Abstract
Background:
Quality of care doesn’t only include the delivery of care, but also the experience. Experience encompasses aspects like respect, communication, and emotional support, which are particularly important to mothers because childbirth is one of the most significant life experiences with long-lasting effects on self-perception as a woman and mother. The study aims to assess the quality of care for women’s childbirth experiences in the maternity department of Kasr Alainy Medical Hospital in Cairo.
Design and methods:
A cross-sectional observational study was conducted in a tertiary care hospital in Egypt over a period of 4 months. Around 200 women who were inpatients at the maternity department during the study period agreed to participate. A researcher-administered questionnaire covering demographic characteristics, birth information, and intrapartum care experience was used. This was adapted from the validated ReproQ questionnaire, which is based on WHO standards, using systematic random sampling from the hospital delivery register.
Results:
Out of 201 respondents, around 45% were below 25 years old, and the majority (65%) were between 20 and 35 years old. The average score for overall satisfaction was 4.1 out of 5, with more than 80% giving a score of 4 or 5, indicating satisfaction or very satisfaction. The highest scores were in dignity, while the lowest were in choice and autonomy.
Conclusion:
The only sociodemographic factor showing a significant association was the place of health service provision. Women receiving full maternal service at the same hospital were generally more satisfied.
Introduction
Global efforts to strengthen the quality of maternal healthcare and women’s experience during childbirth have attracted greater attention over the past few years. 1 Enhancing women’s care experience has become a critical element in improving maternal healthcare, especially the quality of childbirth.2,3
Quality of care doesn’t only include the delivery of care, but also the experience. Experience encompasses various aspects like respect, communication, and emotional support, which are particularly important to mothers because childbirth is one of the most significant life experiences that has long-lasting effects on self-perception both as a female and a mother. 4 This is in addition to their feelings toward their newborn, adaptation to motherhood roles, and future delivery experiences. 5
Expectations of the forthcoming birth influence the childbirth experience, information provided by healthcare providers, and interpersonal communication, 4 which can be enhanced through addressing the mothers’ expectations and ensuring their rights to access, safety, comfort, dignity, privacy, and confidentiality, and the right to express their views about the services rendered.6,7
Efforts to upgrade the quality of care have mainly concentrated on improving care provision, with little emphasis on underlying social determinants of communication interactions. 10 A positive childbirth experience has been associated with age, parity, prenatal education, expectations, social status, being informed, experience of feeling in control, method of delivery, medications, experience of support from caregivers and partners, length of labor, and the birth situation and receiving accurate and adequate information.8,9
Some women experience disrespectful, abusive, and neglectful treatment during pregnancy and childbirth at health facilities. 4 This treatment denies pregnant women their dignity, respect, and autonomy and violates their human rights. It also discourages them from seeking and utilizing maternal health care services and negatively affects their health and well-being. 10
Childbirth services should, therefore, be receptive to women and the community, as women with poor healthcare worker-client rapport, relationships, and substandard healthcare cause them further distress.11,12 Therefore, it is important to understand Egyptian women’s experiences of childbirth care provided by healthcare providers in relation to the WHO recommendations for respectful maternity care. 6
This study aims to assess the quality of care in women’s childbirth experiences at the maternity department of Kasr Alainy Medical Hospital in Cairo and to determine the factors associated with these experiences, which is one of the largest hospitals in Egypt.
Methodology
Study setting and design
This cross-sectional observational study was conducted on women admitted to the maternity ward of Kasr Alainy Public Tertiary Hospital, Cairo, Egypt, over 3 months, between March and June 2022. Kasr Alainy Hospital is one of the largest hospitals and a major national referral center, serving patients from all over the country. It is a public, university-affiliated teaching hospital that offers both free and paid services, enabling access for a wide socioeconomic spectrum of patients. The hospital serves women from diverse regions and socioeconomic backgrounds, providing both routine and high-risk obstetric care.13–15
Sampling and population
Mothers who agreed to be included in the study, were admitted in the first stage of labor, and delivered without any complications, were included. Women admitted during the second stage of labor, delivered before arrival in the hospital, or delivered a stillbirth were excluded from the study. Eligible women were approached in the postpartum wards by trained female research assistants uninvolved in clinical care. Systematic random sampling based on the hospital delivery register was used to identify respondents. Every fourth mother who met the study eligibility criteria was sampled to ensure an even distribution of respondents throughout the recruitment period and to minimize selection bias. If a selected woman declined participation or was unavailable, the next eligible woman on the list was approached to maintain the sampling interval.
