Advancing the health of women and newborns: predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda

Advancing the health of women and newborns: predictors of patient satisfaction among women... Abstract Objective Identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. Design Cross-sectional. Setting Twenty-six health facilities in Southern Kayonza (SK) and Kirehe districts. Participants Sample of women ≥ 16 years old receiving antenatal and delivery care between November and December 2013. Intervention Survey of patient satisfaction with antenatal and delivery care to inform quality improvement (QI) initiatives aimed at reducing neonatal mortality. Main Outcome Measure Overall satisfaction with antenatal and delivery care (reported as excellent or very good). Results In multivariate logistic regression analysis, high perceived quality [odds ratio (OR) = 3.03, 95% confidence intervals (CI): 1.565.88], respect [OR = 4.13, 95% CI: 2.16–7.89], and confidentiality [SK: OR = 7.50, 95% CI: 2.16–26.01], [Kirehe: OR = 1.54, 95% CI: 0.60–3.94] were associated with higher overall satisfaction with ANC, while having ≥1 child compared to none [OR = 0.46, 95% CI: 0.25–0.84] was associated with lower satisfaction. For maternity services, <5 years of school versus ≥5 years [OR = 0.13, 95% CI: 0.026–0.69] and higher cleanliness [OR = 19.23, 95% CI: 2.22–166.83], self-reported quality [OR = 10.52, 95% CI: 1.81–61.22], communication [OR = 8.78, 95%CI: 1.95–39.59], and confidentiality [OR = 8.66, 95% CI: 1.20–62.64] were all positively associated with high satisfaction. Higher comfort [OR: 0.050, 95% CI: 0.0034–0.71] and Kirehe vs. SK district [OR: 0.21, 95% CI: 0.042–1.01] were associated with lower satisfaction. Conclusions Patient-centeredness (including interpersonal relationships), organizational factors, and location are important individual determinants of satisfaction for women seeking maternal care at study facilities. Understanding variation in these factors should inform QI efforts in maternal and newborn health programs. patient satisfaction, antenatal care, delivery, quality of healthcare, maternal and newborn health, Rwanda Introduction While there has been recent progress towards reducing maternal and neonatal mortality (MDG 5), critical gaps remain in the developing world, with more than 300 000 women dying each year during pregnancy and childbirth [1], and almost 3 million neonates dying each year [2]. Quality antenatal care (ANC) and facility-based delivery with a skilled health worker are important interventions to improve pregnancy outcomes, reducing maternal and perinatal mortality [3, 4], yet coverage of these services remains insufficient. In Rwanda, reduction of maternal and neonatal mortality is a key national priority [5]. As of 2015, although 99% of pregnant women received at least one ANC visit from a skilled provider, less than half of Rwandan women report receiving all four recommended standard ANC visits [6]. Patient satisfaction can influence health-seeking behaviors and adherence to care, including in ANC and maternity settings in Africa [7–10]. Satisfied patients are more likely to return to care and recommend services to others, which may support effective coverage of services [10, 11]. Prior research suggests that in Sub-Saharan Africa, factors that influence patients’ satisfaction with health services include interpersonal (provider–patient) relationships, technical quality and organizational factors (such as cleanliness and comfort) [10–14]. The Rwandan Ministry of Health (MOH), supported by Partners In Health (PIH), launched the All Babies Count Initiative (ABC) in 2013 [15]. The goal of ABC was to reduce neonatal mortality by improving the quality of ANC and maternity care in two rural districts over an 18-month period. ABC consisted of three components: (a) healthcare worker training followed by on-site mentorship, (b) essential equipment and materials and (c) a quality improvement (QI) strategy using district-wide learning collaboratives, which included training and support for improving patient-centered care. In order to assess experiential quality as a key domain of quality and a likely driver of care-seeking behavior, a patient satisfaction survey was conducted at baseline. The objective of this study is to describe baseline levels and primary predictors of patient satisfaction with antenatal and maternity care services at the time of delivery in rural Rwanda and to inform the QI processes of the ABC initiative. Methods Study setting The study was conducted in all 16 health centers (HCs) in Kirehe and 8 HCs in Southern Kayonza (SK) districts and the two district hospitals. ANC occurs at the HCs and deliveries at all 26 facilities. These rural districts are located in the Eastern Province of Rwanda, serving a catchment population of ~480 000 [16]. In partnership with the MOH, PIH has provided clinical and infrastructure support to the public health system in SK since 2005, expanding to Kirehe in 2009 [17, 18]. The ABC initiative built on an ongoing district-wide strengthening program started in 2009 to reduce neonatal mortality [17]. Survey design A conceptual framework was developed to inform survey design. Using a model created by Donabedian [19], three domains of factors influencing patient satisfaction were identified: (1) organizational components, (2) technical quality and (3) interpersonal factors. These factors have been found to influence patient satisfaction with maternal health services in Sub-Saharan Africa [11, 20, 21]. Our conceptual framework outlines the link between these factors and satisfaction with antenatal and maternity care (Fig. 1). Using this framework, 22 independent variables with potential links to patient satisfaction were identified and included in the survey: (1) patient characteristics, including age, marital status, education level, socioeconomic status, number of children, patient knowledge of danger signs and access (measured by travel time, cost of transportation, difficulty of payment for transport and overall difficulty of obtaining transportation); (2) organizational components, including length of wait time, acceptability of wait time, cleanliness and comfort; (3) reported technical quality of care received, including technical skills and perceived quality of care and (4) interpersonal factors, including understanding, communication, respect, promptness and confidentiality. The primary outcome—overall satisfaction—was assessed through the question: ‘Overall, how satisfied were you with the care that you received?’ Additional survey questions can be found in the Appendix. Figure 1 View largeDownload slide Conceptual framework for antenatal care (ANC) and maternity service satisfaction. Figure 1 View largeDownload slide Conceptual framework for antenatal care (ANC) and maternity service satisfaction. Questions regarding satisfaction and perceptions of care employed a standard 5-point likert scale: excellent, very good, good, fair and poor. Both antenatal and maternity surveys were translated into Kinyarwanda, back-translated to ensure accuracy and conducted in Kinyarwanda. Surveys were administered by four data collectors, who received training in survey administration, data collection and research ethics. Each participant received a written and verbal explanation of purposes, risks, benefits and alternatives to study participation, and provided informed consent (signed or marked if unable to write). No compensation was provided for participation in the study. Data collectors visited health facilities on ANC visit days between November and December 2013, with all women attending ANC eligible for study participation. Additionally, any woman in the maternity ward who had delivered at least 4 h previously was eligible to participate in the maternity survey. Additional inclusion criteria included being at least 16 years of age and willingness and ability to provide consent. Exclusion criteria included acute maternal illness such as clinical instability, and having had a fetal or neonatal death in the current delivery. All surveys were conducted in a private location away from health providers and other patients. The study was approved by the Rwanda National Ethics Committee and the Partners Institutional Review Board. Statistical methods Potential predictors of satisfaction were converted to binary variables. For questions measured on a likert scale (technical skills, quality of care, understanding, communication, respect, promptness, confidentiality and overall satisfaction), responses were divided into positive responses (excellent or very good: EVG) or neutral/negative (good, fair or poor). Our primary outcome was high (EVG) overall satisfaction. Earlier studies in this population revealed differences in measures of quality of care across districts [15], so we included district as a potential effect modifier. Bivariate associations were tested between reported EVG satisfaction