|Year : 2020 | Volume
| Issue : 2 | Page : 132-137
Maternal satisfaction with services provided in the neonatal step-down ward in a public sector hospital in North India
Raghav Taneja1, Prerna Batra1, Jagdish Sadiza2
1 Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
2 Department of Clinical Psychology, Institute of Human Behavior and Allied Sciences, Delhi, India
|Date of Submission||30-Dec-2019|
|Date of Decision||02-Mar-2020|
|Date of Acceptance||17-Feb-2020|
|Date of Web Publication||21-Apr-2020|
Prof. Prerna Batra
Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Background: Early transfer of baby to mother in step down ward is an approach that can improve maternal satisfaction among parents of neonates admitted in NICU. Objective: To assess the satisfaction of mothers of neonates admitted in the neonatal step down ward of a public sector hospital. Methods: This cross sectional study was conducted in neonatal step down ward of a public sector hospital in North India. One hundred mothers of neonates (< 34 weeks gestation and/or <1800 g birth weight) admitted to the step down ward were included in the study. Mothers of neonates born with major congenital malformations, mothers who were HIV or Hepatitis B positive or had any other chronic illness were excluded. The mothers were interviewed on the day of discharge using a semi-structured questionnaire. It comprised of 35 questions, categorized into 8 domains, namely interpersonal relationships with staff, personal requirements of mother, health services provided by hospital, caregiver proficiency, education and guidance, kangaroo mother care, food provision, and environment of the ward. Maternal satisfaction was marked on a three-point Likert scale. Results: Among the mothers interviewed, a vast majority expressed the utmost satisfaction with the interpersonal relationships with the staff (97.5%). Deficit in satisfaction was observed with the health services (79.57%), and education and guidance by the hospital (78.87%). Conclusion: Neonatal step down set up with early involvement of mother in care of neonates makes mother-baby duo ready for discharge and offers new possibilities for neonatal management in resource-poor countries. Multicentric studies with objectivized outcomes and larger sample size are required for implementing this setup.
Keywords: Maternal satisfaction, neonatal care, neonates, step-down ward
|How to cite this article:|
Taneja R, Batra P, Sadiza J. Maternal satisfaction with services provided in the neonatal step-down ward in a public sector hospital in North India. J Clin Neonatol 2020;9:132-7
|How to cite this URL:|
Taneja R, Batra P, Sadiza J. Maternal satisfaction with services provided in the neonatal step-down ward in a public sector hospital in North India. J Clin Neonatol [serial online] 2020 [cited 2020 Jun 4];9:132-7. Available from: http://www.jcnonweb.com/text.asp?2020/9/2/132/283027
| Introduction|| |
Traditional system of neonatal care includes separation of neonate from its mother in neonatal intensive care unit (NICU), where timely information regarding baby's condition is provided to the parents. The mother's involvement is mostly restricted to the provision of expressed breast milk in NICU and handling babies once or twice a day. Separation of the family from their baby makes them more anxious. There is a delay in parental-neonatal attachment, hampering emotional bonding between mother-baby duo. Mothers feel exhausted, and guilty over abandoned work at home. Hospital readmissions rates are higher due to the family's perception of ill health of the baby. Sankar et al. reported poor parental satisfaction in several aspects, such as parental involvement (77.75% satisfaction) and services offered by the health system (70.25% satisfaction), in traditional NICU care and advised a step toward family-centered care (FCC).
FCC is a team-oriented approach that involves families in the care of neonates requiring NICU care. Families are an active part of understanding and implementing breastfeeding, kangaroo care, and care planning by their limitless presence along their baby. Furthermore, it enables the family members to take care of their neonates with fewer expenses and optimal quality. However, this concept carries its own disadvantages. Finlayson et al. reported little to support the FCC practice as narrated by the mothers. There was apprehension among these mothers who were spending a lot of time in the NICU and constantly witnessing the fragile condition of preterms in NICU. Excessive information can lead to parental confusion, which can decrease confidence in health-care systems, increase anxiety, and eventually decrease parental satisfaction. On the contrary, De Bernardo, et al. showed a better satisfaction and distress level with the FCC system of neonatal care.
In a busy hospital like ours, where 18,000–20,000 deliveries take place per year and NICU is mostly overcrowded, it is difficult to follow the pattern of FCC. Short of it, early transfer of the baby with mother, as soon as the baby is stable and involving mothers and the family in baby's care was found to be an acceptable approach. This helps in the decongestion of NICU, thus providing more focused care to babies needing intensive care and utilizing maternal care for babies as early as possible. We have a step-down unit, where all preterm and very low birth weight (VLBW) babies are shifted once they are hemodynamically stable and no longer need ventilator support. Mothers are involved in gavage feeding of the baby and kangaroo mother care (KMC) under the direct supervision of doctors and nurses. Group sessions are taken daily with mothers with interactive discussions regarding the care of the baby, and their queries are addressed. This also forms a mother support group.
