Person-centered maternity care and satisfaction with post-abortion care: A facility-based cross-sectional survey in Northern Uganda

Abstract

Background:

The experience of post-abortion care (PAC) is crucial to the quality of PAC services. However, there is limited literature on women’s experience with PAC, particularly the aspects of person-centered maternity care (PCMC) and satisfaction with PAC services.

Objective:

To examine the relationship between PCMC and satisfaction with PAC services.

Design:

A facility-based analytical cross-sectional study.

Methods:

A survey was conducted among 370 women aged 15–49 who sought PAC services at public health facilities in Lira city, Northern Uganda. Data were collected using a validated questionnaire. Data analysis included descriptive statistics, the Spearman correlation test, and multiple linear regression.

Results:

The mean age of study participants was 26.1 (±6.3) years. The overall PCMC median score was 21.5 (interquartile range (IQR): 11) out of 36. The median scores for the sub-scales were as follows: 6 (IQR: 6–6) for dignity and respect out of 9; 9 (IQR: 5–13) for communication and autonomy out of 18; and 8 (IQR: 6–9) for supportive care out of 9. Satisfaction with PAC services’ score ranged from 6 to 42, and the median satisfaction score was 30 (IQR range: 28–32). Bivariate analysis revealed a weak but significant correlation between the overall PCMC scale and satisfaction with PAC services (r = 0.21, p < 0.001). Sub-scales of dignity and respect and communication and autonomy also had a weak but significant correlation with satisfaction with PAC services (r = 0.16, p = 0.002, and r = 0.21, p < 0.001 respectively). In a linear regression model, communication and autonomy score was significantly associated with higher satisfaction with PAC score (β = 0.10; 95% confidence interval (CI): 0.01, 0.19; p < 0.001).

Conclusions:

PCMC, particularly the aspects of communication between clients and providers and the promotion of clients’ autonomy, is associated with higher satisfaction with PAC services. Efforts to increase clients’ satisfaction with PAC should focus on strengthening communication between clients and providers and promoting clients’ autonomy during care.

Plain language summary

Relationship between person-centered maternity care and satisfaction with post-abortion care

Why was the study done? This study looked at how person-centered maternity care relates to women’s satisfaction with post-abortion care in Lira city, Northern Uganda. What did the researchers do? We surveyed women aged 15 to 49 who received post-abortion care (PAC) services at public health facilities in Lira city, Northern Uganda. The data were gathered using a reliable questionnaire. We used basic descriptive statistics to analyze the data, looked for relationships between variables using a Spearman correlation test, and applied multiple linear regression to explore further connections. What did the researchers find? The average age of participants was 26 years. The overall score for person-centered maternity care (PCMC) was 21.5 out of 36. Looking at specific aspects, the median score for dignity and respect was 6 out of 9, for communication and autonomy it was 9 out of 18, and for supportive care, it was 8 out of 9. Satisfaction with post-abortion care (PAC) services ranged from 6 to 42, with a median score of 30. A slight but important connection was found between higher PCMC scores and greater satisfaction with PAC services. Specifically, dignity and respect, as well as communication and autonomy, were also linked to satisfaction, though the relationship was modest. What do the findings mean? Improving communication between clients and healthcare providers, as well as encouraging clients to make their own decisions, helps increase satisfaction with post-abortion care (PAC) services. To boost satisfaction with PAC, efforts should focus on enhancing how providers communicate with clients and ensuring that clients feel empowered to have a say in their care.

Keywords

Person-centered maternity care satisfaction post-abortion women and Uganda

Introduction

Inadequate access to safe, timely, affordable, and respectful post-abortion care (PAC) is a critical public health and human rights issue.¹ Globally, 6 out of 10 unintended pregnancies end in induced abortion.¹ Around 45% of all abortions are unsafe, of which 97% are performed in developing countries.¹ The abortion rate in Uganda stands at 39 per 1000 women aged 15–49, which is higher than the rate of 34 per 1000 women in East Africa.² Globally, it is estimated that 4.7%–13.2% of maternal deaths each year can be attributed to unsafe abortion, with developing nations bearing the brunt of this problem.¹