and the independent predictors using chi-squared test. Breslow–Day tests of homogeneity were used to test for significant effect measure modification by district of the association between independent predictors and overall patient satisfaction. All variables found to be statistically significant (P < 0.05) in the bivariate analysis were kept for use in regression analysis, except for ‘difficulty obtaining transport’ due to substantial missing responses for this question across surveys. Multivariate logistic regression analysis was used to identify predictors of EVG satisfaction. A backwards, stepwise selection approach was used to select covariates with a threshold of P < 0.05, except for district, which was included in the final model. After fitting the main effects models, interaction terms were tested between district and independent predictors found to have significantly different stratified odds ratios as identified by the Breslow–Day tests, and any interaction terms that were significant were also included in the final model. For goodness-of-fit, calibration using Hosmer–Lemeshow chi-square tests and discrimination using c-statistics were assessed. Statistical analysis was done using STATA version 13 (StataCorp.2013, Stata Statistical Software: Release 13. College station, TX: StataCorp LP). Results are reported as Odds Ratios (OR), 95% confidence intervals (CI) and P-values with alpha = 0.05. Results ANC and maternity demographic characteristics This study included 278 women from Kirehe district (ANC: 204, maternity: 74) and 198 from SK (ANC: 166, maternity: 32). Demographics were similar across districts for both surveys (Table 1). Overall, about half of women reported high satisfaction with services, (ANC: 59%, maternity: 52%). Patients in SK reported higher satisfaction than patients in Kirehe (ANC: 83% vs. 40%, maternity: 84% vs. 39%). Table 1 Demographic characteristics of patients who attended antenatal care and maternity services Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  aANC, antenatal care. bSD, standard deviation. cIQR, interquartile range. dEVG, excellent very good. Table 1 Demographic characteristics of patients who attended antenatal care and maternity services Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  aANC, antenatal care. bSD, standard deviation. cIQR, interquartile range. dEVG, excellent very good. Bivariate analysis Among ANC respondents, patient, organizational, technical and interpersonal relationship factors were associated with overall satisfaction in our bivariate analyses, although differed between the districts (Table 2a). Lower parity (no prior children versus ≥1 children) was associated with greater satisfaction (Kirehe: 53% vs. 34%, P = 0.010, SK: 89% vs. 80%, P = 0.162). Patients reporting very clean (Kirehe: 79% vs. 37%, P = 0.002, SK: 92% vs. 80%, P = 0.069) or very comfortable (Kirehe: 50% vs. 39%, P = 0.504, SK: 92% vs. 77%, P = 0.019) facilities reported higher satisfaction than those who did not. Patients who reported EVG technical skills (Kirehe: 52% vs. 38%, P = 0.190, SK: 96% vs. 65%, P < 0.001) and quality of care (Kirehe: 66% vs. 32%, P < 0.001, SK: 95% vs. 49%, P < 0.001) reported higher satisfaction compared to those who did not. Several interpersonal relationship factors tested were also significantly associated with high satisfaction in both districts, including higher ratings of provider understanding, (Kirehe: P = 0.001, SK: P < 0.001), communication (Kirehe: P = 0.048, SK: P < 0.001), respect (Kirehe: P < 0.001, SK: P < 0.001), promptness (Kirehe: P = 0.001, SK: P = 0.039), and confidentiality (Table 2a). Table 2a Bivariate relationships between demographic and health system factors associated with high patient satisfaction in antenatal services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for stratified odds ratios. Table 2a Bivariate relationships between demographic and health system factors associated with high patient satisfaction in antenatal services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for stratified odds ratios. For maternity services, patients reporting higher cleanliness (Kirehe: 75% vs. 31%, P = 0.004, SK: 100% vs. 72%, P = 0.046), and higher provider technical skills (Kirehe: 71% vs. 31%, P = 0.005, SK: 100% vs. 64%, P = 0.007) had higher overall satisfaction compared to those who did not. The same pattern was seen for women reporting EVG overall quality of care (Kirehe: 56% vs. 33%, P = 0.097, SK: 100% vs. 56%, P = 0.001). All interpersonal relationship factors, were positively associated with high satisfaction, including communication, promptness and confidentiality (Table 2b). Table 2b Bivariate relationships between demographic and health system factors associated with high patient satisfaction with maternity services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for odds ratios stratified by district. Table 2b Bivariate relationships between demographic and health system factors associated with high patient satisfaction with maternity services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for odds ratios stratified by district. Multivariable analysis—logistic regression While many significant bivariate associations with ANC satisfaction were identified, fewer remained upon adjustment for other covariates in our ANC regression model (Table 3). In our final ANC model, we found that patients with more living children (1+ vs. 0) were less likely to report high satisfaction [OR = 0.46, 95% CI: 0.25–0.84]. Women who reported greater perceived quality of services [OR = 3.03, 95% CI: 1.56–5.88] and higher respect [OR = 4.13, 95% CI: 2.16–7.89] were more likely to report high overall satisfaction. In SK, patients who reported high confidentiality had 7.5 times the odds of reporting high overall satisfaction compared to those reporting low confidentiality [OR = 7.50, 95% CI: 2.16–26.01], while in Kirehe, this association was not significant [OR = 1.54, 95% CI: 0.60–3.94]. Table 3. Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among antenatal care respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  aHosmer–Lemeshow chi-squared test P-value = 0.5828, c-statistic = 0.8446. bEVG, excellent or very good. Table 3. Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among antenatal care respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  aHosmer–Lemeshow chi-squared test P-value = 0.5828, c-statistic = 0.8446. bEVG, excellent or very good. In our maternity regression model, several variables across domains were found to be significant predictors of high overall satisfaction. Our final model (Table 4) showed that participants with higher levels of education (≥5 years of school) were less likely to report high overall satisfaction than those with lower levels of education [OR = 0.13, 95% CI: 0.03–0.69]. Reporting high quality of maternity services [OR = 10.52, 95% CI: 1.81–61.22], positive nurse communication [OR = 8.78, 95% CI: 1.95–39.59], and positive confidentiality practices [OR = 8.66, 95% CI: 1.19–62.64] were all associated with high overall satisfaction in our model. While higher ratings of cleanliness were associated with higher overall satisfaction [OR = 19.23, 95% CI: 2.22–166.83]; higher ratings of comfort were significantly associated with lower likelihood of reporting high satisfaction [OR = 0.049, 95% CI: 0.0034–0.71]. Receiving care in Kirehe district was associated with significantly lower odds of high satisfaction compared to SK district [OR = 0.21, 95% CI: 0.04–1.03]. Table 4 Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among maternity respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  aHosmer–Lemeshow chi-squared test P-value = 0.7163, c-statistic = 0.9182. bEVG, excellent or very good. Table 4 Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among maternity respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  aHosmer–Lemeshow chi-squared test P-value = 0.7163, c-statistic = 0.9182. bEVG, excellent or very good. Discussion Our study assessed women’s satisfaction with ANC and maternity services in rural Rwanda prior to initiation of an intervention to improve service quality and reduce maternal and neonatal mortality. Our findings showed that about half of ANC and maternity patients were highly satisfied, thus suggesting substantial room for improvement. For ANC patients, no prior children, patient–provider interactions, including respect and confidentiality as well as perceived technical quality were all associated with higher satisfaction. Among women in maternity, while interpersonal interactions and quality were still important, organizational factors including cleanliness and comfort, as well as education level, were also associated with patient satisfaction. Our results provide insight into the drivers of patient satisfaction with maternal care in Rwanda at the patient and care delivery levels. Our finding that women with no prior living children reported greater