumed that an excellent grade of satisfac- tion for the antenatal care services would be 80% of clients. To achieve 90% power and 95% confidence in- • Communicating with clients in their native language could be the key to satisfying their antenatal service needs. • Presence of community support group members or Arabic speaking health staff improves cooperation of participants in a study. Applications to Patient Care • Health staff should communicate effectively with expectant mothers during their antenatal visits, as this is key to improving their satisfaction. • If possible, waiting time for laboratory tests results should be reduced and clients informed about the nor- mal procedure and time needed for such tests. • The process of health education for expectant mothers in Musandam should be reviewed and made more client-friendly. 327 S AT I S FA C T I O N A M O N G E X P E C TA N T M O T H E R S W I T H A N T E N ATA L C A R E S E R V I C E S I N T H E M U S A N D A M R E G I O N O F O M A N Table 1: Characteristics of the study population, Musandam region, Oman No. % Age group <20 4 4.8 20 to 24 28 33.7 25 to 29 26 31.3 30 to 34 17 20.5 35 and more 8 9.6 Wilayat Khasab 50 60.2 Deba 23 27.7 Bukha 8 9.6 Madaha 2 2.4 Nationality Omani 66 79.5 Non-Omani 17 20.5 Literacy level Illiterate 13 15.7 Can read & write 4 4.8 School education 51 61.4 Higher education 15 18.1 Babies in past Aborted 25 30.1 No babies 18 21.7 1 to 3 babies 47 56.6 4 or more babies 18 21.7 Married life (n = 76) <1 year 10 12.0 1 to 4.9 years 19 22.9 5 to 9.9 years 15 18.1 10 and more years 33 39.8 Occupation Home maker 68 81.9 Teacher 7 8.4 Staff nurse 1 1.2 X-ray technician 1 1.2 In Air force 1 1.2 Head teacher 1 1.2 S. Nutrition 1 1.2 Missing 3 3.6 Pregnancy stage 1st trimester 12 14.5 2nd trimester 21 25.3 3rd trimester 50 60.2 Total 83 328 M O H A M M E D G H O B A S H I A N D R A J I V K H A N D E K A R terval of the study with a 10% acceptable error of mar- gin, we needed to interview 78 clients. To compensate for possible refusals, we included five more women. In fact, in the field part of our study, all enrolled agreed to participate thus the final sample was 83 women. The participants were selected in series in a health institution on a randomly selected day and were those coming for an antenatal visit. First, we randomly se- lected the health institution. Then we selected one day from five working days of the week to visit each institution. On that day, we enrolled the women in se- quence (meaning pregnant women visiting the clinic one after another as they presented on the day that was randomly fixed for conducting the study in that insti- tution.), as per the number required for that health in- stitution. The numbers interviewed per health institu- tion were based on the proportion of females in the 20 to 40 years age group in that catchment area. Arabic speaking Omani nursing staff and medical orderlies were our study staff. The Community Sup- port Group (CSG) members who were Omani nation- als were also involved as they were known to most of the participants and hence we could reduce the risk of the impact of involving health staff in the study. These CSG members assured the participants that negative responses would not affect the service being offered to them. They were trained in the study methodology. A pilot study to test the methods and the questionnaire was carried out in Khasab hospital, Musandam, prior to the field work. This helped us in fine-tuning the questions to suit local Arabic words as well as stand- ardising the method of conducting the interview. During the study period, the staff visited the female waiting area of the antenatal clinics. They explained the purpose of the study to waiting expectant mothers and obtained their verbal consent to participate. Their replies were noted. The response of the person accom- panying the patient was not noted, but also considered as additional feedback for administrators. The inter- view was conducted in a separate room. The available resources, personal care given by the attending staff and the time spent at six places namely reception, the nursing station, doctor’s consultation room, labora- tory, counselling and pharmacy were covered in the interview. A close-ended questionnaire was prepared to collect responses. Each question had five grades of response. We calculated cumulative points by sum- ming up the responses addressing the same group of questions. To minimize the social desirability bias, we explained the purpose of the survey, involved the CSG members in the Arabic translation, explained the questions and options for responses, especially if the health staff was non-Arabic speaking, and strictly fol- lowed the cultural and social norms. The identity of the participants was de-linked from the responses. The person analysing the data was unaware of the study area and the names of the par- ticipants. The data was computed using EPI Data. 10 The frequency and percentage proportions of the im- portant outcomes were calculated using the Statisti- cal Package for Social Studies (SPSS), Version 9. We used the parametric method of univariate analysis. Each strong positive response was given +2 points. A positive response was given +1 point. An equivocal re- sponse was awarded ‘0’ score. A negative answer was considered as poor and was given ‘-1’ score. Severe dissatisfaction was graded as ‘very poor’ and given a ‘-2’ score. The overall satisfaction of the expectant mother was graded into ‘Excellent’, ‘Good’, ‘Poor’ and ‘Very poor’ categories by using the 25% percentile of the sum of response for different categories of antena- tal services. Topic Level of Satisfaction Satisfaction with Excellent Good Poor Very Poor Clinic 62 21 0 0 Attending doctor 67 16 0 0 Attending nurse/midwife 72 11 0 0 Waiting time 11 62 8 2 Laboratory services 12 11 0 0 Pharmacy support 0 81 2 0 Total 49 34 0 0 Note: The option ‘cannot say’ was not ticked by any participant for any of the questions Table 2: Satisfaction with different components of antenatal care in the Musandam region of Oman 329 S AT I S FA C T I O N A M O N G E X P E C TA N T M O T H E R S W I T H A N T E N ATA L C A R E S E R V I C E S I N T H E M U S A N D A M R E G I O N O F O M A N R E S U L T S Eighty-three participants were sequentially enrolled and interviewed in our study. Their profile suggests that they were educated and distributed in different wilayats (districts) of Musandam region [Table 1]. The distribution of 15 to 45 years old participants in re- lation to the population in different wilayats of Mu- sundam region was calculated. The proportion of the target population in Khasab, Daba, Bukha, Madah wilayats was 64.6%, 18.3%, 9.4% and 7.7% respec- tively. The population of Madah wilayyat was under- represented in our study. Of the 17 non-Omani par- ticipants, seven were Muslim while five each were of Hindu and Christian religion. All 66 Omani females were Muslims. The levels of satisfaction for different components of the antenatal care service delivery were calculated [Table 2]. Forty-nine respondents (59%) reported an ‘Excellent’ grade of overall satisfaction. The rest of the participants reported ‘Very good’ levels of satisfaction. Waiting times during the visit and the support in the pharmacy fell short of clients’ expectations. The wait- ing time was counted and compared with the response of the client. The leading causes of satisfaction are given in Table 3. The positive behaviour of the health staff and the warm reception mothers received in the antenatal care unit were the most satisfying parts of the services. Weakness in the laboratory services, long waiting periods in the clinics, especially during the morning hours, and non-availability of Arabic speaking doctors were the areas for improvement [Table 4]. We consid- ered waiting time after the registration of a new/old case. A ‘very poor’ grade of satisfaction was consid- ered to be a weak area of antenatal services. The dis- satisfaction expressed mainly related to the process of imparting health education (commitment, availability of time and language barrier) and not to the availabil- ity of health education material. D I S C U S S I O N The importance of client satisfaction and feedback has been highlighted in the literature,10, 11 but scien- tists have used different methods of assessing patient satisfaction. Noting observations, evaluating available resources, reviewing the attendance with time and even monitoring the time spent at different places of antenatal care are different methods used. In our study, we recorded client’s perception about overall care and also different components of the antenatal care services. Each method has advantages and dis- advantages. Direct observations are more specific and reliable but they do not incorporate clients’ perspec- tives. Feedback from clients is collected only through suggestion boxes in many institutions, but they may mainly contain complaints and rarely positive experi- ences. Even these complaints are written often with- out proper understanding of the limitations of the providers; hence, the outcomes of such studies should be linked to the review of available resources before interpreting them. Our study showed that clients, in general, have a positive opinion of the antenatal care services offered in the Musandam region. This matched with the obser- vations of Yan T et al.12 and Hildingsson et al. 13 In the former study, the participants were pregnant women with foetal anomalies in a province of Canada, while the later study covered three European countries. Interaction of caregivers with the clients has al- ways been the key to high satisfaction with the service. 14, 15 In our study, an ‘Excellent’ grade of satisfaction for subcomponents of health staff behaviour confirms this observation. Doctors were considered ideal for imparting technical knowledge, providing emotional Topic Number % 95% Confidence Interval Reception by health staff is good 47 56.6 45.9-67.3 Clear instructions 7 8.4 2.4-14.4 Medical orderly available with doctor in ANC 5 6.0 0.9-11.1 Put number on cards 7 8.4 2.4-14.4 Good, clean clinic 8 9.6 3.3-15.9 Good clinic arrangement 4 4.8 0.2-9.4 Good laboratory services 2 2.4 0.0-5.7 Satisfied with service 6 7.2 1.6-12.8 Timely work 1 1.2 0.0-3.5 Table 3: Causes of satisfaction with antenatal care in the Musandam region 330 M O H A M M E D G H O B A S H I A N D R A J I V K H A N D E K A R support and assisting in decision making, although female nurses and midwifes were more acceptable as they can reassure pregnant women and alleviate their anxiety. 