Abortion is the termination of pregnancy before the fetus is viable; it is a safe intervention when carried out by skilled health personnel using a method suitable to the duration of the pregnancy.¹ Although abortion is illegal in Uganda, PAC was adopted as part of a set of intervention packages introduced to taper the risks of abortion complications.^3,4 PAC consists of emergency treatment of incomplete abortion and its complications, contraceptive counseling and provision, and evaluation and treatment of sexually transmitted diseases.³

The quality of PAC can be assessed based on (i) the provision of PAC service and (ii) the woman’s experience of PAC services.^5,6 Person-centered maternity care (PCMC) is care that is respectful and responsive to women’s individual preferences, needs, and values based on the experience of care received.^6,7 Meanwhile, the experience of care can be defined as the sum of all interactions that patients have with the healthcare system.^6,7 These interactions are shaped by an organization’s culture, the influence of women’s or service users’ cultural expectations, and health systems factors such as funding, staffing, infrastructure, competency of the service providers to provide PAC, and availability of equipment.^8
–10 Previous studies have focused on access to and provision of PAC services.^6,7,11,12 Consequently, there is a dearth of literature documenting women’s experience with PAC, particularly aspects of PCMC and satisfaction with PAC services rendered in healthcare facilities. Nevertheless, the experience of PAC is just as important as the provision of PAC services.

In Uganda, a significant percentage of clients seek and acquire PAC services from public health facilities because the services are legal and free of charge. Out of the 567 facilities in Central and Northern Uganda, 366 are public health facilities, and half offer PAC services, although the person-centered outcomes and satisfaction with services offered in these facilities are not documented.¹³ The study results on the person-centered outcomes and satisfaction with PAC in the context of Uganda will strengthen the demand to improve the quality of PAC services in public health facilities and guide facilities to design person-centered measures to achieve this improvement. Therefore, this study examined the relationship between PCMC and satisfaction with PAC services among women in Lira city, Northern Uganda.

Materials and methods

Study design and setting

A facility-based cross-sectional study was conducted in two high-volume public health facilities in Lira city, Northern Uganda from December 2022 to April 2023 and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines¹⁴ (Supplemental Appendix 1). The city is located approximately 342 km by road from Kampala, the capital city of Uganda. Lira city has one referral hospital, one level IV health center, and four level III health centers qualified to offer PAC services.¹⁵

Level III health facilities provide outpatient care, maternity services, child health services, HIV/AIDS management, family planning, basic laboratory services, health education, and referrals to higher-level care.¹⁵ Level IV health facilities offer comprehensive outpatient and inpatient care, surgical services, maternity services, emergency care, laboratory services, HIV/AIDS management, family planning, health education, and serve as referral centers for lower-level facilities.¹⁵ Meanwhile, referral hospitals provide specialized inpatient and outpatient care, advanced surgical services, emergency care, intensive care, diagnostic and laboratory services, comprehensive HIV/AIDS management, maternity and pediatric services, mental healthcare, and serve as referral centers for lower-level health facilities.¹⁵

In Uganda, PAC services are provided at health center level IV and above. The gynecological clinics and wards where PAC services are provided are staffed by a team of healthcare professionals, including midwives, nurses, and doctors, who play critical roles in delivering care to women in need.¹³ In many facilities, the ratio of service providers to patients is estimated to be as high as 1:2000¹³ and yet PAC cases can be as high as 150 per month in these facilities.

Study population

All women of reproductive age (15–49 years) who received PAC services at selected public health facilities were eligible to participate in the study. Women who received PAC care more than 72 h prior to recruitment were excluded for fear of inaccurate recall given the nature of the survey while those who were in distress or critical condition after the procedure at the time of data collection were excluded from the study for ethical reasons.

Sample size and sampling

Using the sample size formula for prevalence studies¹⁶ with a 95% confidence interval (CI), a 5% margin of error, and a non-response proportion of 10%, with a prevalence of 50% for an unknown population, a sample size of 385 participants was calculated. The study participants were selected using a consecutive sampling technique in which every subject meeting the inclusion criteria was selected until the required sample size was achieved. This sampling technique was used to realize the required sample size because of the low clinic attendance.