satisfaction with ANC suggests that women’s expectations from prior birth experiences may influence satisfaction, a finding that is consistent with prior studies [22]. Additionally, while we found that lower levels of maternal education were associated with greater satisfaction with maternity care, prior research has shown mixed results on the relationship between patient education and satisfaction with care. For example, a study in Ethiopia found greater satisfaction with ANC among women with lower levels of education [23], while a Ugandan study found that women with some education reported higher satisfaction with health services compared to women with no education [14]. Consistent with findings from other studies [10–13], interpersonal relationships were important contributors to patient satisfaction with ANC and maternity care in our models, specifically respect, communication, and confidentiality. Our finding that cleanliness was a significant predictor of satisfaction with maternity care is also consistent with prior research indicating that this is an important organizational factor contributing to patient satisfaction [13], although recent research has suggested that this may be relatively less important to satisfaction than technical and interpersonal components of care [20]. Surprisingly, we found a small inverse association between reported comfort and reported satisfaction in the maternity model. In the bivariate analysis, we found that no Kirehe patients who reported high comfort also reported high satisfaction, and no SK patients who reported high comfort also reported low satisfaction, which produced uninformative cells in the district-level comparisons. For this reason, we would be cautious in generalizing the finding on comfort beyond our sample. Our data showed a significant difference in satisfaction between the two districts studied. This may reflect true differences in the quality and experience of care provided, as suggested in a prior study reporting technical measures of quality in the region [15]. Between the districts, SK has received PIH support for a longer period of time than Kirehe, which may have contributed to increased experiential quality of services. Furthermore, the greater geographic spread of health centers in Kirehe as compared to SK may have resulted in greater systems-level challenges to the provision of responsive and high-quality health services in Kirehe. There are some limitations to consider in the interpretation of this study. Our analysis is based on cross-sectional data, limiting the ability for causal inference. Additionally, our study was powered for ANC outcomes, so the number of maternity surveys collected was small, which may limit statistical power and generalizability of predictors of maternity services satisfaction to other contexts. Another possible limitation is a bias towards reporting positive satisfaction if deemed more socially desirable [24]. However, we found that many participants provided answers that were not at the higher end of the satisfaction spectrum, indicating that any such desirability effect is likely small. Since mothers who suffered poor outcomes (maternal death, still births and neonatal death) were excluded from maternity surveys, maternity satisfaction results could in fact be biased towards more positive reported satisfaction. However, as these poor outcomes are relatively rare, and near-miss events are typically more common and included in these surveys, we expect this bias to be minimal. Finally, although we assessed patients’ perception of quality of care provided, we did not have an objective measure of technical quality of care provided at the time of assessment, nor did we measure patients’ actual health status, or their expectations for the care they received. Studies have suggested that a patient’s general health level and the actual outcome of care can influence satisfaction [13, 25], suggesting that this could be an important measure for future research. Patient satisfaction is increasingly recognized as an essential component of evaluating health systems in developing countries [26]. While a few studies have found significant effects of health interventions in Africa on improving patient satisfaction [27–30], patient satisfaction is still infrequently measured in assessing the success of health interventions in resource-limited settings. This study demonstrates both the feasibility and utility of measuring patient satisfaction as a critical component of QI initiatives. As the world moves towards more people-centered medical care, efforts are underway to make medical service delivery more responsive to individual preferences, needs and values. At the completion of this survey, we presented the results in district-wide coordination meetings, allowing participants to discuss shortcomings in satisfaction measures and ideas for QI. In promoting the health of pregnant women and newborns, ensuring both access to and utilization of high-quality people-centered ANC and maternity care is essential. Research suggests that patients who are more satisfied with the care they receive may be more likely to seek ANC and maternity care [8, 9]. Our results underscore that satisfaction with maternal care can vary by location and individual, reinforcing the need for healthcare delivery interventions to reflect local needs and context and highlighting the importance of patient-centered metrics in assessing quality of care. Only through this integrated measurement and local response to identified gaps can we achieve our goals of improving quality and increasing adherence to ANC and maternity care. Supplementary material Supplementary material is available at International Journal for Quality in Health Care online. Acknowledgments We gratefully acknowledge the support of the Doris Duke Charitable Foundation’s Africa Health Initiative. We would also like to thank Dr Bethany Hedt-Gauthier for her analytic support, Dr Victor Mivumbi of the Rwanda Ministry of Health for his technical support. We would like to thank the following individuals for their participation in data collection: Peter Barebwa, Ancille Musabende, Wellars Ndayambaje and Ibrahim Hakizimana. We are especially grateful to the women of Kirehe and Southern Kayonza districts who participated in this study. Funding This work was supported by the Doris Duke Charitable Foundation’s Africa Health Initiative. S.H.I. was supported in part by the National Institutes of Health research training grant [NIH, T32 CA 009001]. References 1 WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division. Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division . Geneva, Switzerland: World Health Organization, 2015. 2 UNICEF, WHO, World Bank, UN-DESA Population Division. Levels & Trends in Child Mortality: Report 2015: Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation . New York, NY: United Nations Children’s Fund, 2015. 3 Heaman MI, Newburn-Cook CV, Green CG et al.  . Inadequate prenatal care and its association with adverse pregnancy outcomes: a comparison of indices. BMC Pregnancy Childbirth  2008; 8: 15– 22. Google Scholar CrossRef Search ADS PubMed  4 Baqui AH, El-Arifeen S, Darmstadt GL et al.  . Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial. J Perinatol  2016; 36: 71– 6. Google Scholar CrossRef Search ADS PubMed  5 Government of Rwanda, Ministry of Health. Third Health Sector Strategic Plan: July 2012–June 2018 . Kigali, Rwanda: Ministry of Health of Rwanda, 2012. 6 Rwanda, National Institute of Statistics of Rwanda. Rwanda Demographic and Health Survey: 2014/2015 . Kigali, Rwanda: Republic of Rwanda, National Institute of Statistics of Rwanda, 2015. 7 Dang BN, Westbrook RA, Black WC et al.  . Examining the link between patient satisfaction and adherence to HIV care: a structural equation model. PLoS ONE  2013; 8: e54729. Google Scholar CrossRef Search ADS PubMed  8 Gupta S, Yamada G, Mpembeni R et al.  . Factors associated with four or more antenatal care visits and its decline among pregnant women in Tanzania between 1999 and 2010. PLoS ONE  2014; 9: e101893. Google Scholar CrossRef Search ADS PubMed  9 Kruk ME, Hermosilla S, Larson E et al.  . Bypassing primary care clinics for childbirth: a cross-sectional study in the Pwani region, United Republic of Tanzania. Bull World Health Organ  2014; 92: 246– 53. Google Scholar CrossRef Search ADS PubMed  10 D’Ambruoso L, Abbey M, Hussein J. Please understand when I cry out in pain: women’s accounts of maternity services during labour and delivery in Ghana. BMC Public Health  2005; 5: 140. Google Scholar CrossRef Search ADS PubMed  11 Bazant ES, Koenig MA. Women’s satisfaction with delivery care in Nairobi’s informal settlements. Int J Qual Health Care  2009; 21: 79– 86. Google Scholar CrossRef Search ADS PubMed  12 Miller JS, Mhalu A, Chalamilla G et al.  . Patient satisfaction with HIV/AIDS care at private clinics in Dar es Salaam, Tanzania. AIDS Care  2014; 26: 1150– 4. Google Scholar CrossRef Search ADS PubMed  13 Westaway MS, Rheeder P, Van Zyl DG et al.  . Interpersonal and organizational dimensions of patient satisfaction: the moderating effects of health status. Int J Qual Health Care  2003; 15: 337– 44. Google Scholar CrossRef Search ADS PubMed  14 Nabbuye-Sekandi J, Makumbi F, Kasangaki A et al.  . Patient satisfaction with services in outpatient clinics at Mulago hospital, Uganda. Int J Qual Health Care  2011; 23: 516– 23. Google Scholar CrossRef Search ADS PubMed  15 Magge H, Anatole M, Cyamatare FR et al.  . Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda. Arch Dis Child  2015; 100: 565– 70. Google Scholar CrossRef Search ADS PubMed  16 Rwanda, National Institute of Statistics of Rwanda. 2012 Population and Housing Census: Report on the Provisional Results . Kigali, Rwanda: Republic of Rwanda, National Institute of Statistics of Rwanda, 2012. 17 Drobac PC, Basinga P, Condo J et al.  . Comprehensive and integrated district health systems strengthening: the Rwanda Population Health Implementation and Training (PHIT) Partnership. BMC Health Serv Res  2013; 13: S5. Google Scholar CrossRef Search ADS PubMed  18 Iyer HS, Kamanzi E, Mugunga JC et al.  . Improving district facility readiness: a 12-month evaluation of a data-driven health systems strengthening intervention in rural Rwanda. Glob Health Action  2015; 8: 28365. Google Scholar CrossRef Search ADS PubMed  19 Donabedian A. The quality of care. How can it be assessed? JAMA  1988; 260: 1743– 8. Google Scholar CrossRef Search ADS PubMed  20 Larson E, Vail D, Mbaruku GM et al.  . Moving toward patient-centered care in Africa: a discrete choice experiment of preferences for delivery care among 3,003 Tanzanian women. PLoS ONE  2015; 10: e0135621. Google Scholar CrossRef Search ADS PubMed  21 Uzochukwu BS, Onwujekwe OE, Akpala CO. Community satisfaction with the quality of maternal and child health services in southeast Nigeria. East Afr Med J  2004; 81: 293– 9. Google Scholar CrossRef Search ADS PubMed  22 Larson E, Hermosilla S, Kimweri A et al.  . Determinants of perceived quality of obstetric care in rural Tanzania: a cross-sectional study. BMC Health Serv Res  2014; 14: 483. Google Scholar CrossRef Search ADS PubMed  23 Chemir F, Alemseged F, Workneh D. Satisfaction with focused antenatal care service and associated factors among pregnant women attending focused antenatal care at health centers in Jimma town, Jimma zone, South West Ethiopia; a facility based cross-sectional study triangulated with qualitative study. BMC Research Notes  2014; 7: 164– 71. Google Scholar CrossRef Search ADS PubMed  24 Nederhof AJ. Methods of coping with social desirability bias: a review. Eur J Soc Psychol  1985; 15: 263– 80. Google Scholar CrossRef Search ADS   25 Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med  2001; 52: 609– 20. Google Scholar CrossRef Search ADS PubMed  26 Kruk ME, Freedman LP. Assessing health system performance in developing countries: a review of the literature. Health Policy  2008; 85: 263– 76. Google Scholar CrossRef Search ADS PubMed  27 Weaver MR, Myaya M, Disasi K et al.  . Routine HIV testing in the context of syndromic management of sexually transmitted infections: outcomes of the first phase of a training programme in Botswana. Sex Transm Infect  2008; 84: 259– 64. Google Scholar CrossRef Search ADS PubMed  28 Ajuwon AJ, Okuribido B, Sadiq GT et al.  . Outcome of interventions to improve the quality of reproductive health services provided by private health facilities in selected states in Nigeria. Afr J Med Med Sci  2006; 35: 369– 74. Google Scholar PubMed  29 Onyango-Ouma W, Laisser R, Mbilima M et al.  . An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool. Health Policy Plan  2001; 16: 24– 32. Google Scholar CrossRef Search ADS PubMed  30 Chimwaza AF, Chimango JL, Kaponda CP et al.  . Changes in clients’ care ratings after HIV prevention training of hospital workers in Malawi. Int J Qual Health Care  2012; 24: 152– 60. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Advancing the health of women and newborns: predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda

Loading next page...
 
/lp/ou_press/advancing-the-health-of-women-and-newborns-predictors-of-patient-f2drMFp830
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
ISSN
1353-4505
eISSN
1464-3677
D.O.I.
10.1093/intqhc/mzy103
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective Identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. Design Cross-sectional. Setting Twenty-six health facilities in Southern Kayonza (SK) and Kirehe districts. Participants Sample of women ≥ 16 years old receiving antenatal and delivery care between November and December 2013. Intervention Survey of patient satisfaction with antenatal and delivery care to inform quality improvement (QI) initiatives aimed at reducing neonatal mortality. Main Outcome Measure Overall satisfaction with antenatal and delivery care (reported as excellent or very good). Results In multivariate logistic regression analysis, high perceived quality [odds ratio (OR) = 3.03, 95% confidence intervals (CI): 1.565.88], respect [OR = 4.13, 95% CI: 2.16–7.89], and confidentiality [SK: OR = 7.50, 95% CI: 2.16–26.01], [Kirehe: OR = 1.54, 95% CI: 0.60–3.94] were associated with higher overall satisfaction with ANC, while having ≥1 child compared to none [OR = 0.46, 95% CI: 0.25–0.84] was associated with lower satisfaction. For maternity services, <5 years of school versus ≥5 years [OR = 0.13, 95% CI: 0.026–0.69] and higher cleanliness [OR = 19.23, 95% CI: 2.22–166.83], self-reported quality [OR = 10.52, 95% CI: 1.81–61.22], communication [OR = 8.78, 95%CI: 1.95–39.59], and confidentiality [OR = 8.66, 95% CI: 1.20–62.64] were all positively associated with high satisfaction. Higher comfort [OR: 0.050, 95% CI: 0.0034–0.71] and Kirehe vs. SK district [OR: 0.21, 95% CI: 0.042–1.01] were associated with lower satisfaction. Conclusions Patient-centeredness (including interpersonal relationships), organizational factors, and location are important individual determinants of satisfaction for women seeking maternal care at study facilities. Understanding variation in these factors should inform QI efforts in maternal and newborn health programs. patient satisfaction, antenatal care, delivery, quality of healthcare, maternal and newborn health, Rwanda Introduction While there has been recent progress towards reducing maternal and neonatal mortality (MDG 5), critical gaps remain in the developing world, with more than 300 000 women dying each year during pregnancy and childbirth [1], and almost 3 million neonates dying each year [2]. Quality antenatal care (ANC) and facility-based delivery with a skilled health worker are important interventions to improve pregnancy outcomes, reducing maternal and perinatal mortality [3, 4], yet coverage of these services remains insufficient. In Rwanda, reduction of maternal and neonatal mortality is a key national priority [5]. As of 2015, although 99% of pregnant women received at least one ANC visit from a skilled provider, less than half of Rwandan women report receiving all four recommended standard ANC visits [6]. Patient satisfaction can influence health-seeking behaviors and adherence to care, including in ANC and maternity settings in Africa [7–10]. Satisfied patients are more likely to return to care and recommend services to others, which may support effective coverage of services [10, 11]. Prior research suggests that in Sub-Saharan Africa, factors that influence patients’ satisfaction with health services include interpersonal (provider–patient) relationships, technical quality and organizational factors (such as cleanliness and comfort) [10–14]. The Rwandan Ministry of Health (MOH), supported by Partners In Health (PIH), launched the All Babies Count Initiative (ABC) in 2013 [15]. The goal of ABC was to reduce neonatal mortality by improving the quality of ANC and maternity care in two rural districts over an 18-month period. ABC consisted of three components: (a) healthcare worker training followed by on-site mentorship, (b) essential equipment and materials and (c) a quality improvement (QI) strategy using district-wide learning collaboratives, which included training and support for improving patient-centered care. In order to assess experiential quality as a key domain of quality and a likely driver of care-seeking behavior, a patient satisfaction survey was conducted at baseline. The objective of this study is to describe baseline levels and primary predictors of patient satisfaction with antenatal and maternity care services at the time of delivery in rural Rwanda and to inform the QI processes of the ABC initiative. Methods Study setting The study was conducted in all 16 health centers (HCs) in Kirehe and 8 HCs in Southern Kayonza (SK) districts and the two district hospitals. ANC occurs at the HCs and deliveries at all 26 