15 Health education and communication in the local language are stressed to improve client satisfaction. 14, 16 In our study, the presence of Arabic speaking CSG members helped us in overcoming the language bar- rier between service providers and clients. The dissatisfaction with the laboratory services and facilities and the long waiting period for antena- tal care, especially in the morning hours, were noted in our study. We did not note the time taken waiting for a laboratory test and the waiting time for the test results; hence we are not sure if the dissatisfaction of clients about the length of waiting time was genuine or whether it was due to improper counselling about time needed for laboratory procedures. Further stud- ies should therefore explore this issue and propose corrective measures if required. These issues were also the reasons for low satisfaction in a study covering four countries including Saudi Arabia (a neighbouring country of the present study area). 17 Few participants in our study were practising a religion other than the Muslim one. In addition, we had not planned to study the influence of religion on the main outcomes. Hence, we could not associate the client’s religion to the level of satisfaction for antena- tal care in our study. Tsianakas et al. has reported that health providers’ lack of cultural appreciation was one of the reasons for dissatisfaction among women of Islamic background in Australia. 18 Thus, if antenatal care is delivered with specific consideration to the re- ligion commonly practiced in this area, it will be more acceptable. Fifty participants were in their third trimester of pregnancy. In antenatal services, women visit more frequently during this period compared to the earlier trimesters. Their response could be a cumulative one of their experience of services not only for the current visit but also of the earlier visits. In such circumstanc- es, high satisfaction is suggestive of availability of sat- isfactory antenatal services for at least one year in the study area. Due to the possibility of misclassification bias, we did not study differential satisfaction in rela- tion to the trimester of pregnancy. Sixty-six females (79.5%) had school education in our study. The literate participants are likely to be more aware of newer developments in the field of an- tenatal care and their expectations are also likely to be higher compared to the illiterate females. In view of the high literacy rate among the participants, the high satisfaction rate for the antenatal care services in our study is worth noting. Waiting time has been reported to influence the satisfaction of clients. 5, 17 In our study also, this factor was linked to dissatisfaction with the services; howev- er, it did not match with the time noted independently by field staff. Although we did not have any bench- mark for the time required at different stages of the antenatal care, grievances about delays, especially in laboratory tests should be taken into consideration in the future. Communication by providers to with the women during antenatal visits plays an important role.12, 15 Three out of eight doctors were able to speak Arabic with patients in our study area. The clients’ stress on the need for Arabic speaking doctors and it being one Topic Number % 95% Confidence Interval Laboratory services 30 36.1 25.8 46.4 Crowding clinic in the morning 16 19.3 10.8 27.8 Non-availability of Arabic speaking doctor 12 14.5 6.9 22.1 Health education services not good 6 7.2 1.6 12.8 No explanation of antenatal clinic 6 7.2 1.6 12.8 Not listening to complaints of pregnant women 1 1.2 0 3.5 Unavailability of gynaecologist 5 6.0 0.9 11.1 Long waiting time 5 6.0 0.9 11.1 No Sonar test 5 6.0 0.9 11.1 Table 4: Causes of dissatisfaction among pregnant women, Musandam region 331 S AT I S FA C T I O N A M O N G E X P E C TA N T M O T H E R S W I T H A N T E N ATA L C A R E S E R V I C E S I N T H E M U S A N D A M R E G I O N O F O M A N of the main reasons for dissatisfaction, suggest that language could be a possible barrier in communica- tion between doctors and expectant mothers in our study area. Our staff belonged to the Ministry of Health, the only health service provider in this remote region of Oman. The possibility of social desirability bias can- not be ruled out entirely in such circumstances, but the community’s willingness to voice dissatisfaction about deficiencies in governmental services is often observed in hospitals. They give written complaints to the administrators or raise the issue in the Majlis Al Shura (national parliament) through the local repre- sentatives. In such a