Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis

Abstract

Background:

In approximately 15% of all pregnancies, a potentially fatal complication that necessitates medical attention arises, requiring a significant obstetrical intervention for the pregnant women to survive. Between 70% and 80% of maternal life-threating complication have been treated through emergency obstetric and newborn services. This study investigates women’s satisfaction with emergency obstetric and newborn care services in Ethiopia and factors associated with their satisfaction.

Methods:

In this systematic review and meta-analysis, we searched electronic databases, such as PubMed, Google Scholar, HINARI, Scopus, and Web of Sciences for primary studies. A standardized data collection measurement tool was used to extract the data. STATA 11 statistical software was used to analyze the data, and I² tests were used to evaluate heterogeneity. The pooled prevalence of maternal satisfaction was predicted using a random-effects model.

Results:

Eight studies were included. The pooled prevalence of maternal satisfaction with emergency obstetric and neonatal care services was 63.15% (95% confidence interval: 49.48–76.82). Age (odds ratio = 2.88, 95% confidence interval: 1.62–5.12), presence of birth companion (odds ratio = 2.66, 95% confidence interval: 1.34–5.29), satisfaction with health workers’ attitudes (odds ratio = 4.02, 95% confidence interval: 2.91–5.55), educational status (odds ratio = 3.59, 95% confidence interval: 1.42–9.08), length of stay at health facility (odds ratio = 3.71, 95% confidence interval: 2.79–4.94), and antenatal care visits (odds ratio = 2.22, 95% confidence interval: 1.52–3.24) were associated with maternal satisfaction with emergency obstetric and neonatal care service.

Conclusion:

This study found a low level of overall maternal satisfaction with emergency obstetric and neonatal care services. To increase maternal satisfaction and utilization, the government should focus on improving the standards of emergency maternal, obstetric, and newborn care by identifying gaps in maternal satisfaction regarding the services provided by healthcare professionals.

Keywords

emergency obstetric and newborn care Ethiopia maternal satisfaction meta-analysis

Introduction

Emergency obstetric and newborn care (EmONC; basic versus comprehensive) refers to caring for women and newborns during pregnancy, delivery, and postpartum to prevent serious complications or death.^1
–4 The World Health Organization (WHO) estimates that, globally, approximately 15% of expected births develop life-threatening complications during pregnancy, delivery, or at the postpartum period. EmONC services are a set of key obstetric services or signal functions provided for pregnant women and newborns against fatal complications, such as bleeding, infection, prolonged or obstructed labor, eclampsia, and asphyxia.^1,5 Emergency care is recognized as an essential and effective component of obstetric services.^6,7

Since 2008, the Ethiopian government has been providing standard EmONC in all health facilities.⁸ The government has undertaken numerous initiatives to improve the utilization and quality of maternal and newborn services, including expanding health services to rural residences, training and deploying skilled birth attendants, upgrading emergency obstetric care facilities, implementing maternal and perinatal death surveillance and responses, and constructing maternity waiting homes within health facilities. Although these have improved healthcare coverage and utilization at all levels, providing quality services remains a major challenge.^9,10 In 2016, the Ethiopia Demographic and Health Survey (EDHS) reported a maternal mortality rate of 412 per 100,000 (0.412%) live births.¹¹ The major causes of maternal death in Ethiopia are hemorrhage, hypertension during pregnancy, obstructed labor, sepsis, and anemia.^12,13 The provision of EmONC is crucial and is currently the recommended intervention to prevent maternal and newborn morbidity and mortality by treating obstetric and newborn complications.^3,14,15 It can prevent about 70%–80% of maternal deaths if applied appropriately and correctly.^16,17

Basic EmONC (BEmONC) has seven key and critical obstetric services: administration of parenteral antibiotics, administration of parenteral anticonvulsants, administration of parenteral uterotonic agents, removal of retained products, assisted vaginal delivery, manual removal of the placenta, and resuscitation of the newborn.^14,18 Blood transfusion and cesarean delivery of the fetus with components of BEmONC services are collectively named as comprehensive EmONC (CEmONC).^4,19