facilities. These rural districts are located in the Eastern Province of Rwanda, serving a catchment population of ~480 000 [16]. In partnership with the MOH, PIH has provided clinical and infrastructure support to the public health system in SK since 2005, expanding to Kirehe in 2009 [17, 18]. The ABC initiative built on an ongoing district-wide strengthening program started in 2009 to reduce neonatal mortality [17]. Survey design A conceptual framework was developed to inform survey design. Using a model created by Donabedian [19], three domains of factors influencing patient satisfaction were identified: (1) organizational components, (2) technical quality and (3) interpersonal factors. These factors have been found to influence patient satisfaction with maternal health services in Sub-Saharan Africa [11, 20, 21]. Our conceptual framework outlines the link between these factors and satisfaction with antenatal and maternity care (Fig. 1). Using this framework, 22 independent variables with potential links to patient satisfaction were identified and included in the survey: (1) patient characteristics, including age, marital status, education level, socioeconomic status, number of children, patient knowledge of danger signs and access (measured by travel time, cost of transportation, difficulty of payment for transport and overall difficulty of obtaining transportation); (2) organizational components, including length of wait time, acceptability of wait time, cleanliness and comfort; (3) reported technical quality of care received, including technical skills and perceived quality of care and (4) interpersonal factors, including understanding, communication, respect, promptness and confidentiality. The primary outcome—overall satisfaction—was assessed through the question: ‘Overall, how satisfied were you with the care that you received?’ Additional survey questions can be found in the Appendix. Figure 1 View largeDownload slide Conceptual framework for antenatal care (ANC) and maternity service satisfaction. Figure 1 View largeDownload slide Conceptual framework for antenatal care (ANC) and maternity service satisfaction. Questions regarding satisfaction and perceptions of care employed a standard 5-point likert scale: excellent, very good, good, fair and poor. Both antenatal and maternity surveys were translated into Kinyarwanda, back-translated to ensure accuracy and conducted in Kinyarwanda. Surveys were administered by four data collectors, who received training in survey administration, data collection and research ethics. Each participant received a written and verbal explanation of purposes, risks, benefits and alternatives to study participation, and provided informed consent (signed or marked if unable to write). No compensation was provided for participation in the study. Data collectors visited health facilities on ANC visit days between November and December 2013, with all women attending ANC eligible for study participation. Additionally, any woman in the maternity ward who had delivered at least 4 h previously was eligible to participate in the maternity survey. Additional inclusion criteria included being at least 16 years of age and willingness and ability to provide consent. Exclusion criteria included acute maternal illness such as clinical instability, and having had a fetal or neonatal death in the current delivery. All surveys were conducted in a private location away from health providers and other patients. The study was approved by the Rwanda National Ethics Committee and the Partners Institutional Review Board. Statistical methods Potential predictors of satisfaction were converted to binary variables. For questions measured on a likert scale (technical skills, quality of care, understanding, communication, respect, promptness, confidentiality and overall satisfaction), responses were divided into positive responses (excellent or very good: EVG) or neutral/negative (good, fair or poor). Our primary outcome was high (EVG) overall satisfaction. Earlier studies in this population revealed differences in measures of quality of care across districts [15], so we included district as a potential effect modifier. Bivariate associations were tested between reported EVG satisfaction and the independent predictors using chi-squared test. Breslow–Day tests of homogeneity were used to test for significant effect measure modification by district of the association between independent predictors and overall patient satisfaction. All variables found to be statistically significant (P < 0.05) in the bivariate analysis were kept for use in regression analysis, except for ‘difficulty obtaining transport’ due to substantial missing responses for this question across surveys. Multivariate logistic regression analysis was used to identify predictors of EVG satisfaction. A backwards, stepwise selection approach was used to select covariates with a threshold of P < 0.05, except for district, which was included in the final model. After fitting the main effects models, interaction terms were tested between district and independent predictors found to have significantly different stratified odds ratios as identified by the Breslow–Day tests, and any interaction terms that were significant were also included in the final model. For goodness-of-fit, calibration using Hosmer–Lemeshow chi-square tests and discrimination using c-statistics were assessed. Statistical analysis was done using STATA version 13 (StataCorp.2013, Stata Statistical Software: Release 13. College station, TX: StataCorp LP). Results are reported as Odds Ratios (OR), 95% confidence intervals (CI) and P-values with alpha = 0.05. Results ANC and maternity demographic characteristics This study included 278 women from Kirehe district (ANC: 204, maternity: 74) and 198 from SK (ANC: 166, maternity: 32). Demographics were similar across districts for both surveys (Table 1). Overall, about half of women reported high satisfaction with services, (ANC: 59%, maternity: 52%). Patients in SK reported higher satisfaction than patients in Kirehe (ANC: 83% vs. 40%, maternity: 84% vs. 39%). Table 1 Demographic characteristics of patients who attended antenatal care and maternity services Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  aANC, antenatal care. bSD, standard deviation. cIQR, interquartile range. dEVG, excellent very good. Table 1 Demographic characteristics of patients who attended antenatal care and maternity services Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  Characteristics  ANCa  Maternity  Kirehe  Kayonza  Total  Kirehe  Kayonza  Total  n  %  n  %  N  %  n  %  n  %  N  %  Total  204  100  166  100  370  100  74  100  32  100  106  100  Personal information   Age    Mean, SDb  26.6  6.0  27.1  6.6  26.8  6.3  26.6  6.2  26.8  7.5  26.7  6.6   Current marital status    Married  103  50  78  47  181  49  33  45  17  53  50  47    Not married  101  50  87  53  188  51  41  55  15  47  56  53   How many years of school have you completed?    Up to 4 years primary  116  57  59  38  175  49  46  62  15  54  61  60    5 years primary or more  88  43  95  62  183  51  28  38  13  46  41  40   Which of the following items are present at your home?    Radio  131  64  121  73  252  68  43  59  19  61  62  60    Bicycle  91  45  70  42  161  44  33  45  20  65  53  51    Electricity  23  11  35  21  58  16  4  5  4  13  8  8    Goats  90  44  79  48  169  46  37  51  16  52  53  51    Running water  11  5  7  4  18  5  9  12  3  10  12  12    Motobike  4  2  5  3  9  2  5  7  1  3  6  6    Mobile phone  120  59  121  73  241  65  32  44  16  52  48  46    Cows  68  33  45  27  113  31  21  29  7  23  28  27  How many living children do you have, including your newborn?    Median, IQRc  1  [0–3]  1  [0–3]  1  [0–3]  2  [1–4]  2  [1–4]  2  [1–4]  Healthcare services   Did you receive antenatal care at this facility where you delivered your baby?    