The sample size was calculated with a 5% margin of error, a 95% confidence level, and an infinite population. We used the average good experience reported by two studies implemented in Ethiopia (80%) 16 and Egypt (93.7%). 17 Thus, we assumed an 86.9% proportion of good delivery experience. The sample was adjusted for a 20% dropout rate, indicating a final sample size of 193 respondents.
Data collection
A structured interview questionnaire was used as the data collection tool. Data were collected using a researcher-administered questionnaire covering demographic characteristics, birth information, and experiences of intrapartum care, which took the interviewer 10–15 min to complete with each client. Women’s experiences of intrapartum care were assessed according to the ReproQ questionnaire, 18 which is based on the same eight domains and standards identified in WHO’s review, that is, Dignity, Autonomy, Confidentiality, Communication, Prompt Attention, Social Consideration, Quality of Basic Amenities, and Choice and Continuity, in addition to sociodemographic and personal background details.
These domains are considered universally significant within all healthcare systems, encompassing interactions with clients, whether involving personal or non-personal health services, as well as interactions between the population and health insurers and other administrative entities within the healthcare system. While it is acknowledged that individuals may prioritize these domains differently and that specific domains may hold greater relevance in certain healthcare interactions, we assume these eight domains comprehensively address the quality of any healthcare interaction.
This study used the ReproQ version by Scheerhagen et al. a previously validated questionnaire with a Cronbach Alpha score of 0.68 and 0.89.19,22 The text was translated into Arabic (by NAS and AAH), then back-translated with minor adaptations, and piloted among 10 women in a different public hospital to fit the Egyptian context. During this piloting phase, specific terms were adapted better to reflect common expressions and practices within Egyptian maternity settings, ensuring cultural appropriateness.
Experience of intrapartum care will be assessed with a 5-point Likert scale (5 = strongly agree; 1 = strongly disagree), with negative statements receiving an inverse score (5 = strongly disagree; 1 = strongly agree).
Data analysis
Data were coded and analyzed using SPSS version 21. Descriptive statistics were used to summarize the data, with categorical variables (e.g. education, mode of delivery) presented as frequencies and percentages. For quantitative variables, the distribution was first assessed; means and standard deviations (SD) were reported for normally distributed data, while medians and interquartile ranges (IQR) were used for non-normally distributed variables. To explore associations between women’s overall satisfaction and their sociodemographic characteristics, Pearson’s chi-square test (χ²) was used for comparisons involving categorical variables. The statistical significance level was set at p ≤ 0.05. “No response/missing” values were reported in Table 1 but were excluded from the rest of the analysis.
Demographic characteristics of the respondents.
Ethical consideration and informed consent
All activities for data collection ensured confidentiality according to the Helsinki Declaration of Biomedical Ethics. 20 The anonymity of the respondents was also ensured through the use of codes. Ethical approval number O21007 was obtained from the Obstetrics and Gynecology department’s Kasr Alainy Medical School ethics review committee.
Written Informed consent was obtained from each client after proper orientation regarding the impact and the objectives of the study and the confidentiality of the collected data, as approved in the study protocol.
Results
About 201 eligible women participated in our study based on the inclusion criteria and within the timeline mentioned above. Some respondents enrolled and consented to our survey; however, they declined to answer certain questions when they didn’t want to, ensuring their autonomy.
Regarding the demographic characteristics of the respondents (Table 1), it was noticed that the majority (65%) were between 20 and 35 years old. In contrast, only 30 (14.9%) respondents were younger than 19. The largest percentage of respondents, 75 (37.3%), said they were illiterate, while 52 (25.9%) reported they could read and write. In comparison, only 26 respondents (around 13%) received some college education or a higher degree.
The respondents’ residences are roughly equally distributed between those living in urban areas (52.5%) and those living in rural areas (47.5%). The majority of the respondents, 154 (78.6%), are housewives. About a quarter of the respondents, 51 (25.4%), reported that their income is less than their expenses. 147 respondents (73.1%) are multiparous.
Furthermore, 61 respondents (30.7%) received antenatal care outside the hospital where they gave birth and were referred to the hospital during the birth phase. In contrast, 56 respondents (28.1%) didn’t receive any antenatal care before birth. In comparison, 52 respondents (26.1%) received antenatal care elsewhere, referred during the antenatal phase to a hospital, and only 30 (15.1%) received antenatal care from a gynecologist. 159 respondents (79.1%) required hospital admission for their newborn to receive clinical care.