The present study was conducted to assess maternal satisfaction after implementation of this new system of care in step-down ward of NICU in our hospital.
| Materials and Methods|| |
This cross-sectional study was carried out in the step-down ward of NICU of a tertiary care teaching hospital after obtaining clearance from the institutional ethics committee. Mothers of 100 neonates were enrolled as a sample of convenience after fulfilling the inclusion criteria and taking written informed consent.
Mothers of babies with birth weight <1800 g and/or preterms (<34 weeks gestation) were enrolled in the study. Gestation was calculated by following either the last menstrual period and/or Ballard's score. If a disparity of >2 weeks was found between the above two methods, then the Ballard score was taken as final. Mothers of neonates born with major congenital malformations, mothers who were HIV or hepatitis B positive or had any other chronic illness were excluded from the study.
Mothers were interviewed by the investigator using a semi-structured questionnaire. The interview was conducted on the day of discharge and was recorded and analyzed. A case record form containing demographic details, including the baby's age, gender and gestational age, educational status, and socioeconomic status of the mother was filled.
Development of questionnaire
A semi-structured questionnaire was prepared, which included 35 questions, categorized into eight domains, namely interpersonal relationships with staff, personal requirements of the mother, health services provided by the hospital, caregiver proficiency, education and guidance, KMC, food provision, and environment of the ward. Maternal satisfaction was marked on a three-point Likert scale as 0, 1 or 2, with 0 corresponding to “not at all satisfied,” and 2 corresponding to “completely satisfied.” The responses of mothers who did not have any experience with the concerned questionnaire were recorded as not applicable.
A pilot work was conducted on 10 mothers, and responses were video recorded. Modifications were made based on suggestions made by the clinical psychologist.
Descriptive statistics were applied for data analysis. Open-ended responses were described using percentages.
| Results|| |
Out of 100 mothers interviewed, 39 were primiparous. Majority of the mothers (90/100) were housewives. Approximately one fourth (28/100) were illiterate, whereas almost half (52/100) were educated till school. Sixty out of hundred belonged to lower- and upper-middle status as per Kuppuswamy's scale. All babies were singletons, with 50 females.
Responses of all the interviewed mothers with respect to individual questions in all eight domains are given in [Table 1].
|Table 1: Responses of the interviewed mothers with respect to individual questions in the eight domains|
Click here to view
Interpersonal relationships with hospital staff
Attitude, information, attention, means, and efficacy of communication constitute the interpersonal relationships between the staff and the mothers. About 97.5% maternal satisfaction was observed in this domain. Primiparas stated that they were nervous at first, but their anxiety was addressed well by the doctors and nurses with thorough explanations. Some mothers complained that the staff ought to be more courteous and polite toward them.
Personal requirements of the mother
Most often, mothers raised the issue of visits by relatives permitted by the hospital. Free movement of relatives inside the ward is restricted due to the risk of infection. This was a major cause of dissatisfaction. It was observed that literate women understood that this restriction was for the safety, sanitation, and sterility of the ward. Formula milk was readily available for mothers who were having difficulty lactating. Few mothers complained about the unavailability of diapers in the ward, and they had to buy these.
The issue of privacy was also reported as male support staff at times entered the rooms without knocking, making them uncomfortable. Some felt that they were kept for an unnecessarily longer duration and were unhappy about the delayed discharge.
Health services provided by the hospital in step-down ward
Nearly all mothers were content with the round-the-clock presence of nurses in the ward. However, 23 of them advocated the need for an elaborate evening doctor round also. Even though medications for babies were readily delivered to their beds, mothers were despondent about the fact that they had to leave their children to collect their own medicine from the obstetrics ward. Better coordination from the obstetrics department was required.
The investigation results and reports were not shown to the mothers and were directly sent to the doctors. It was observed that literate women wanted to see the reports themselves, whereas others felt that seeing them would aggravate their anxiety. Occasionally, delay in investigation reports caused a delay in discharge from the ward.
Babies of four mothers did not require any investigations and have been included under the “NOT APPLICABLE” column.
The policy of bedding-in is practiced in the step-down ward, and radiant warmers are kept only for extremely low birth weight babies, who had difficulty in maintaining temperature. In most rooms, there was a single radiant warmer, while there were none in a few. Mothers perceived this as a lack of mandatory care of neonates and were unhappy about this aspect. Frequently, there have been complaints about the lack of hot water, and sometimes, a complete shortage of water.
The mothers were overall satisfied with the care provided in the step-down ward. Some women found it better than NICU where they were not permitted to stay with their babies.