Yes              58  78  28  88  86  81    No              15  20  4  13  19  18    Did not receive any care before delivery              1  1  0  0  1  1   Number of ANC visits    1  130  64  91  55  221  60  7  10  1  3  8  8    2  47  23  41  25  88  24  19  26  5  16  24  23    3  16  8  22  13  38  10  34  47  14  44  48  46    4  6  3  11  7  17  5  12  17  10  31  22  21    >4  5  2  0  0  5  1  0  0  2  6  2  2    I do not remember but I had more than 1 visit  0  0  1  1  1  0               Overall satisfaction (EVGd)  81  40  134  83  215  59  28  39  26  84  54  52  aANC, antenatal care. bSD, standard deviation. cIQR, interquartile range. dEVG, excellent very good. Bivariate analysis Among ANC respondents, patient, organizational, technical and interpersonal relationship factors were associated with overall satisfaction in our bivariate analyses, although differed between the districts (Table 2a). Lower parity (no prior children versus ≥1 children) was associated with greater satisfaction (Kirehe: 53% vs. 34%, P = 0.010, SK: 89% vs. 80%, P = 0.162). Patients reporting very clean (Kirehe: 79% vs. 37%, P = 0.002, SK: 92% vs. 80%, P = 0.069) or very comfortable (Kirehe: 50% vs. 39%, P = 0.504, SK: 92% vs. 77%, P = 0.019) facilities reported higher satisfaction than those who did not. Patients who reported EVG technical skills (Kirehe: 52% vs. 38%, P = 0.190, SK: 96% vs. 65%, P < 0.001) and quality of care (Kirehe: 66% vs. 32%, P < 0.001, SK: 95% vs. 49%, P < 0.001) reported higher satisfaction compared to those who did not. Several interpersonal relationship factors tested were also significantly associated with high satisfaction in both districts, including higher ratings of provider understanding, (Kirehe: P = 0.001, SK: P < 0.001), communication (Kirehe: P = 0.048, SK: P < 0.001), respect (Kirehe: P < 0.001, SK: P < 0.001), promptness (Kirehe: P = 0.001, SK: P = 0.039), and confidentiality (Table 2a). Table 2a Bivariate relationships between demographic and health system factors associated with high patient satisfaction in antenatal services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for stratified odds ratios. Table 2a Bivariate relationships between demographic and health system factors associated with high patient satisfaction in antenatal services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.185    0.012    0.053  0.2357    16-29  59 (43)    91 (88)    150 (63)        30+  22 (33)    43 (73)    65 (52)       Marital status    0.344    0.055    0.634  0.0344    Married  37 (37)    74 (88)    111 (60)        Unmarried  44 (43)    59 (77)    103 (58)       Education level    0.404    0.446    0.014  0.8684    Up to 4 years primary  43 (37)    45 (79)    88 (51)        5+ years primary/secondary  38 (43)    78 (84)    116 (64)       Socioeconomic status (total items at home)    0.286    0.76    0.219  0.3957    2 or fewer items  33 (36)    52 (84)    85 (55)        3+ items  48 (43)    82 (82)    130 (62)       Number of children    0.010    0.162    0.012  0.8720    0 children  36 (53)    47 (89)    83 (69)        1+ children  45 (34)    87 (80)    132 (55)       Travel time    0.574    0.815    1.000  0.6267    <1 hour  20 (54)    28 (80)    48 (67)        >1 hour  7 (64)    3 (75)    10 (67)       Travel payment    0.656    0.322    0.945  0.2844    Free  14 (58)    19 (76)    33 (67)        Paid  13 (52)    15 (88)    28 (67)       Travel payment difficulty  0.662    0.136    0.241  0.2361    A little/very difficult  7 (58)    10 (100)    17 (77)        Not difficult  8 (50)    8 (80)    16 (62)       Travel difficulty    0.171    0.018    0.009  0.2484    A little/very difficult  45 (57)    74 (93)    119 (75)        Not difficult  17 (44)    22 (76)    39 (57)       Patient knowledge    0.512    0.991    0.003  0.5742    7-8 correct out of 8  3 (30)    48 (83)    51 (75)        6 or fewer correct  78 (40)    86 (83)    164 (55)      Organizational factors               Wait time    0.999    0.918    0.070  0.9310    <1 hour  41 (40)    97 (83)    138 (63)        >1 hour  39 (40)    37 (82)    76 (53)       Wait okay    0.178    0.735    0.839  0.3116    Acceptable  55 (37)    109 (83)    164 (59)        Too long/Much too long  25 (48)    25 (81)    50 (60)       Cleanliness    0.002    0.069    <0.0001  0.4397    Very clean  11 (79)    36 (92)    47 (89)        Other  70 (37)    98 (80)    168 (54)       Comfortable    0.504    0.019    <0.0001  0.3666    Very comfortable  5 (50)    55 (92)    60 (86)        Other  76 (39)    78 (77)    154 (52)      Technical adequacy                 Technical skills    0.190    <0.0001    <0.0001  0.0076    Excellent/Very good  12 (52)    85 (96)    97 (87)        Other  68 (38)    40 (65)    108 (45)       Overall quality of care  <0.0001    <0.0001    <0.0001  0.0135    Excellent/Very good  31 (66)    109 (95)    140 (86)        Other  48 (32)    20 (49)    68 (36)      Interpersonal relationship               Understanding    0.001    <0.0001    <0.0001  0.1879    Excellent/Very good  26 (63)    106 (91)    132 (84)        Other  55 (34)    27 (60)    82 (40)       Communication    0.048    <0.0001    <0.0001  0.0036    Excellent/Very good  17 (57)    105 (95)    122 (87)        Other  64 (37)    28 (56)    92 (41)       Respect    <0.0001    <0.0001    <0.0001  0.0062    Excellent/Very good  30 (63)    110 (95)    140 (85)        Other  51 (33)    23 (51)    74 (37)      Promptness    0.001    0.039    <0.0001  0.7413    Excellent/Very good  26 (62)    61 (90)    87 (79)        Other  55 (34)    71 (77)    126 (50)      Confidentiality    0.015    <0.0001    <0.0001  0.0105    Excellent/Very good  17 (61)    120 (92)    137 (86)        Other  64 (37)    14 (45)    78 (38)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for stratified odds ratios. For maternity services, patients reporting higher cleanliness (Kirehe: 75% vs. 31%, P = 0.004, SK: 100% vs. 72%, P = 0.046), and higher provider technical skills (Kirehe: 71% vs. 31%, P = 0.005, SK: 100% vs. 64%, P = 0.007) had higher overall satisfaction compared to those who did not. The same pattern was seen for women reporting EVG overall quality of care (Kirehe: 56% vs. 33%, P = 0.097, SK: 100% vs. 56%, P = 0.001). All interpersonal relationship factors, were positively associated with high satisfaction, including communication, promptness and confidentiality (Table 2b). Table 2b Bivariate relationships between demographic and health system factors associated with high patient satisfaction with maternity services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for odds ratios stratified by district. Table 2b Bivariate relationships between demographic and health system factors associated with high patient satisfaction with maternity services Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Characteristics  Kirehe  Southern Kayonza  Total  BD    n (%)  p-valuea  n (%)  p-valuea  n (%)  p-valuea  p-valueb  Patient characteristics                 Age range    0.382    0.686    0.328  0.9661    16-29  20 (43)    18 (86)    38 (56)        30+  8 (32)    8 (80)    16 (46)       Marital status    0.936    0.682    0.902  0.6868    Married  15 (39)    13 (87)    28 (52)        Unmarried  13 (39)    13 (81)    26 (53)       Education level    0.025    0.278    0.367  0.0432    Up to 4 years primary  22 (49)    14 (78)    36 (57)        5+ years primary/secondary  6 (22)    12 (92)    18 (45)       Socioeconomic status (total items at home)    0.600    0.743    0.608  0.9505    2 or fewer items  14 (41)    12 (86)    26 (54)        3+ items  13 (35)    13 (81)    26 (49)       Number of children    0.212    0.818    0.232  0.7146    First child  8 (30)    9 (82)    17 (45)        Has prior children  20 (44)    17 (85)    37 (57)       Travel time    0.543    0.558    0.338  0.4845    <1 hour  24 (43)    23 (85)    47 (57)        >1 hour  4 (33)    2 (100)    6 (43)       Travel payment    0.278    0.671    0.515  0.2979    Free  0 (0)    1 (100)    1 (33)        Paid  21 (38)    22 (85)    43 (52)       Travel payment difficulty    0.175    0.108    0.744  0.0416    A little/very difficult  15 (43)    11 (73)    26 (52)        Not difficult  4 (24)    8 (100)    12 (48)       Travel difficulty    0.672    0.277    0.937  0.2450    A little/very difficult  12 (46)    10 (77)    22 (56)        Not difficult  13 (41)    12 (92)    25 (56)       Patient knowledge    0.119    0.060    0.918  0.0160    6 correct out of 6  18 (47)    9 (69)    27 (53)        <6 correct  10 (29)    17 (94)    27 (52)      Organizational factors   Transfer time    0.659    none    0.580  1.000    <1 hour  1 (33)    6 (100)    7 (78)        >1 hour  2 (50)    1 (100)    3 (60)      Cleanliness    0.004    0.046    <0.0001  0.407    Very clean  9 (75)    12 (100)    21 (88)        Other  18 (31)    13 (72)    31 (40)      Comfortable    0.064    0.070    0.182  0.0097    Very comfortable  0 (0)    11 (100)    11 (69)        Other  28 (42)    15 (75)    43 (49)      Technical adequacy                 Technical skills    0.005    0.007    <0.0001  0.2237    Excellent/Very good  10 (71)    17 (100)    27 (87)        Other  18 (31)    9 (64)    27 (38)      Overall quality of care    0.097    0.001    <0.0001  0.0449    Excellent/Very good  10 (56)    20 (100)    30 (79)        Other  17 (33)    5 (56)    22 (37)      Interpersonal relationship   Communication    0.004    0.004    <0.0001  0.1498    Excellent/Very good  14 (64)    18 (100)    32 (80)        Other  14 (28)    8 (62)    22 (35)       Respect    0.002    0.038    <0.0001  0.6852    Excellent/Very good  14 (67)    18 (95)    32 (80)        Other  14 (28)    8 (67)    22 (35)       Promptness    0.028    0.056    <0.0001  0.6246    Excellent/Very good  10 (63)    21 (91)    31 (79)        Other  18 (32)    5 (63)    23 (36)       Confidentiality    0.002    0.005    <0.0001  0.6634    Excellent/Very good  9 (82)    19 (95)    28 (90)        Other  19 (31)    4 (50)    23 (33)      Bold text: p-values<0.05. aChi-square test p-value. bBreslow-Day test of homogeneity for odds ratios stratified by district. Multivariable analysis—logistic regression While many significant bivariate associations with ANC satisfaction were identified, fewer remained upon adjustment for other covariates in our ANC regression model (Table 3). In our final ANC model, we found that patients with more living children (1+ vs. 0) were less likely to report high satisfaction [OR = 0.46, 95% CI: 0.25–0.84]. Women who reported greater perceived quality of services [OR = 3.03, 95% CI: 1.56–5.88] and higher respect [OR = 4.13, 95% CI: 2.16–7.89] were more likely to report high overall satisfaction. In SK, patients who reported high confidentiality had 7.5 times the odds of reporting high overall satisfaction compared to those reporting low confidentiality [OR = 7.50, 95% CI: 2.16–26.01], while in Kirehe, this association was not significant [OR = 1.54, 95% CI: 0.60–3.94]. Table 3. Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among antenatal care respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  aHosmer–Lemeshow chi-squared test P-value = 0.5828, c-statistic = 0.8446. bEVG, excellent or very good. Table 3. Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among antenatal care respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P>|z|  Number of live children (1+ vs. 0)  0.46  0.25–0.84  0.012  EVG quality vs. other  3.03  1.56–5.88  0.001  Kayonza: EVG confidentiality vs. other  7.50  2.16–26.01  0.002  Kirehe: EVG confidentiality vs. other  1.54  0.60–3.94  0.37  EVG respect vs. other  4.13  2.16–7.89  <0.0001  Kirehe vs. Kayonza  1.08  0.43–2.74  0.87  aHosmer–Lemeshow chi-squared test P-value = 0.5828, c-statistic = 0.8446. bEVG, excellent or very good. In our maternity regression model, several variables across domains were found to be significant predictors of high overall satisfaction. Our final model (Table 4) showed that participants with higher levels of education (≥5 years of school) were less likely to report high overall satisfaction than those with lower levels of education [OR = 0.13, 95% CI: 0.03–0.69]. Reporting high quality of maternity services [OR = 10.52, 95% CI: 1.81–61.22], positive nurse communication [OR = 8.78, 95% CI: 1.95–39.59], and positive confidentiality practices [OR = 8.66, 95% CI: 1.19–62.64] were all associated with high overall satisfaction in our model. While higher ratings of cleanliness were associated with higher overall satisfaction [OR = 19.23, 95% CI: 2.22–166.83]; higher ratings of comfort were significantly associated with lower likelihood of reporting high satisfaction [OR = 0.049, 95% CI: 0.0034–0.71]. Receiving care in Kirehe district was associated with significantly lower odds of high satisfaction compared to SK district [OR = 0.21, 95% CI: 0.04–1.03]. Table 4 Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among maternity respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  aHosmer–Lemeshow chi-squared test P-value = 0.7163, c-statistic = 0.9182. bEVG, excellent or very good. Table 4 Multivariate logistic regression modela with predictors of reported ‘EVG’ satisfactionb among maternity respondents Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  Reported EVG overall patient satisfaction  Odds ratio  95% Conf. interval  P > |z|  5+ years school vs. ≤4 years primary school  0.13  0.026–0.69  0.016  EVG cleanliness vs. other  19.23  2.22–166.83  0.007  EVG comfort vs. other  0.049  0.0034–0.71  0.027  EVG quality vs. other  10.52  1.81–61.22  0.009  EVG communication vs. other  8.78  1.95–39.59  0.005  EVG confidentiality vs. other  8.66  1.20–62.64  0.032  Kirehe vs. Kayonza  0.21  0.042–1.01  0.052  aHosmer–Lemeshow chi-squared test P-value = 0.7163, c-statistic = 0.9182. bEVG, excellent or very good. Discussion Our study assessed women’s satisfaction with ANC and maternity services in rural Rwanda prior to initiation of an intervention to improve service quality and reduce maternal and neonatal mortality. Our findings showed that about half of ANC and maternity patients were highly satisfied, thus suggesting substantial room for improvement. For ANC patients, no prior children, patient–provider interactions, including respect and confidentiality as well as perceived technical quality were all associated with higher satisfaction. Among women in maternity, while interpersonal interactions and quality were still important, organizational factors including cleanliness and comfort, as well as education level, were also associated with patient satisfaction. Our results provide insight into the drivers of patient satisfaction with maternal care in Rwanda at the patient and care delivery levels. Our finding that women with no prior living children reported greater satisfaction with ANC suggests that women’s expectations from prior birth experiences may influence satisfaction, a finding that is consistent with prior studies [22]. Additionally, while we found that lower levels of maternal education were associated with greater satisfaction with maternity care, prior research has shown mixed results on the relationship between patient education and satisfaction with care. For example, a study in Ethiopia found greater satisfaction with ANC among women with lower levels of education [23], while a Ugandan study found that women with some education reported higher satisfaction with health services compared to women with no education [14]. Consistent with findings from other studies [10–13], interpersonal relationships were important contributors to patient satisfaction with ANC and maternity care in our models, specifically respect, communication, and confidentiality. Our finding that cleanliness was a significant predictor of satisfaction with maternity care is also consistent with prior research indicating that this is an important organizational factor contributing to patient satisfaction [13], although recent research has suggested that this may be relatively less important to satisfaction than technical and interpersonal components of care [20]. Surprisingly, we found a small inverse association between reported comfort and reported satisfaction in the maternity model. In the bivariate analysis, we found that no Kirehe patients who reported high comfort also reported high satisfaction, and no SK patients who reported high comfort also reported low satisfaction, which produced uninformative cells in the district-level comparisons. For this reason, we would be cautious in generalizing the finding on comfort beyond our sample. Our data showed a significant difference in satisfaction between the two districts studied. This may reflect true differences in the quality and experience of care provided, as suggested in a prior study reporting technical measures of quality in the region [15]. Between the districts, SK has received PIH support for a longer period of time than Kirehe, which may have contributed to increased experiential quality of services. Furthermore, the greater geographic spread of health centers in Kirehe as compared to SK may have resulted in greater systems-level challenges to the provision of responsive and high-quality health services in Kirehe. There are some limitations to consider in the interpretation of this study. Our analysis is based on cross-sectional data, limiting the ability for causal inference. Additionally, our study was powered for ANC outcomes, so the number of maternity surveys collected was small, which may limit statistical power and generalizability of predictors of maternity services satisfaction to other contexts. Another possible limitation is a bias towards reporting positive satisfaction if deemed more socially desirable [24]. However, we found that many participants provided answers that were not at the higher end of the satisfaction spectrum, indicating that any such desirability effect is likely small. Since mothers who suffered poor outcomes (maternal death, still births and neonatal death) were excluded from maternity surveys, maternity satisfaction results could in fact be biased towards more positive reported satisfaction. However, as these poor outcomes are relatively rare, and near-miss events are typically more common and included in these surveys, we expect this bias to be minimal. Finally, although we assessed patients’ perception of quality of care provided, we did not have an objective measure of technical quality of care provided at the time of assessment, nor did we measure patients’ actual health status, or their expectations for the care they received. Studies have suggested that a patient’s general health level and the actual outcome of care can influence satisfaction [13, 25], suggesting that this could be an important measure for future research. Patient satisfaction is increasingly recognized as an essential component of evaluating health systems in developing countries [26]. While a few studies have found significant effects of health interventions in Africa on