Recruitment of participants

The ward-in-charges (ward managers) helped the research assistants to identify and recruit the eligible study participants at the health facilities while some of the participants were also directly identified by the research assistants at the health facilities. The research assistants were two pre-internship midwives (midwives who had completed their Bachelor of Science in Midwifery degree and were awaiting placement in public health facilities for clinical practice by the Ministry of Health) who were trained in the study protocol. Upon identifying the eligible prospective participants, the research assistants explained the purpose, benefits, and risks of participating in the study to the prospective participants. A written informed consent was signed at the health facility and prospective participants were recruited into the study.

Data collection procedures

Face-to-face surveys were conducted by two pre-internship midwives using a pre-tested structured questionnaire (Supplemental Appendix 2). The questionnaire comprised three sub-sections, namely, (i) sociodemographic characteristics, (ii) level of PCMC, and (iii) satisfaction with PAC services. The level of PCMC was assessed using the PCMC scale which is valid and reliable.^17,18 The scale is a 13-item scale with a total score range of 0–36, where each item has a 4-point response scale (i.e., 0 = no, never; 1 = yes, a few times; 2 = yes, most of the time; and 3 = yes, all the time).^17,18 The tool is divided into three sub-scales, namely dignity and respect (score range 0–9), communication and autonomy (score range 0–18), and supportive care (score range 0–9).^17,18

Satisfaction with PAC services was the outcome variable and was assessed using the Six Simple Questions scale, which has a high-reliability index (α = 0.86).¹⁹ Satisfaction with PAC was measured on a 7-point Likert scale where 1 = strongly disagree and 7 = strongly agree. The scores for the scale ranged from 6 to 42 and were classified based on percentiles.¹⁹ The surveys were conducted in private rooms in either English or the local dialect and lasted for 20–35 min.

Statistical analysis

Every questionnaire was checked for completeness at the end of each interview. A data entry screen was created in STATA version 17 (StataCorp, College Station, TX, USA) with checks to ensure accuracy during entry. Data were scanned for out-of-range and missing values before commencing data analysis. Variables were analyzed using descriptive and inferential statistics.

Continuous variables (i.e., PCMC and satisfaction with PAC) were tested for normal distribution with the Shapiro–Wilk test. Normally distributed variables were reported as mean and standard deviation while non-normally distributed variables were reported as median and interquartile range (IQR). To allow easy comparison across the different PCMC domains, re-scaled scores were calculated as the fraction of the total possible score for each domain and normalized to 100.

The correlations between PCMC scores and satisfaction with PAC scores were tested using Spearman’s rank correlation test since PCMC and satisfaction with PAC scores were non-normally distributed. A linear regression was run to examine the relationship between PCMC and satisfaction with PAC (outcome variable) while controlling the influence of age, level of education, occupation, marital status, gravidity, and parity on the relationship between PCMC and satisfaction with PAC services. The level of significance was set at 95% and p-value at 0.05.

Results

Out of the 385 women contacted, 370 agreed to participate, representing a response proportion of 96.1%.

Sociodemographic characteristics of women who received PAC services in Lira city

The mean age of study participants was 26.1 (±6.3) years. The majority of the participants were married (73.63%), attained primary education (49.73%), and had been pregnant more than two times (51.89%; Table 1).

Table 1.

Sociodemographic characteristics of women who received PAC services in Lira city, Northern Uganda, 2023 (N = 370).

Variable	Frequency	Percent (%)
Age group
15–19	48	13.0
20–24	137	37.0
25–29	84	22.7
30–34	47	12.7
35–39	43	11.6
⩾40	11	3.0
Education level
No formal education	78	21.1
Primary education	184	49.7
Secondary education	79	21.4
>Secondary education	29	7.8
Occupation
Agriculture	172	46.5
Salaried worker	15	4.1
Self-employed	71	19.2
Unemployed	112	30.3
Marital status
Single	55	15.0
Married	271	73.6
Cohabiting	33	9.0
Divorced/Separated	6	1.6
Widowed	3	0.1
Pregnancy
1–2	178	56.2
3–4	63	19.9
⩾5	76	24.0
Parity
0	123	33.2
1–2	141	38.1
3–4	60	16.2
⩾5	46	12.4

PAC, post-abortion care.