Nine babies faced emergency situations in the step-down ward. They were first stabilized in the ward itself and then transferred to NICU for further management. Four out of nine mothers were unsatisfied. They felt that the baby should not have been shifted out of NICU till the time it was absolutely fine. There were 13 cases in which the baby had to be transferred to the NICU due to maternal emergencies. The mothers were satisfied with the mode of transportation of their babies from the ward to NICU. More than half of the babies required gavage feeding, which was conducted hassle-free.
Education and guidance
All the mothers were adequately assisted in the transition from gavage feeding to Katori feeding technique. Eight women were uninformed about temperature assessment and danger sign identification, while more than a third of them were not briefed about follow-up in the ophthalmology department for retinopathy of prematurity (ROP).
Only 27 mothers were completely satisfied with the discharge and follow-up advice.
Kangaroo mother care
Other than the eleven mothers who claimed that they were not notified about the daily group counseling sessions held in the ward, nearly all the women were completely satisfied in all aspects. Fourteen of them wanted the classes to be held twice daily, as they believed it would benefit the women who were admitted in the afternoon.
All mothers, except one, availed food provided in the ward. More than half of them felt that the menu hardly changed and that they were being fed the same things repeatedly. However, they were satisfied with the quality, quantity, and nutritional value of the food. There were multiple complaints about the chapatis (bread) being unsatisfactory as they felt they made it differently at home.
Some of them wanted salt and sugar according to their preference. A few of them wanted more milk than that was being given to them.
Environment of the ward
The mothers were very happy about the cleanliness of the ward except the occasional presence of flies and mosquitoes. Eighty-three percent were satisfied with the temperature maintained inside the ward. Some believed that the number of beds could be increased in some of the rooms as they felt lonesome at times.
Mean (standard deviation) of satisfaction and percentage satisfaction was calculated in each domain, as shown in [Table 2]. Maximum satisfaction was seen in interpersonal relationships with hospital staff, whereas health services provided by the hospital and education and guidance to the mothers, especially follow-up for ROP and other follow-up advice were least satisfactory.
|Table 2: Mean (standard deviation) of satisfaction and percentage satisfaction in each domain|
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| Discussion|| |
In the present study, a high maternal satisfaction was observed in most of the domains, namely, interpersonal relationship, personal requirements of the mother, caregiver proficiency, KMC, food provision, and environment step-down ward. The satisfaction level was found to be slightly low in aspects of health services provided by the hospital, education, and guidance.
Birth of a child is a stressful experience for the mother. Moreover, when she is made aware of the fact that her baby requires special attention due to some reason, the distress escalates. The baby requires to be placed in a specialized environment where it can receive all the care it needs. This isolation immediately after birth creates a feeling of frustration and dissatisfaction among mothers. Some of the parents, though express gratitude for the skilled staff and new technologies that saved the lives of their babies; others were not content with the way they and their babies were treated in the NICUs. Chourasia et al. analyzed maternal stress factors in NICU set up and observed that the major stressors among mothers were “not feeding baby myself” and “feeling helpless about how to help my baby.” Lack of privacy, provision of a structured feeding schedule, exhaustion, and anxiety were the factors that affected maternal breast milk supply adversely during neonate's NICU stay. Factors that are likely to provide lactation support and direct breastfeeding were shown to improve satisfaction among mothers. FCC is increasingly being identified as an approach to healthcare that recognizes the importance of the family to a patient's recovery. It also defines the responsibilities of the health-care team to provide support for families of seriously ill patients. Parental involvement in the care of the baby is an extension of the concept to NICUs. It carries the advantage of alleviating the parent's apprehensions and improves the confidence to provide postdischarge care to these babies, thereby reducing re-hospitalization rates. Reis et al. reported consistency and continuity of health-care providers improved health-care provider relationship with parents and established an effective communication. Family-centered care has the potential to take care of these aspects. Weiss et al. by performing a three-step intervention in NICU, showed that establishing effective communication with the parents and informing them about their infants and the required care can result in increased satisfaction (P < 0.01).
Other advantages of FCC for health organizations include less cost, due to shortening the duration of hospitalization, decreasing the prevalence of infections, and re-hospitalization rates. In resource-limited countries like India FCC can be a practice that can be utilized to improve care, increase professional satisfaction and decrease litigation charges apart from decreasing costs and effective utilization of resources. In a comparative study between FCC and non-FCC group, De Bernardo et al., reported greater satisfaction in the FCC group with respect to timely and appropriate information, while it was comparable in ability to communicate with health-care workers. They felt satisfied with concern for their privacy owing to the private rooms made available to them to discuss diagnoses and therapies. Although both the groups felt stressed, the level of stress was lower in the FCC group.
On contrary to the popular belief among clinicians regarding FCC, Finlayson et al. did not find much to support it in mother's narratives. They emphasized the importance of staff-mother interactions to facilitate the mother's role as a primary caregiver in NICU.