improving patient satisfaction [27–30], patient satisfaction is still infrequently measured in assessing the success of health interventions in resource-limited settings. This study demonstrates both the feasibility and utility of measuring patient satisfaction as a critical component of QI initiatives. As the world moves towards more people-centered medical care, efforts are underway to make medical service delivery more responsive to individual preferences, needs and values. At the completion of this survey, we presented the results in district-wide coordination meetings, allowing participants to discuss shortcomings in satisfaction measures and ideas for QI. In promoting the health of pregnant women and newborns, ensuring both access to and utilization of high-quality people-centered ANC and maternity care is essential. Research suggests that patients who are more satisfied with the care they receive may be more likely to seek ANC and maternity care [8, 9]. Our results underscore that satisfaction with maternal care can vary by location and individual, reinforcing the need for healthcare delivery interventions to reflect local needs and context and highlighting the importance of patient-centered metrics in assessing quality of care. Only through this integrated measurement and local response to identified gaps can we achieve our goals of improving quality and increasing adherence to ANC and maternity care. Supplementary material Supplementary material is available at International Journal for Quality in Health Care online. Acknowledgments We gratefully acknowledge the support of the Doris Duke Charitable Foundation’s Africa Health Initiative. We would also like to thank Dr Bethany Hedt-Gauthier for her analytic support, Dr Victor Mivumbi of the Rwanda Ministry of Health for his technical support. We would like to thank the following individuals for their participation in data collection: Peter Barebwa, Ancille Musabende, Wellars Ndayambaje and Ibrahim Hakizimana. We are especially grateful to the women of Kirehe and Southern Kayonza districts who participated in this study. Funding This work was supported by the Doris Duke Charitable Foundation’s Africa Health Initiative. S.H.I. was supported in part by the National Institutes of Health research training grant [NIH, T32 CA 009001]. References 1 WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division. Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division . Geneva, Switzerland: World Health Organization, 2015. 2 UNICEF, WHO, World Bank, UN-DESA Population Division. Levels & Trends in Child Mortality: Report 2015: Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation . New York, NY: United Nations Children’s Fund, 2015. 3 Heaman MI, Newburn-Cook CV, Green CG et al.  . Inadequate prenatal care and its association with adverse pregnancy outcomes: a comparison of indices. BMC Pregnancy Childbirth  2008; 8: 15– 22. Google Scholar CrossRef Search ADS PubMed  4 Baqui AH, El-Arifeen S, Darmstadt GL et al.  . Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial. J Perinatol  2016; 36: 71– 6. Google Scholar CrossRef Search ADS PubMed  5 Government of Rwanda, Ministry of Health. Third Health Sector Strategic Plan: July 2012–June 2018 . Kigali, Rwanda: Ministry of Health of Rwanda, 2012. 6 Rwanda, National Institute of Statistics of Rwanda. Rwanda Demographic and Health Survey: 2014/2015 . Kigali, Rwanda: Republic of Rwanda, National Institute of Statistics of Rwanda, 2015. 7 Dang BN, Westbrook RA, Black WC et al.  . Examining the link between patient satisfaction and adherence to HIV care: a structural equation model. PLoS ONE  2013; 8: e54729. Google Scholar CrossRef Search ADS PubMed  8 Gupta S, Yamada G, Mpembeni R et al.  . Factors associated with four or more antenatal care visits and its decline among pregnant women in Tanzania between 1999 and 2010. PLoS ONE  2014; 9: e101893. Google Scholar CrossRef Search ADS PubMed  9 Kruk ME, Hermosilla S, Larson E et al.  . Bypassing primary care clinics for childbirth: a cross-sectional study in the Pwani region, United Republic of Tanzania. Bull World Health Organ  2014; 92: 246– 53. Google Scholar CrossRef Search ADS PubMed  10 D’Ambruoso L, Abbey M, Hussein J. Please understand when I cry out in pain: women’s accounts of maternity services during labour and delivery in Ghana. BMC Public Health  2005; 5: 140. Google Scholar CrossRef Search ADS PubMed  11 Bazant ES, Koenig MA. Women’s satisfaction with delivery care in Nairobi’s informal settlements. Int J Qual Health Care  2009; 21: 79– 86. Google Scholar CrossRef Search ADS PubMed  12 Miller JS, Mhalu A, Chalamilla G et al.  . Patient satisfaction with HIV/AIDS care at private clinics in Dar es Salaam, Tanzania. AIDS Care  2014; 26: 1150– 4. Google Scholar CrossRef Search ADS PubMed  13 Westaway MS, Rheeder P, Van Zyl DG et al.  . Interpersonal and organizational dimensions of patient satisfaction: the moderating effects of health status. Int J Qual Health Care  2003; 15: 337– 44. Google Scholar CrossRef Search ADS PubMed  14 Nabbuye-Sekandi J, Makumbi F, Kasangaki A et al.  . Patient satisfaction with services in outpatient clinics at Mulago hospital, Uganda. Int J Qual Health Care  2011; 23: 516– 23. Google Scholar CrossRef Search ADS PubMed  15 Magge H, Anatole M, Cyamatare FR et al.  . Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda. Arch Dis Child  2015; 100: 565– 70. Google Scholar CrossRef Search ADS PubMed  16 Rwanda, National Institute of Statistics of Rwanda. 2012 Population and Housing Census: Report on the Provisional Results . Kigali, Rwanda: Republic of Rwanda, National Institute of Statistics of Rwanda, 2012. 17 Drobac PC, Basinga P, Condo J et al.  . Comprehensive and integrated district health systems strengthening: the Rwanda Population Health Implementation and Training (PHIT) Partnership. BMC Health Serv Res  2013; 13: S5. Google Scholar CrossRef Search ADS PubMed  18 Iyer HS, Kamanzi E, Mugunga JC et al.  . Improving district facility readiness: a 12-month evaluation of a data-driven health systems strengthening intervention in rural Rwanda. Glob Health Action  2015; 8: 28365. Google Scholar CrossRef Search ADS PubMed  19 Donabedian A. The quality of care. How can it be assessed? JAMA  1988; 260: 1743– 8. Google Scholar CrossRef Search ADS PubMed  20 Larson E, Vail D, Mbaruku GM et al.  . Moving toward patient-centered care in Africa: a discrete choice experiment of preferences for delivery care among 3,003 Tanzanian women. PLoS ONE  2015; 10: e0135621. Google Scholar CrossRef Search ADS PubMed  21 Uzochukwu BS, Onwujekwe OE, Akpala CO. Community satisfaction with the quality of maternal and child health services in southeast Nigeria. East Afr Med J  2004; 81: 293– 9. Google Scholar CrossRef Search ADS PubMed  22 Larson E, Hermosilla S, Kimweri A et al.  . Determinants of perceived quality of obstetric care in rural Tanzania: a cross-sectional study. BMC Health Serv Res  2014; 14: 483. Google Scholar CrossRef Search ADS PubMed  23 Chemir F, Alemseged F, Workneh D. Satisfaction with focused antenatal care service and associated factors among pregnant women attending focused antenatal care at health centers in Jimma town, Jimma zone, South West Ethiopia; a facility based cross-sectional study triangulated with qualitative study. BMC Research Notes  2014; 7: 164– 71. Google Scholar CrossRef Search ADS PubMed  24 Nederhof AJ. Methods of coping with social desirability bias: a review. Eur J Soc Psychol  1985; 15: 263– 80. Google Scholar CrossRef Search ADS   25 Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med  2001; 52: 609– 20. Google Scholar CrossRef Search ADS PubMed  26 Kruk ME, Freedman LP. Assessing health system performance in developing countries: a review of the literature. Health Policy  2008; 85: 263– 76. Google Scholar CrossRef Search ADS PubMed  27 Weaver MR, Myaya M, Disasi K et al.  . Routine HIV testing in the context of syndromic management of sexually transmitted infections: outcomes of the first phase of a training programme in Botswana. Sex Transm Infect  2008; 84: 259– 64. Google Scholar CrossRef Search ADS PubMed  28 Ajuwon AJ, Okuribido B, Sadiq GT et al.  . Outcome of interventions to improve the quality of reproductive health services provided by private health facilities in selected states in Nigeria. Afr J Med Med Sci  2006; 35: 369– 74. Google Scholar PubMed  29 Onyango-Ouma W, Laisser R, Mbilima M et al.  . An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool. Health Policy Plan  2001; 16: 24– 32. Google Scholar CrossRef Search ADS PubMed  30 Chimwaza AF, Chimango JL, Kaponda CP et al.  . Changes in clients’ care ratings after HIV prevention training of hospital workers in Malawi. Int J Qual Health Care  2012; 24: 152– 60. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

International Journal for Quality in Health CareOxford University Press

Published: May 15, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off