situation, fear of compromised antenatal care is unlikely to be the cause of the high proportion of ‘Excellent’ scores in our study. A postal response approach for collecting information has less risk of social desirability bias and was used by Brown et al.19 However, such an approach was not feasible in our study as the terrain in the Musandam region is very difficult and the community is well accustomed to verbal surveys at their health institutions mainly for estimating the magnitude of key diseases. As our sample was selected by sequential methods all clients that attended the antenatal services during 2005 did not have an opportunity to participate in the study. Hence the outcome of the present survey should be generalised with caution for all the expect- ant mothers of the region. C O N C L U S I O N S The women attending antenatal care services in Mu- sandam were highly satisfied with the services offered, but there is scope for further improvement. The Min- istry of Health in consultation with the caregivers should focus on improving antenatal services. A C K N OW L E D G ME N TS This subject was the thesis of Dr. M Ghobashi for his Master’s degree in Hospital Administration. We thank the health administrators of the region of Musandam and the Maternal and Child Health Care Program of Oman for its support of the study. We appreciate the contribution of community support group members and of the dedicated nursing staff of the Musandam health institutions. We thank the par- ticipating women for their overwhelming responses. Mr Saleh Al Harby assisted in data entry and statistical analysis. R E F E R E N C E S 1. Ivanov LL, Flynn BC. Utilization and satisfaction with prenatal care services. West J Nurs Res 1999; 21:372- 386. 2. Seclen-Palacin JA, Benavides B, Jacoby E, Velasquez A, Watanabe E. Is there a link between continuous quality improvement programs and health service users’ satis- faction with prenatal care? An experience in Peruvian hospitals. Rev Panam Salud Public. 2004; 16:149-157. 3. Luyben AG, Fleming VE. Women’s needs from antena- tal care in three European countries. Midwifery 2005; 21:212-223. 4. Uzochukwu BS, Onwujekwe OE, Akpala CO. Commu- nity satisfaction with the quality of maternal and child health services in southeast Nigeria. East Afr Med J 2004; 81:293-299. 5. Bronfman-Pertzovsky MN, Lopez-Moreno S, Magis- Rodriguez C, Moreno-Altamirano A, Rutstein S. Prena- tal care at the first level of care: characteristics of pro- viders that affect users’ satisfaction. Salud Publica Mex 2003; 45:445-454. 6. Dowswell T, Renfrew MJ, Gregson B, Hewison J. A re- view of the literature on women’s views on their mater- nity care in the community in the UK. Midwifery 2001; 17:194-202. 7. Al-Mandhari A. Quality of PHC services in Al-Dhahira region. PhD thesis. Liverpool University, UK, 2002. 8. Director General of Health Planning, Ministry of Health, Oman. Health Status Indicators. In: Annual Health Re- port Year 2004. Muscat: Al Zahra Printers, 2005. p. 1-4 and 2-2. 9. Ministry of Health, Oman, UNICEF & UNFPA. Care during delivery. In: National Health Survey 2000 Re- productive Health Study. Vol. 2. Muscat: Ministry of Health, 2000. p. 96. 10. Lauritsen JM, Ed. EpiData Data Entry, Data Manage- ment and Basic Statistical Analysis System. Odense, Denmark: EpiData Association, 2000-2006. 11. Wong ST, Korenbrot CC, Stewart AL. Consumer assess- ment of the quality of interpersonal processes of prena- tal care among ethnically diverse low-income women: development of a new measure. Women’s Health Issues 2004; 14:118-129. 12. Yan T, Wen SW, Walker MC, Beduz MA, Kim PC. Fetal Alert Network: Women’s satisfaction with the current state of prenatal care for pregnancies complicated by fe- tal anomalies: a survey of five academic perinatal units in Ontario. J Obstet Gynaecol Can 2007; 29:308-314. 13. Hildingsson I, Rådestad I. Swedish women’s satisfaction with medical and emotional aspects of antenatal care. J Adv Nurs 2005; 52:239-249. 14. Tandon SD, Parillo KM, Keefer M. Hispanic women’s perceptions of patient-centeredness during prenatal care: a mixed-method study. Birth 2005; 32:312-317. 15. Douglas S, Cervin C, Bower KN. What women expect of family physicians as maternity care providers. Can Fam Physician 2007 May; 53:874-879. 16. Büchi S, Cignacco E, Lüthi D, Spirig R. Needs and ex- pectations of Tamil women attending an antenatal care department at a Swiss university hospital. Pflege 2006; 19:295-302. 17. Nigenda G, Langer A, Kuchaisit C, Romero M, Rojas G, Al-Osimy M, Villar J, et al. Women’s opinions on an- tenatal care in developing countries: results of a study in Cuba, Thailand, Saudi Arabia and Argentina. BMC Public Health. 2003; 20:3-17. 18. Tsianakas V, Liamputtong P. What women from an Is- lamic background in Australia say about care in preg- nancy and prenatal testing. Midwifery 2002; 18:25-34. 19. Brown SJ, Bruinsma F. Future directions for Victoria’s public maternity services: is this “what women want”? Aust Health Rev 2006; 30:56-64. 332 M O H A M M E D G H O B A S H I A N D R A J I V K H A N D E K A R 2