Satisfaction with PAC services among women in Lira city, Northern Uganda

Women’s overall satisfaction with PAC was not normally distributed (Shapiro–Wilk p < 0.001), as shown in Figure 1. Satisfaction with PAC services’ score ranged from 6 to 42 and the median satisfaction score was 30 (IQR range: 28–32) with 50 participants (13.5%) below the 28 score, 237 participants (64.1%) between the 28 and 32 scores, and 83 participants (22.4%) above the 32 score.

Figure 1.

Histogram showing distribution of satisfaction scores (N = 370).

PCMC among women in Lira city, Northern Uganda

The overall PCMC score was not normally distributed (Shapiro–Wilk p < 0.001; Figure 2(a)). The median PCMC score was 21.5 (IQR range: 17–28) out of 36 with 85 participants (23.0%) below the 17 score, 193 participants (52.2%) between the 17 and 28 scores, and 92 participants (24.9%) above the 28 score. The sub-scale scores for dignity and respect were not normally distributed (Shapiro–Wilk p < 0.001; Figure 2(b)). The median dignity and respect score was 6 (IQR range: 6–6) out of 9 with 82 participants (22.2%) below the 6 score, 202 participants (54.6%) at the score of 6, and 86 participants (23.2%) above the 6 score. The sub-scale scores for communication and autonomy were not normally distributed (Shapiro–Wilk p < 0.001; Figure 2(c)). The median communication and autonomy score was 9 (IQR range: 5–13) out of 12 with 82 participants (22.2%) below the 5 score, 197 participants (53.2%) between the 5 and 13 scores, and 91 participants (24.6%) above the 13 score. The sub-scale scores for supportive care were not normally distributed (Shapiro–Wilk p < 0.001) (Figure 2(d)). The median supportive care score was 8 (IQR range: 6–9) out of 9 with 65 participants (17.6%) below the 6 score and 305 participants (82.4%) between the 6 and 9 scores.

Figure 2.

Histograms showing distribution of overall PCMC scale and sub-scale scores (N = 370). (a) Overall PCMC. (b) Dignity and respect. (c) Communication and autonomy. (d) Supportive care.

Upon re-scaling the scores to 100%, the overall PCMC percentage mean score was 60.9% (SD ± 20.1), whereas the percentage mean scores for the sub-scales were 60.9% (SD ± 18.3) for dignity and respect, 51.7% (SD ± 30.3) for communication and autonomy, and 79.4% (SD ± 22.1) for supportive care (Figure 3).

Figure 3.

Percentage mean scores of person-centered maternity care among women in Lira city, Northern Uganda (N = 370).

Correlation between PCMC scores and satisfaction with PAC scores among women in Lira city, Northern Uganda

A weak positive but significant correlation was observed (Spearman r = 0.21, p < 0.001) between PCMC full scale and satisfaction with PAC (Figure 4(a)). A weak positive but significant correlation was observed (Spearman r = 0.16, p = 0.002) between the dignity and respect sub-scale and satisfaction with PAC (Figure 4(b)). Also, a weak positive but significant correlation was observed (Spearman r = 0.21, p < 0.001) between the communication and autonomy sub-scale and satisfaction with PAC (Figure 4(c)). There was no correlation observed (Spearman r = 0.07, p = 0.16) between the supportive care sub-scale and satisfaction with PAC (Figure 4(d)).

Figure 4.

Correlation between overall PCMC and sub-scale scores and satisfaction with post-abortion care scores among women in Lira city, Northern Uganda (N = 370). (a) PCMC scores and satisfaction scores. (b) Dignity and respect scores and satisfaction scores. (c) Communication and autonomy scores and satisfaction scores. (d) Supportive care scores and satisfaction scores.