Patient satisfaction is the patient’s reaction in the form of a “cognitive evaluation” and “emotional response” to the care they receive.²⁰ Patient satisfaction is an important measure of healthcare quality, as it offers information on the provider’s success in meeting clients’ expectations and is a key determinant of patients’ behavioral intentions.²¹ Maternal satisfaction is an important quality outcome indicator for healthcare providers and settings; hence, its measurement is of vital importance as health worker services are determinants of overall satisfaction during a hospital stay.^22,23 It may have an impact on several aspects of patients’ behavior, including resource utilization, compliance with treatments, and the regularity with which they communicate with their caregivers.^24,25

Various primary studies have been conducted in Ethiopia to determine maternal satisfaction with EmONC services.^{14,16,17,26
–29} The reports indicate that there is a considerable variation in maternal satisfaction with EmONC services at the national level, ranging from 34.7%¹⁴ to 84.7%.²⁸ Similarly, the factors associated with maternal satisfaction with EmONC services differ by studies.^{16,17,26
–30} Identifying gaps in maternal satisfaction regarding the services provided may aid in improving care delivery. As a result, the purpose of this systematic review and meta-analysis was to find out the pooled prevalence of maternal satisfaction with EmONC services and its associated factors.

Methods

Study design

This study aimed to estimate the prevalence of maternal satisfaction with EmONC services and its associated factors in Ethiopia using a systematic review and meta-analysis approach. The protocol follows guidelines for the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).³¹

Eligibility criteria

Inclusion criteria

Period: Articles reported until December 20, 2022 were included.

Language: Only articles published in the English language were searched.

Publication status: All published and unpublished studies, Ethiopian university digital libraries, and research institute websites were included.

Exclusion criteria

Articles in which the response variable was not clearly defined and measured, and articles of poor quality were excluded. We also excluded qualitative papers, case studies, and secondary works (e.g. review articles, commentaries, editorials, and unpublished conference abstracts).

Search strategy and data sources

Articles were searched using PubMed, Google Scholar, EMBASE, HINARI, Scopus, and Web of Sciences without time restrictions. Furthermore, manual searches of cross-references were conducted to identify additional relevant articles. The search terms and phrases were “availability,” “magnitude,” “prevalence,” “satisfaction,” “emergency obstetric and neonatal care,” “comprehensive,” “determinants,” “predictors,” “associated factors,” and “Ethiopia.” In addition, Ethiopian universities’ digital libraries were searched for relevant unpublished studies (Additional file 1).

Population: Mothers of all age categories were included in studies that reported the prevalence of maternal satisfaction with emergency obstetric and neonatal care services in Ethiopia and the associated factors.

Explanatory variables: Determinants of maternal satisfaction with emergency obstetric and neonatal care services (i.e. socio-demographic variables, such as age, educational status, occupational status, and residence), obstetric-related factors, and behavior-related factors.

Response variable: The primary outcome was the prevalence of maternal satisfaction and factors associated with EmONC services among mothers in Ethiopia as reported in the included studies.

Identification and study selection: The included studies were exported to Endnote X7 reference manager software, and duplicate articles were removed. After reviewing the titles and abstracts, studies were screened. The articles were screened and independently evaluated by three authors (B.G.K., F.Y.B., and B.C.D.). Furthermore, we assessed the full texts based on the aims, methodology, participants, and objectives of the studies. Conflicts were resolved through conversation and general agreement using predetermined criteria.

Quality assessment

The identified and included cross-sectional studies were assessed using the Newcastle-Ottawa Scale quality assessment tool adapted for cross-sectional studies.³² Three authors independently weighed the quality of each original study based on the Newcastle-Ottawa Scale quality assessment tool criteria. Primary studies with a medium score (meeting 50% quality evaluation criteria) and high quality (⩾7 out of 10) were included in the analysis. Discrepancies among the three researchers were addressed using their quality evaluation results (Additional file 2).

