Introduction
Pregnancy is a unique experience for each mother. The ultimate goal for the mother and her healthcare providers is to have a safe and desirable experience [1]. This includes giving birth without complications for the mother and her baby. However, undesired complications may occur during pregnancy, labor, or after delivery. These complications can be mild, moderate, or in some cases, severe enough to threaten the mother’s or baby’s lives [2-5].
Globally, >270000 maternal deaths, 3.3-4 million neonatal deaths, and 2.6 million third trimester stillbirths occur annually [6]. According to the World Health Organization (WHO), about 830 women die from pregnancy- or childbirth-related complications around the world per day [7]. To curb this high mortality rate, the WHO recommends providing skilled care during pregnancy, childbirth, and the immediate postnatal period [8]. Providing timely and high-quality post-delivery care could help prevent/minimize the development of several complications [5].
The postnatal period is highly critical, as most maternal and newborn deaths occur during this time [9, 10]. Despite its importance, it is the most neglected period for providing quality services [11, 12]. According to some studies, providing quality services during the postnatal period is unrecognized and rated as a low priority compared to other maternity care aspects [13, 14]. Moreover, a study conducted in 30 low-income countries reported that 7 out of 10 women received no postnatal care [15]. In Palestine, the case quality was not much better, as only 23%-34% of women received postpartum care [16, 17]. Two more recent studies revealed slight improvements [18, 19].
As mentioned in the previous reports, postnatal care is neglected and often does not meet women’s postpartum health needs [20, 21] {Berhe, 2016 #324}. This may lead to long-term health complications [22]. Most maternal and newborn deaths occur during this time [5, 23]. Approximately two-thirds of maternal deaths occur after delivery [24]. Fifty five percent of maternal deaths in Palestine occurred during the postpartum period [25, 26]. Therefore, focusing on improving access to quality postnatal care is crucial to reduce morbidity and mortality rates among the mother and the newborn [27].
In an attempt to improve the quality of postpartum care, reduce postpartum complications, and ensure women’s bio-psychological health, the WHO recommends healthcare should be provided at 6 hours, 6 days, 6 weeks, and 6 months post-delivery [10].
Women living in the Gaza Strip receive almost free-of-charge antenatal and postnatal care. Because of the crowdedness of maternity departments, uncomplicated cases are usually discharged within few hours after labor. Early discharge can affect the quality of postnatal care; thus, endangering women’s lives. The quality of care in the postnatal period and the quality of antenatal care have been explored in several countries and the Gaza Strip [28], respectively. However, studying the quality of postnatal care has been overlooked in the Gaza Strip. Therefore, this study aimed to determine the perceptions of Palestinian women living in the Gaza Strip about the quality of care they receive in the early postpartum period.
Materials and Methods
This study used an analytical cross-sectional design. The study population comprised all women admitting to postnatal departments after delivery at state hospitals in the Gaza Strip, Palestine. A great majority of deliveries occur at the state hospitals. Therefore, the setting for this study included all 4 state hospitals in the Gaza Strip with postnatal departments. These hospitals were geographically distributed to cover all clients over the Gaza Strip.
A convenience sample of 200 participants was used in this study. Inclusion criteria included women aged ≥18 years, give birth at one of the 4 state hospitals in the Gaza, and being admitted to postnatal departments, regardless of the delivery type (vaginal delivery vs. cesarean section). Women who required emergency interventions or were transferred to the Intensive Care Unit (ICU) were not involved in the study.
After reviewing the literature, the researchers developed a self-administered questionnaire to conduct this study. The questionnaire consisted of two parts. The first part covered demographic data and obstetric history. The second part consisted of 32 items investigating the study participants’ perception about the provided postnatal care in 4 domains; postnatal care provided by midwives (8 items), postnatal baby care (10 items), health education (10 items), as well as communication and psychological support (4 items). The items are rated on a 5-point Likert-type scale (1=completely disagree to 5=strongly agree).
