To Evaluate the Perceptions of Quality of Care and Driver's of Women's Decisions About Institutional Delivery at LifeSpring Hospital, Hyderabad
Background: The Millennium Development Goals (MDG) 4 and 5 of the United Nations has set the target of reducing maternal deaths to 109 per 100,000 live births and infant deaths to 27 per 1000 live births level by 2015 respectively. India reported an MMR 212 per 100,000 live births in 2007-2009 and a neonatal mortality rate (NMR) of 32 per 1000 live births in 2010 accounting for more than 20% of maternal deaths and 25% of neonatal deaths globally respectively. Unless issues such as reduction in delay in reaching the appropriate health facility in time and receiving care for obstetric and neonatal complications before, during and after childbirth such as infections and premature birth, are addressed, India is unlikely to achieve the MMR and NMR reduction targets by 2015 as envisaged in the MDGs. To a large extent the accessibility and utilization of reproductive and child health services play an important role in determining the extent of both maternal and neonatal mortality. More than 80% of maternal and neonatal deaths can be prevented through increasing institutional deliveries and by improving the quality of healthcare provided to the women and the newborn babies. Over the past few decades, reduced government spending on public healthcare services and its consequent deterioration has led to a gradual shift in patient volume towards the rapidly expanding private health services in India. Therefore a highly competitive environment makes it necessary for private healthcare services to measure and respond to patient expectations by incorporating their views into quality of health service assessments. Studies like Alden et al. (2004) among working and lower middle income women in urban reproductive health clinics in Vietnam, found that patient perception of quality of services is positively and significantly associated with both reutilization of services and recommendation of the facility to others. While several studies such as the Rao et. al study (2006) and the Kumari et. al study (2009) in government health facilities in India have identified aspects of patient perception of quality of care that impact patient satisfaction, there has been very little research on aspects of patient perception of quality of reproductive healthcare and its impact on decisions to reutilize services. This study is designed to fill this knowledge gap.
Methods: This study, descriptive and cross-sectional using a survey methodology was administered in five branches of Life Spring Hospitals, a chain of 12 private, for-profit maternity hospitals providing prenatal, perinatal and postnatal care to women in Hyderabad, India. It examined associations between patient perception of various components of the quality of care and predisposition for using the facility for a future delivery. The specific components of quality of care within facilities included cleanliness, availability of modern diagnostic equipment, technical and interactive skills of doctors and clinic staff. The study also tried to compare these associations between patients presenting for prenatal, perinatal and postnatal care.
Results: 72% of survey respondents were between the age group of 18 to 25 years, 97% had some level of formal education, that is, school level (up to 12th grade) or university level (graduate or beyond), 75% had a household income of less than or equal to10,000 INR per month and 80% of respondents had a previous child, of which, 64% had delivered at LifeSpring Hospitals. The probability of choosing LifeSpring Hospitals for a previous delivery among respondents receiving prenatal care varied significantly by main reason for choice of facility (cost = 66.67%, proximity to home = 50% , facility environment = 15.79%) (p < 0.05*), among respondents receiving postnatal care by age (18 to 25 yrs = 91.30% , = or > 26 yrs = 64.71%) (p < 0.05*). Among overall respondents indicating a predisposition for LifeSpring Hospitals for a future delivery, the mean score of a composite of overall perception factors (facility cum interactive perception factors) (LifeSpring Hospitals = 3.570 and Others = 3.156) (p < 0.05*), facility perception factors (LifeSpring Hospitals = 3.193 and Others = 2.555) (p < 0.05*) and interaction perception factors (LifeSpring Hospitals = 3.793 and Others = 3.517) (p < 0.05*) was significantly higher compared to those who reported a predisposition for other facilities. Among respondents receiving perinatal care, indicating a predisposition for LifeSpring Hospitals for a future delivery, the mean score of a composite of overall perception factors (facility cum interactive perception factors) (LifeSpring Hospitals = 3.636 and Others = 3.313) (p < 0.05*) and facility perception factors (LifeSpring Hospitals = 3.256 and Others = 2.333) (p < 0.05*) was significantly higher compared to those who reported a predisposition for other facilities. Among respondents receiving postnatal care, indicating a predisposition for LifeSpring Hospitals for a future delivery, the mean score of a composite of overall perception factors (facility cum interactive perception factors) was significantly higher compared to those who reported a predisposition for other facilities (LifeSpring Hospitals = 3.531 and Others = 3.078) (p < 0.05*).
Discussion: Age, income level, education level, parity, perception of charges and reasons such as cost, proximity to home and facility environment (including a specific doctor at the facility, treatment by the staff and the quality of equipment available at the facilities) do not appear to be important drivers of patient's decision to deliver at LifeSpring Hospitals in the future. However, patient perception of LifeSpring's facilities (including waiting time, crowding and outpatients hours) and interactive skills of staff (including length of consultation time, explanation of tests, staff dynamics, comfort level with advice and patient inclusion in decision making) appear to be important drivers of women's decision to deliver at LifeSpring Hospitals in the future.
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