Data extraction

Following the selection of the studies, three authors used a standardized data extraction form to extract the necessary data independently. The primary author, year of publication, study setting, sample size, study design, response rate, the prevalence of maternal satisfaction, and specific factors associated with maternal satisfaction with EmONCs were included in Microsoft Excel. If two or more studies reported a single variable to be common, the significant factor would be selected.

Publication bias and heterogeneity

Electronic databases and manual searches were conducted to minimize the risk of bias. Funnel plots were used to assess publication bias, and the Egger’s regression test was used to determine the statistical significance of the publication bias, with a p-value less than 0.05.³³ To detect publication bias, we used Duval and Tweedie’s nonparametric trim-and-fill analysis with a random-effects model, which revealed the presence of publication bias (Egger’s test, p < 0.05).³⁴ A point estimate was performed to reduce random variation among the primary studies. Sensitivity analysis was also performed to identify the source of heterogeneity. The random-effects model was used to assess heterogeneity across studies using inverse variance (I²) statistics and the corresponding p-values.

Statistical analysis

Microsoft Excel was used for data entry, and STATA version 11 software was used for analysis. The factors associated with maternal satisfaction with EmONCs were examined based on the eligibility criteria. We considered at least two studies that reported at least one associated factor with maternal satisfaction with EmONCs, common to their measure of effect and 95% confidence interval (CI). The DerSimonian–Laird method was used to assess the differences between studies. Texts, tables, and forest plots with effects and 95% CI measures were used to present the findings. I² statistics were used to test for statistical heterogeneity at a p-value of less than or equal to 0.05.³³

Results

In total, 725 primary articles were identified using various databases. Of these, 204 articles were eliminated due to repetition, and 521 articles were reviewed for eligibility. Of the 521 articles, 317 were excluded because of irrelevance, and another 196 were excluded because of limited statistical analysis, an irrelevant source population, and an inconsistent study report. Finally, eight articles that met the inclusion criteria were used in this systematic review and meta-analysis (see Figure 1).

Figure 1.

PRISMA flowchart diagram of the study selection for systematic review and meta-analysis on maternal satisfaction with EmONC services and associated factors in Ethiopia, 2023.

Characteristics of the included studies

Eight qualified cross-sectional studies reported in English were included. A total of 3180 mothers participated in the study. The sample size was 265 from Amhara region²⁹ and 477 from Oromia region.²⁷ The prevalence of maternal satisfaction with EmONCs was between 34.7%¹⁴ and 84.7%²⁸ (Table 1). The quality scores of the primary studies were good (Additional file 2).

Table 1.

Summary of eight observational studies included in this study that assessed maternal satisfaction with EmONC services and associated factors in Ethiopia, 2023.