Relationship between PCMC and satisfaction with PAC among women in Lira city, Northern Uganda (N = 370)

In a linear regression model, communication and autonomy score was significantly associated with higher satisfaction with PAC score (β = 0.10; 95% confidence interval (CI: 0.01, 0.19); p < 0.001). This suggests that better communication and greater autonomy during care are linked to higher satisfaction levels. There was no evidence of a statistically significant association between other variables and satisfaction with PAC services (Table 2).

Table 2.

Linear regression analysis to examine the relationship between PCMC and satisfaction with PAC among women in Lira city, Northern Uganda (N = 370).

Variables	β (95% CI)	p-value
PCMC sub-scales
Dignity and respect	0.09 (−0.07, 0.25)	0.277
Communication and autonomy	0.10 (0.01, 0.19)	0.03*
Supportive care	−0.08 (−0.22, 0.07)	0.302
Age
15–19	Ref
20–24	0.05 (−0.35, 0.46)	0.798
25–29	0.21 (−0.27, 0.69)	0.384
30–34	−0.22 (−0.81, 0.37)	0.458
35–39	−0.20 (−0.83, 0.43)	0.535
40 and above	−0.47 (−1.17, 0.23)	0.187
Education level
No formal education	Ref
Primary education	0.13 (−0.19, 0.45)	0.423
Secondary education	0.27 (−0.14, 0.68)	0.201
>Secondary education	0.703 (−0.05, 1.46)	0.067
Occupation
Agriculture	Ref
Salaried worker	0.17 (−0.53, 0.87)	0.630
Self-employed	−0.06 (−0.50, 0.38)	0.786
Unemployed	−0.14 (−0.42, 0.14)	0.326
Marital status
Single	Ref
Married	0.09 (−0.48, 0.66)	0.746
Cohabiting	0.50 (−0.19, 1.20)	0.156
Divorced/separated	−0.19 (−0.81, 0.43)	0.541
Widowed	0.02 (−1.01, 1.04)	0.973
Number of pregnancy
1–2	Ref
2–3	−0.29 (−0.64, 0.06)	0.103
⩾5	0.51 (−0.37, 1.38)	0.254
Parity
0	Ref
1–2	−0.32 (−1.13, 0.48)	0.431
3–4	0.01 (−0.87, 0.88)	0.991
⩾5	0.01 (−0.79, 0.90)	0.891

CI, confidence interval; PAC, post-abortion care; PCMC, person-centered maternity care; Ref, reference category.

Significant variable at p < 0.05.

Discussion

We examined the relationship between PCMC and satisfaction with PAC services among women in Lira city, Northern Uganda. We found that the overall PCMC percentage mean score was 60.9%, whereas the percentage mean score for the sub-scales was 60.9% for dignity and respect, 51.7% for communication and autonomy, and 79.4% for supportive care. The overall satisfaction with PAC mean score was 25.71 (SD = 5.29). PCMC, particularly the aspects of communication between clients and providers and the promotion of clients’ autonomy, is associated with higher satisfaction with PAC services (β = 0.10; 95% CI (0.01, 0.19); p < 0.001). This suggests that efforts to increase clients’ satisfaction with PAC should focus on strengthening communication between clients and providers and promoting clients’ autonomy during care.

Our findings showed that implementation of PCMC during PAC was moderate (60.9%) in the context of public health facilities in Northern Uganda. This might be attributed to a lack of appropriate training for healthcare providers on the key aspects of PCMC such as communication with clients and respect for the clients’ autonomy.²⁰ Our findings showed that implementation of PCMC during PAC in the context of public health facilities in Northern Uganda is lower compared to implementation in other countries.^11,21,22 The currently low level of PCMC during PAC calls for capacity building among skilled health personnel to improve the overall quality of PAC services.

Patient satisfaction is an important and commonly used indicator for measuring the quality of healthcare because it affects clinical outcomes and patient retention.⁷ In this study, only 83 (22.43%) of the women reported high satisfaction scores (above the 75th percentile). This could be attributed to the restrictive policy framework for the provision of abortion services in Uganda, which makes service providers disinterested in the provision of even PAC services.²³ Notably, this finding is significantly lower than the 82% and 87% levels of satisfaction with PAC services reported among women in Mexico²⁴ and Ethiopia,⁷ respectively. The disparity in findings could be attributed to differences in study context and the measure of satisfaction used across the studies. Our findings highlight the need to rethink the policy framework for the provision of abortion services in Uganda and train skilled health personnel to offer quality PAC services.