Health-care providers have a lack of understanding and implementing the concept of the FCC model in clinical practice. A systematic review by Shields et al. could not draw definite conclusions regarding the efficacy of FCC and suggested the need for a more effective model.
This model of care of preterm and VLBW babies that involves the early transfer of babies with mothers can provide a middle path between traditional NICU care and FCC. Parents are prepared to take care of the needs of low birth weight babies under direct supervision and made ready for discharge. Babies are discharged once they start showing consistent weight gain, on full volume cup feed or breastfeeding, have no acute problem, and the mother is ready for discharge.
A similar system plan was implemented by Erdeve et al. in Thailand. In the case group, the infants and their mothers were admitted to a private room in the hospital, involving the mother in the care of her baby, while the control infants were admitted to NICU, and the mothers were not active participants in the baby's care. The results showed that the number of readmissions and acute care visits were significantly decreased in the intervention group. Bhutta et al. showed that the length of stay and hospital-acquired infections in the step-down unit were significantly decreased in infants whose mothers had provided all major nursing care before discharge. Mother in Neonatal ICU is another model that has been started recently in India seems to be a promising strategy, though comparative results with the traditional system of FCC are required. The limitation of this study is the lack of control to compare with the traditional system. More objective outcomes in the form of the duration of hospital stay, weight at discharge and in follow-up, sustained breastfeeding rates and readmission can provide further insight into the success of this system of care.
| Conclusion|| |
Early transfer of neonates after stabilization in the NICU led to high maternal satisfaction rates. Further studies, if show consistent results, can help in implementing this policy in resource-limited countries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fishering R, Broeder JL, Donze A. A qualitative study: NICU nurses as NICU parents. Adv Neonatal Care 2016;16:74-86.
Erdeve O, Arsan S, Yigit S, Armangil D, Atasay B, Korkmaz A. The impact of individual room on rehospitalization and health service utilization in preterms after discharge. Acta Paediatr 2008;97:1351-7.
Sankar V, Batra P, Saroha M, Sadiza J. Parental satisfaction in the traditional system of neonatal intensive care unit services in a public sector hospital in North India. South Afr J Child Health 2017;11:54-7.
Ramezani T, Hadian Shirazi Z, Sabet Sarvestani R, Moattari M. Family-centered care in neonatal intensive care unit: A concept analysis. Int J Community Based Nurs Midwifery 2014;2:268-78.
Coughlin M, Gibbins S, Hoath S. Core measures for developmentally supportive care in neonatal intensive care units: Theory, precedence and practice. J Adv Nurs 2009;65:2239-48.
Finlayson K, Dixon A, Smith C, Dykes F, Flacking R. Mothers' perceptions of family centred care in neonatal intensive care units. Sex Reprod Healthc 2014;5:119-24.
De Bernardo G, Svelto M, Giordano M, Sordino D, Riccitelli M. Supporting parents in taking care of their infants admitted to a neonatal intensive care unit: A prospective cohort pilot study. Ital J Pediatr 2017;43:36.
Chourasia N, Surianarayanan P, Adhisivam B, Vishnu Bhat B. NICU admissions and maternal stress levels. Indian J Pediatr 2013;80:380-4.
Alves E, Rodrigues C, Fraga S, Barros H, Silva S. Parents' views on factors that help or hinder breast milk supply in neonatal care units: Systematic review. Arch Dis Child Fetal Neonatal Ed 2013;98:F511-7.
Gianni ML, Bezze EN, Sannino P, Baro M, Roggero P, Muscolo S, et al
. Maternal views on facilitators of and barriers to breastfeeding preterm infants. BMC Pediatr 2018;18:283.
Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, et al
. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med 2017;45:103-28.
Reis MD, Scott SD, Rempel GR. Including parents in the evaluation of clinical microsystems in the neonatal intensive care unit. Adv Neonatal Care 2009;9:174-9.
Weiss S, Goldlust E, Vaucher YE. Improving parent satisfaction: An intervention to increase neonatal parent-provider communication. J Perinatol 2010;30:425-30.
Shields L, Zhou H, Pratt J, Taylor M, Hunter J, Pascoe E. Family-centred care for hospitalised children aged 0-12 years. Cochrane Database Syst Rev 2012;10:CD004811.
Bhutta ZA, Khan I, Salat S, Raza F, Ara H. Reducing length of stay in hospital for very low birthweight infants by involving mothers in a stepdown unit: An experience from Karachi (Pakistan). BMJ 2004;329:1151-5.
Chellani H, Mittal P, Arya S. Mother-neonatal intensive care unit (M-NICU): A novel concept in Newborn Care. Indian Pediatr 2018;55:1035-6.
[Table 1], [Table 2]