Authors and publication year	Region	Study design	Setting	Sample size	Definition of satisfaction	Prevalence	Factors
Berhane et al.¹⁴	Tigray	Cross-section	Public health facilities	398	Magnitude of quality with the service: the responses categorized into satisfied and dissatisfied finally changes to the level of quality score in percentage, with a good quality satisfied score of 75% and above.	34.7	Rural residents, presence of a companion
Negash et al.³⁰	SNNPR	Cross-section	Public health facilities	413	Satisfaction was assessed using 23 variables with Cronbach’s alpha of 0.62. Five-point Likert scale items were used and were later dichotomized into “satisfied” and “dissatisfied”	44.8	Age ⩾ 35 years, presence of a birth companion
Kumsa et al.²⁶	Oromia	Cross-section	Public health facilities	403	The level of satisfaction was measured by a composite score of 19 items that were later dichotomized into “satisfied” and “dissatisfied”	79.4	Availability of drugs and supplies, health workers’ communication, the attitude of health workers
Tiruneh et al.¹⁶	Amhara	Cross-section	Public health facilities	404	Mothers who scored more than or equal to 75% on the 18 satisfaction measuring items were categorized as “satisfied,” after transformation of the individual’s satisfaction score from 1% to 100% for each item	65.1	Antenatal care visits, women waiting less than 15 min, mothers staying < 1 day, obtaining a welcoming environment and getting providers explanation of examinations
Melak et al.²⁹	Amhara	Cross-section	Public health facilities	265	Mothers who scored 75% and more on 18 items of the patient satisfaction questionnaire were categorized under “satisfied” for the overall satisfaction level.	81	Short waiting time of clients, educational level
Getenet et al.²⁸	Harar	Cross-section	Public health facilities	398	Mothers who scored 75% and more on 18 items of the patient satisfaction questionnaire were categorized under “satisfied” for the overall satisfaction level.	84.7	Waiting time seen by the healthcare provider, availability of emergency drugs, not having antenatal care follow-up, previous experience of home delivery and planning to deliver in the hospital
Alemayehu et al.¹⁷	SNNPR	Cross-section	Public health facilities	422	12 items with a 5-point Likert scale (ranging from strongly dissatisfied to satisfied) were used to assess the woman’s satisfaction with the EmONC services given at the health facility and computed out of 100%.	40.8	Educational status, age, duration of stay at the facility, number of patients in the delivery room and care provider’s experience
Urgessa and Teshome²⁷	Oromia	Cross-section	Public health facilities	477	Mothers who scored 75% and more in 18 items of the patient satisfaction questionnaire were categorized under “satisfied” for the overall satisfaction level.	74.6	Educational status, monthly income, assisted vaginal delivery, and maintaining privacy measures

Prevalence of maternal satisfaction with EmONC services

The random-effect model shows that the pooled prevalence of maternal satisfaction with EmONC services in Ethiopia was 63.15% (95% CI: 49.48–76.82) with a high level of heterogeneity (I² = 99.8%, p < 0.001) (see Figure 2).

Figure 2.

Forest plot of the pooled prevalence of maternal satisfaction with EmONC services and associated factors in Ethiopia, 2023.

Publication bias and heterogeneity

Egger’s test and funnel plots were used to assess publication bias. The p-value for Egger’s test was 0.128, which was not statistically significant, implying that no publication bias existed. The funnel plot shows a symmetrical distribution of the included papers, implying that there was no indication of publication bias in this meta-analysis (Figure 3). Based on the findings, there was a presence of heterogeneity across the studies, as evidenced by I² statistics (I² = 99.8%, p < 0.001). A meta-analysis was used to determine the pooled prevalence of maternal satisfaction with EmONC services in Ethiopia using a random-effect model.

Figure 3.

(a) Funnel plot to test publication bias of eight studies. (b) Result of trim-and-fill analysis for adjusting publication bias of the eight studies (no needs have trim-and-fill analysis) (data unchanged).

Sensitivity analysis

The authors used a leave-one-out sensitivity analysis to identify the potential sources of heterogeneity in the pooled prevalence of maternal satisfaction with EmONC services. The sensitivity analysis revealed that the findings were not dependent on a specific study. The pooled prevalence of maternal satisfaction with EmONC services varied, ranging from 60.83% (60.03–61.63) to 69.93% (69.17–70.67) after the deletion of five studies (see Figure 4).

Figure 4.

Sensitivity analysis of pooled prevalence on maternal satisfaction with EmONC services and associated factors in Ethiopia, 2023.

Factors affecting maternal satisfaction with EmONC services

This study revealed that maternal age, women’s educational status, the presence of a birth companion, antenatal care (ANC) follow-up, satisfaction with the attitude of health workers, and time spent at a health facility were strongly related to maternal satisfaction with EmONC services.

Three studies described the association of age (above 35 years) with maternal satisfaction with EmONC services.^17,28,30 One study found no association with maternal satisfaction, whereas two studies found that age significantly affects maternal satisfaction with EmONC services. The overall pooled estimate revealed that age significantly affects maternal satisfaction with EmONC services (adjusted odds ratio (AOR) = 2.88, 95% CI: 1.62–5.12). No heterogeneity was observed among the studies (Figure 5).