Figure 1 illustrates each domain’s overall score and satisfaction score. Table 2 presents the analysis of overall satisfaction among service beneficiaries with the services provided at the maternal wards of Kasr Alainy Hospital, along with a disaggregation of the responses. Service beneficiaries were asked about their satisfaction with different aspects of the services provided: services respecting dignity, autonomy of beneficiaries, confidentiality, and ease of communication. The lowest average scores were in the autonomy domain questions. The lowest scores were on the providers’ accessibility by phone, with an average score of 1.9; choosing your healthcare provider, with an average score of 2.0; and sharing in the decision for pain treatment procedures, with an average score of 2.1. Meanwhile, the highest scores were mostly in the Dignity domain questions at 4.6, with the following questions getting the highest average score: being treated with respect by your health care provider, being treated kindly by your health care provider, feeling that you received appropriate attention by your health care provider, and receiving the needed emotional support.
Radar graph showing the average score for each domain, including the overall satisfaction score.
Overall satisfaction with the services provided at the maternity wards at Kasr Alainy Hospital during the time of the study.
Furthermore, the highest non-responses were in the confidentiality questions, particularly regarding the confidentiality of the information you provided, with almost 10% not responding, and if their medical record was kept confidential, with almost 26% not responding. The non-responses are either not knowing the answer or declining to answer.
Table 3 illustrates the relation between the different sociodemographic characteristics of the service beneficiaries and their overall satisfaction. The average satisfaction score was 4.1, as shown in Table 2. The breakdown indicates that more than 80% gave a score of either 4 or 5, corresponding to being satisfied or very satisfied. These 2 responses were the highest among all the sociodemographic groups. Using a chi-squared test, we found a statistically significant relation between the place of health service provision and overall satisfaction. All the other sociodemographic variables did not show any statistical significance in relation to overall satisfaction.
The relation between the sociodemographic characteristics of the service beneficiaries and their overall satisfaction with the services provided at the maternity wards at Kasr Alainy Hospital.
<0.05 is statistically significant.
Discussion
Our study was not the first instance of implementing the ReproQ questionnaire, but it was the first time it was tailored for our hospital context in Egypt. According to a scoping review conducted in 2020, no studies were published on measuring the experiences of pregnant women and newborns at the facility level in Egypt and most of the Eastern Mediterranean countries. 21 This study serves as a valuable pilot for the WHO questionnaire in the Eastern Mediterranean Region.
Our study showed the lowest satisfaction rates in the domains of autonomy and choice, particularly in “services provided autonomously” and “Service beneficiary choice of the health care provider and continuity of services,” with overall scores of 3 and 3.1, respectively. Unfortunately, this is not the first instance of similar findings in these domains. Scheerhagen et al., in the Netherlands, reported similar findings in these domains. 22 Comparable patterns have also been documented in low- and middle-income countries, including studies in Guinea, Ethiopia, and India, where women’s involvement in decision-making and autonomy during childbirth were similarly limited.23,24 Such findings are alarming, undermining women’s role and jeopardizing their well-being because women’s autonomy is a cornerstone and a necessity in maternity care. 25 Based on the literature, the feeling of not being seen or heard by their healthcare providers has been reported by women who had negative or traumatic birth experiences.26–28 Additionally, these women often felt that healthcare providers viewed their births as routine. 29 However, many challenges exist when safeguarding clients’ autonomous choices, including time constraints and strict medical protocols. 30
Furthermore, the dignity domain, categorized under “Services respecting the dignity of the beneficiary,” was the only domain with a score of more than 4, achieving an overall score of 4.5. This is vital as it shows that patients receive care in a respectful, caring, non-discriminatory setting, a cornerstone of maternal health services. 22
Moreover, despite implementing a random, systematic sampling approach, 56.5% (113) of our respondents had a cesarean section. Although this is very concerning, it aligns with the Egyptian Demographic Health Survey 2014, which shows a 52% prevalence of cesarean sections. This was explained in the Egypt Health Issues Survey 2015, where women stated that having a previous cesarean delivery, problems during pregnancy, and problems during labor were the top reasons for such a decision. Therefore, this requires further investigation and interventions as this is against the recommendations of the World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO), who strictly advise stopping cesarean sections and only performing a cesarean section when necessary.31,32