In our study, the presence of good communication between clients and providers, and the promotion of clients’ autonomy were significantly associated with higher clients’ satisfaction with PAC services. This result is consistent with studies conducted in Tanzania, Zanzibar,²⁵ and Ethiopia⁷ where client–provider interactions and the ability of the service provider to address all the questions raised by the clients were significantly associated with higher clients’ satisfaction with PAC services. These results suggest that communication and autonomy may be the most important aspects of person-centered maternal care; therefore, emphasis should be placed on these during the provision of care.

Strengths and limitations

The study has some limitations. We assessed clients in public health facilities, although PAC in Uganda is also available in the private sector. We also excluded women who received PAC care more than 72 h prior to recruitment for fear of inaccurate recall. Thus, our results are not generalizable to women seeking PAC in the private sector and those who sought PAC care more than 72 h prior to the study recruitment. Additionally, our interviews might have been influenced by courtesy bias,²⁶ where participants, out of politeness or a desire to please, may have overestimated the levels of PCMC and satisfaction with PAC services because the interviews were conducted within the healthcare facility. However, we used valid and reliable tools to measure these factors, ensuring that our study findings are both informative and provide a solid foundation for further research on the quality of PAC services in Uganda.

Conclusions

Our findings indicate that PCMC, particularly effective communication between clients and providers and the promotion of client autonomy, plays a crucial role in strengthening satisfaction with PAC services. To improve overall satisfaction with PAC, healthcare providers should prioritize building strong communication channels with clients and actively support their involvement in decision-making during care. Further research should explore the relationship between PCMC and satisfaction with PAC across various contexts, employing a study design capable of establishing causal relationships and utilizing comprehensive tools with a broader range of assessment items. Additionally, qualitative studies are needed to gather the perspectives of service providers and clients regarding PCMC and satisfaction with PAC services.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251318897 – Supplemental material for Person-centered maternity care and satisfaction with post-abortion care: A facility-based cross-sectional survey in Northern Uganda

Supplemental material, sj-docx-1-whe-10.1177_17455057251318897 for Person-centered maternity care and satisfaction with post-abortion care: A facility-based cross-sectional survey in Northern Uganda by Samson Udho, Emmanuel Ekung, Deborah Andrinar Namutebi, Josephine Aryek-kwe, Abraham Rubaihayo, Marvin Musinguzi, Eustes Kigongo, Annaloice Penduka, Yvonne Delphine Nsaba Uwera, Bosco Opio and Jasper Ogwal-Okeng in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057251318897 – Supplemental material for Person-centered maternity care and satisfaction with post-abortion care: A facility-based cross-sectional survey in Northern Uganda

Supplemental material, sj-docx-2-whe-10.1177_17455057251318897 for Person-centered maternity care and satisfaction with post-abortion care: A facility-based cross-sectional survey in Northern Uganda by Samson Udho, Emmanuel Ekung, Deborah Andrinar Namutebi, Josephine Aryek-kwe, Abraham Rubaihayo, Marvin Musinguzi, Eustes Kigongo, Annaloice Penduka, Yvonne Delphine Nsaba Uwera, Bosco Opio and Jasper Ogwal-Okeng in Women’s Health

Footnotes

Acknowledgements

We acknowledge all those who agreed to participate in this study. We also acknowledge the technical support offered by Dr. Julie M. Buser of Center for Reproductive Health Training at the University of Michigan (CIRHT-UM), Dr. Ella August, and the entire Pre-Publication Support Service (PREPSS) for Peer Review during the drafting of the article. Pre-Publication Support Service (PREPSS) supported the development of this article by providing author training, as well as pre-publication peer-review and copy editing.

Declarations

ORCID iDs

Samson Udho

Emmanuel Ekung

Yvonne Delphine Nsaba Uwera

Supplemental material

Supplemental material for this article is available online.

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