Figure 5.

Factors associated with maternal satisfaction with EmONC services in Ethiopia, 2023.

Companionship was found as an important factor affecting maternal satisfaction with EmONC services. As indicated in five studies, there was also an association between the presence of a companion and maternal satisfaction.^{16,17,26,29,30} A statistical difference between them was found in the pooled analysis (AOR = 2.66, 95% CI: 1.34–5.29). There was variation between the studies (I² = 90.2%, p < 0.001). Consequently, a random-effects model was used to estimate the pooled OR (Figure 5).

According to a pooled effect from three studies, participants who received ANC visits were two times more likely to have maternal satisfaction with EmONC services than their counterparts (AOR = 2.22, 95% CI: 1.52–3.24)^27
–29 (see Figure 5).

As indicated in five studies, there was also an association between women’s educational status and maternal satisfaction with EmONC services.^{16,17,26,27,28} A statistical difference between them was found in the pooled analysis (AOR = 3.59, 95% CI: 1.42–9.08). We used the random-effects model to estimate the pooled OR because the heterogeneity test revealed greater heterogeneity between the studies (I² = 85.3%, p < 0.001; see Figure 5).

Similarly, two studies have reported that the length of stay at a health facility was associated with maternal satisfaction with EmONC services.^16,17 The pooled estimate indicated a positive association with maternal satisfaction with EmONC services (AOR = 3.71, 95% CI: 2.79–4.94; see Figure 5).

Another factor that affects maternal satisfaction with EmONC services is the attitude of health workers.^16,26,30 This was supported by the pooled estimates of three independent studies (AOR = 4.02, 95% CI: 2.91–5.55). A random-effects model analysis was conducted to estimate the pooled OR, and there was no evidence of a heterogeneity effect (Figure 5).

Discussion

EmONC services were designed to prevent maternal and neonatal morbidity and mortality by treating obstetric and neonatal complications. Hence, the current systematic review and meta-analysis aimed to estimate the pooled prevalence of maternal satisfaction with EmONC services among mothers in Ethiopia and the factors associated with their maternal satisfaction. Maternal satisfaction with maternity services is an important indicator of the quality of care and the provision of services in the healthcare system.

According to this systematic review and meta-analysis, the pooled prevalence of maternal satisfaction with EmONC services in Ethiopia was 63.15% (95% CI: 49.48–76.82). This finding is in line with a systematic review and meta-analysis of studies conducted in Pakistan and Indonesia in which the pooled prevalence was 63%³⁵ and 56.4%,³⁶ respectively. This variation might be a result of differences in the level of quality service offered, an increased awareness of maternity care services, a change in mothers’ expectations, or the type of health facilities offering the delivery services. In general, maternal health service satisfaction with EmONC services is still low compared to the national prevalence of EmONC in Ethiopia, which is >75%.¹⁶

However, the prevalence of maternal satisfaction with EmONC services is lower than in the study conducted in Ghana (79.8%),³⁷ Nepal (89.8%),³⁸ Egypt (78.5%),³⁹ Nigeria (80%),⁴⁰ and Bangladesh (85%).⁴¹ This variation may be explained by the differences in hospital systems or settings and by mothers’ socioeconomic and cultural backgrounds.

Based on this systematic review and meta-analysis, maternal age greater than 35 years increased the odds of maternal satisfaction with EmONC services. This might be a result of better service that this age group currently receives, which is better than what they received in the past. As women age, the risk of obstetric complications increases; as a result, they require better care to survive.^15,42

Satisfaction with the attitude of health workers was more likely to have good maternal satisfaction with EmONC services (AOR = 4.02, 95% CI: 2.91–5.55). When healthcare professionals had positive attitudes toward caring for a patient, had already established rapport with a patient, or were acquainted with the patient’s culture or community, they were more likely to be sympathetic and understanding.^3,43

Women’s educational status was also positively associated with maternal satisfaction with the EmONC services. This finding is in line with a previous study conducted in Pakistan.³⁵ This could be because of their increased experience and maturity as their educational status increases. Another possible explanation might be that participants who had a higher level of education could read news and follow social media platforms related to pregnancy-related complications and their fatalities.