To ensure the content validity of the instrument, it was reviewed by 5 experts in the field who suggested slight modifications. After modifying the instrument, it was pilot tested on a sample of 30 women who met the inclusion criteria and were randomly selected from the targeted hospitals. The data obtained from these clients were excluded from the study. Slight modifications were conducted on the wording of some items in response to the participants’ comments to make the instrument more user-friendly. The instrument was highly reliable, with a Cronbach’s alpha coefficient of 0.928 for the whole scale.
The required data were collected by 5 trained female nurses who were not involved in patient care. Each questionnaire has a front sheet that explains the study purpose and a consent form for the participants to sign. The obtained data were analyzed in SPSS V. 22. Descriptive statistics, Analysis of Variance (ANOVA), and Independent Samples t-test were used to analyze the acquired data. These analyses used a 95% confidence interval and a significance level of 0.05.
Results
The socio-demographic characteristics and the obstetric history of the participants are presented in Table 1. The achieved results revealed that 174 (87%) of study participants were ≤36 years, 95 (47.5%) of them had secondary education or less, while only 4 (2%) participants reported post-graduate education levels.
The number of pregnancies among the study participants ranged between one and 14, while the number of deliveries ranged between one and 12. Only 13 (8.69%) women were multiparas. The range of giving birth to an alive child was one to 12 children, and the frequency of abortions ranged between one and 6 times. During delivery, 51 (25.5%) of the study participants experienced complications. The most common complication reported by the study participants was postnatal hemorrhage, which was encountered by 34 (17%) individuals.
The participants’ perception regarding the quality of postnatal care was measured in 4 main domains. The overall Mean±SD scores for all domains of the scale were 3.93±0.66, from a maximum possible score of 5, which is above the neutral point of 3.
Table 2 illustrates the frequency, mean, standard deviation, and percentage values of positive responses reported by the study participants related to their perception of the 4 domains on the quality of postnatal care. All scores for the 4 domains were above the neutral point of 3 with the domain related to the quality of postnatal care provided by midwives receiving the highest Mean±SD score of 4.16±0.6. Moreover, a positive response to the great majority of items was high, reflecting positive perception about provided postnatal care.
The collected results revealed that several factors, such as the age category of participants, family income, gravidity, parity, having an abortion or not, and delivery type did not affect the study participants’ perception about the quality of postnatal care. However, the level of education (Table 3) and hospitals where the delivery took place (Table 4) significantly affected the total mean score.
Discussion
The study results revealed that women rated their care positively. The demographic characteristics and obstetric history of the study participants are similar to those of other studies conducted in Palestine and the Gaza Strip [18, 29, 30]. For example, most of the samples in the study by Al Najjar [30] were within the same age group as ours and had a relatively low level of education (secondary school or less); they also indicated similar results concerning the frequency of parity and abortions. The cesarean section rate was less than that of our study.
Nevertheless, cesarean sections rate reported in this study were similar to those reported by the Palestinian Central Bureau of Statistics [31]. The rate of normal vaginal delivery and complications among the study participants were similar to those of Dhaher and Mikolajczyk [18]. The most prevalent postnatal complication reported in our study was hemorrhage. This was also reported in other studies [5, 26], as the most common cause of maternal mortality in the Gaza Strip.
The study participants rated the postnatal care they received as high. Such a high percentage of positive responses was similar to those of other studies in the Netherlands [32], Iran [33], and Australia [34, 35]. However, some results from other countries (especially developing countries) revealed contradicting data in this regard. For example, a study conducted in Malawi [36] indicated that the structure for providing postnatal counseling services was inappropriate and inadequate. Furthermore, the contents of postnatal services were below reproductive health standards as clients were neither monitored nor examined physically at discharge. A study in South Africa revealed that the participants who delivered vaginally were usually left alone to take care of themselves, and nurses were too busy to listen to them [20].
Despite high scores in all of the domains and most of the items, some items received relatively low scores and low positive responses, especially in the domains ‘postnatal health education’ and ‘communication and psychological support.’ These include items related to providing education on family planning, postnatal exercise, breast care, and vaccination program to the baby within the domain of ‘postnatal health education.’ The domain related to “communication and providing psychological support” received the lowest score and lowest positive responses. Providing emotional and psychological care was identified as an essential component for quality postnatal care [34, 37].