Regarding the representativity of the vulnerable groups in our population, women younger than 25 are about 46%, whereas women with a low educational level are 37.31% illiterate and 25.87% can read and write. A recent study on the determinants of experience scores showed that maternal age and educational level have no significant impact on these scores. 33 This aligns with our findings in Table 3, which examined the sociodemographic influence on the ReproQ scores, where most of the included characteristics showed no statistically significant variability. The only significant variation was in the place of service provision, between those who received the full service at Kasr Alainy Hospital, those who were referred during antenatal care or childbirth, and those who did not receive any antenatal care, which showed that those who received the whole service at the same hospital were more satisfied than those who were referred to Kasr Alainy. These can be explained by the important role that antenatal care has on pregnancy outcomes 34 and the effect of individual providers on childbirth experience.29,30 Our findings differed from those of the logistic regression conducted by Kabo et al., who found that older mothers were significantly associated with better reception of intrapartum care. In contrast, the odds of a positive intrapartum care experience among women in tertiary education were significantly lower. 35
The findings highlight the urgent need to address gaps in autonomy, informed consent for service provision, and continuity of care in Egypt’s maternity services. Interventions may include incorporating patient rights and shared decision-making training in the education of obstetric care providers, with a focus on pain management and provider selection. Strengthening antenatal referral systems could improve women’s satisfaction by ensuring continuity of care. At the policy level, adopting national benchmarks for respectful maternity care, in alignment with WHO standards, would allow for systematic monitoring and quality improvement across facilities. Furthermore, these findings align with Egypt’s national maternal health priorities and can inform quality improvement initiatives. These include integrating ReproQ or similar experience-based indicators into hospital performance monitoring systems and considering the adoption of relevant telemedicine and digital health solutions. 36
For future research, we highly recommend that more studies target healthcare facilities in rural cities, as this study focused only on the patients of one of the largest teaching hospitals in Cairo. Additionally, we recommend using the ReproQ to measure clients’ experiences for process evaluation and using the results to guide and improve performance in maternity care units through profiling. Also, a mixed methods approach through adding in-depth qualitative interviews and client involvement would further strengthen the process. Thus, continuing and following up on this study is important, as it revealed gaps in awareness, knowledge, concern, and pre-emptive public health action.
The study has several strengths, including the large sample and the collection of data in routine practice. It covers all clients of Kasr Alainy perinatal units, reflecting the true situation of services and deepening the understanding between different categories of mothers from several perspectives. The diversity of interviewees may have ensured that a range of perspectives was captured successfully. It allowed us to study the childbirth experiences of Egyptian mothers more closely.
This study has some limitations, including being conducted in a single tertiary public hospital in Cairo among randomly selected clients, which may limit the generalizability of the findings to other settings, particularly lower-level or rural facilities. Although systematic sampling was used and refusals were minimal, some selection bias may persist due to non-responses. Interviews were conducted shortly after service provision to reduce recall bias, yet social desirability bias may still have influenced responses. The influence of individual healthcare professionals was not assessed; their behavior could have a stronger impact on personal domains than on setting-related factors. Including all provider perspectives would have required a more complex data collection process.37,38
Conclusion
In conclusion, although much research remains to fill the gaps about obstetric care in Egypt, this study provides valuable insights into various aspects of maternal service provision in the country. We believe this study supports all efforts to empower women and combat all forms of violence against women nationwide. Obstetric violence is an important issue that requires more attention and awareness among healthcare providers.
Footnotes
Acknowledgements
The authors would like to thank all the participants in the study, including the patients and the workers in the hospital who facilitated their work greatly.
Ethical consideration
All data collection activities ensured confidentiality according to the Helsinki Declaration of Biomedical Ethics. The anonymity of the respondents was also ensured through the use of codes. Ethical approval was obtained from Kasr Alainy Faculty of Medicine, Cairo University.
Consent to participate
Informed consent was obtained from each client after proper orientation regarding the impact and the objectives of the study and the confidentiality of the collected data: “Your participation in every aspect of this study is completely voluntary. All the information you provide for the study will be kept completely confidential. We record your responses, but the questionnaire will not have your name on it, and your responses to our questions are identified only by a code, never by name. Although there are no direct benefits to you from participating in this survey, we hope that the survey will be considered a baseline assessment that will guide us in raising client satisfaction during the childbirth experience. The survey will take about {10-15} minutes.”
Author contributions
ATA, NQ, AA, AR, RA, and AAH drafted and finalized the manuscript. SS and NS conducted the analysis. SS, AAH, and NS prepared the data collection tool and coordinated the ethical approval and data collection. AAH supervised the project implementation and drafting. All authors reviewed and approved the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
The datasets used and analyzed during the current study cannot be shared publicly per the protocol IRB approval received. The data in the manuscript cannot be shared publicly due to the ethical restrictions imposed by the Research Ethics Committee. However, the data can be provided by contact with principal investigator Dr. Amira Hegazy