Mothers who had a birth companion at the time of labor reported being almost three times more satisfied with EmONC services than those who did not. This could be explained by the fact that a mother in labor requires special assistance from close family members who may help in healthcare delivery by collaborating effectively with healthcare providers.⁴⁴

Another factor influencing maternal satisfaction with EmONC services was ANC services. Mothers who received ANC follow-up were three times more likely to be satisfied than those who did not (AOR = 2.22; 95% CI: 1.52–3.24). This could be because mothers who have had more ANC visits have become familiarized with their delivery attendants, resulting in a smooth environment in which providers and mothers become friendly during delivery care.⁴⁵ Furthermore, mothers who receive ANC may benefit from the early detection of obstetric complications, allowing them to receive care earlier.¹⁶

Furthermore, length of stay at a health facility was a determining factor for maternal satisfaction with EmONC services. Women who stayed in a health facility on admission were nearly four times more likely to have good satisfaction than those who had no experience with admission. This could be because we focused on severe complications while underestimating the management of some complications as less relevant. This could also result in noncompliance with standards of care and procedures. Evidence also indicates that emergency patients discharged early had a higher risk of dying compared to those who stayed lengthier in hospital.

Aside from its significance, this systematic review and meta-analysis have some limitations. First, all primary studies included in this review were limited to certain parts of the country, and other regions may be underrepresented. Second, this review only considered articles published in English, which may have resulted in the omission of studies published in other languages. Finally, the findings of this systematic review and meta-analysis may not exactly estimate the national pooled prevalence of maternal satisfaction with EmONC services because different categories are used to define maternal satisfaction. Further research should be conducted to determine the types of interventions referred to by maternal satisfaction, obstetric outcomes, health system factors influencing EmONC service utilization, and predictors of women’s satisfaction.

Conclusion

Maternal satisfaction with EmONC services in Ethiopia is suboptimal. Age, presence of a birth companion, satisfaction with the attitude of health workers, women’s educational status, length of stay at a health facility, and ANC visits were factors that affected maternal satisfaction with EmONC services. To increase maternal satisfaction and utilization, the government must focus on improving the standards of emergency maternal, obstetric, and newborn care. When mothers visit health facilities, health professionals should encourage them to bring in their birth companions. Moreover, health promotion and awareness creation should be continuously carried out regarding the importance of ANC follow-up services and EmONC services.

Supplemental Material

sj-doc-3-whe-10.1177_17455057231183854 – Supplemental material for Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis

Supplemental material, sj-doc-3-whe-10.1177_17455057231183854 for Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis by Bekalu Getnet Kassa, Fentahun Yenealem Beyene and Basaznew Chekol Demilew in Women’s Health

Supplemental Material

sj-docx-1-whe-10.1177_17455057231183854 – Supplemental material for Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis

Supplemental material, sj-docx-1-whe-10.1177_17455057231183854 for Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis by Bekalu Getnet Kassa, Fentahun Yenealem Beyene and Basaznew Chekol Demilew in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057231183854 – Supplemental material for Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis

Supplemental material, sj-docx-2-whe-10.1177_17455057231183854 for Maternal satisfaction with emergency obstetric and newborn care services in Ethiopia and the associated factors: A systematic review and meta-analysis by Bekalu Getnet Kassa, Fentahun Yenealem Beyene and Basaznew Chekol Demilew in Women’s Health

Footnotes

Acknowledgements

The authors thank the sources of all the primary studies.

Declarations

ORCID iD

Bekalu Getnet Kassa

Supplemental material

Supplemental material for this article is available online.

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