Our findings were in-line with numerous studies concerning a lack of care provision, like care provided by midwives to their clients [20, 33, 34, 37-40]. These results were expected within the context of the very busy work environment of the postnatal departments in the Gaza Strip. The high workload of the postnatal departments seems not to be unique to the Gaza Strip. Participants in other studies reported that midwives were ‘difficult to contact,’ ‘had no time to listen’ [20, 33], ‘too busy,’ ‘were unavailable’ [13, 20, 21, 34, 35], or were ‘rushed in the postnatal period’ [41], which resulted in inconsistent advice [41] and inconvenient or low-quality care. The chaotic nature of postnatal care forces midwives to reset their priorities to meet the short-term (physical) needs of their clients rather than meeting the individual needs of each client [34, 42], including psychological aspects.
In our study, two factors impacted the study participants’ perception of the quality of provided postnatal care. These included the level of education and the birth hospital. Other variables, such as the number of pregnancies, parity, a history of abortion, delivery type, the frequency of complications, age, and family income had no effect on their perceptions about the quality of postnatal care. The literature suggested consistent or contradictory data to ours. For example, in this study, there were no differences between the study participants’ perceptions about the quality of postnatal care and variables related to parity, age, delivery type, the frequency of complications, economic status, and the number of children. Similarly, Mirzaei, [33] reported no significant association between the level of participants’ satisfaction with postnatal care and parity, age, and the number of children. Additionally, Wiegers [32] reported that parity did not influence the rating of participants about the quality of received postnatal care.
This contradicts other studies that reported that first-time mothers had rated the quality of received postnatal care more negatively, compared to multiparous participants [34]. This sounds logical, as first-time mothers lack the experience of giving birth. They are more apprehensive and afraid of the unknown, which may affect their perception of the quality of postnatal care.
Our study had a few limitations. Due to limited financial resources, the authors used a convenience sample of 200 participants only, which limits the generalizability of the obtained results. Our findings revealed that the study participants perceived postnatal care provided in the Gaza Strip to be relatively high. However, there were some defects in some areas. The deficits were noticed in aspects of postnatal education, communication, and psychological support provision. These defects could be related to understaffing and the high workload of maternity departments in the Gaza Strip.
The challenge for healthcare policymakers and professionals working in maternity departments is to act appropriately upon these findings. Maternal care in general and postnatal care in particular, in the Gaza Strip needs urgent attention. Policy and leadership directions are required in this critical, vulnerable clinical area. To improve the quality of postnatal care, health policymakers must cooperate with midwifery staff to identify and eliminate barriers that impede providing better care. This will be evidenced by the reduction of maternal and neonatal morbidity and mortality rates, decreasing number of hospitalization days, and reduced costs of hospitalization and related healthcare expenditures.
Ethical Considerations
Compliance with ethical guidelines
Before starting the study, ethical approval to conduct the study was obtained from the Research Ethics Committee at the Islamic University of Gaza. Then, the research protocol was approved by the Ministry of Health. The study participants were requested to sign an informed consent that was included on the first page of the questionnaire. The consent states the purpose of the study as well as the voluntary nature of participation and confidentiality of the information gathered. The study participants were advised that they have the right to refuse to participate in the study, which will not affect the care they receive.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors contributions
Concepts, design, manuscript preparation: Areefa Alkasseh, Samar Mwaafy Samaneh; Literature review and statistical analysis: Nasser Abu-El-Noor and Mysoon Abu-El-Noor; Designing, reviewing the questionnaire, and manuscript review: All authors.
Conflict of interest
There are no conflicts of interest to be declared.
Acknowledgements
The research team would like to thank the directors of the hospitals where participants were recruited from for their cooperation and easing the process of data collection. Many thanks to the head nurse for each postnatal department in each hospital.
References
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