NEC Client Satisfaction of antenatal care service

CLIENT SATISFACTION OF ANTENATAL CARE SERVICE IN HEALTH CENTERS IN WET-LET TOWNSHIP, MYANMAR NWAY EINT CHEI A THEMATIC PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PUBLIC HEALTH FACULTY OF GRADUATE STUDIES MAHIDOL UNIVERSITY 2017 COPYRIGHT OF MAHIDOL UNIVERSITY iii ACKNOWLEDGEMENTS I would first like to express my deepest sincere appreciation and heartfelt gratitude to my major advisor, Assoc. Prof. Dr. Nawarat Suwannapong for her times and energy spent in reviewing, advising, correction and mindfulness throughout the whole process of this study until it has been printed eventually. The door to her office was always open whenever I ran into a trouble spot or had a question about my research or writing. She consistently allowed this paper to be my own work, but steered me in the right the direction whenever she thought I needed it. I would also like to give my sincere thanks and appreciation to my co-advisor Assoc. Prof. Dr. Mathuros Tipayamongkholgul for her careful guidance, kind attention, advice and suggestions throughout the research. Next, I would like to give my special thanks to my discussant, Dr. Thitipat Rajatanum for his very valuable comments on this thematic paper. I am very grateful to Dr. Aye Lwin (Township Health Officer), Wet-Let Township hospital, Sagaing Region and his wife for their patience, interest and help throughout this research. I would also like to give my appreciation to the health volunteers for their effort in helping me during data collection. In addition, I would like to give my great thanks to the respondents in this study, pregnant women for sharing their time and experience. I also wish them a good and prosperous life. In addition, I would like to give my sincere thanks to the Dean, the teachers and all of staff in Faculty of Public Health, Mahidol University. Moreover, I will remember the kindness and helpfulness of professors and lecturers for their guidance, help and support to all students throughout our studies in Thailand. The comprehensive knowledge I gained during my one-year study in Bangkok is very useful for me to take back to my home country for application. Furthermore, I would like to special thanks Assoc. Prof. Kulaya Narksawat for supporting my studying and my friends for their supportive relationship. Additionally, it is my honor to receive supports from my beloved family as well as my parents for a long time when I was far away from home country. Finally, I must express my very profound gratitude to my special one, Dr. Ye` Hein for his effort in helping me during the time of data collection and also my study period. I want to express my special thanks to them for their love and encouragement. Even though I failed to mention some names on this page, I dedicated this paper to all those people who helped me and supported me throughout this research. Nway Eint Chei Fac. of Grad. Studies, Mahidol Univ. Thematic paper / iv CLIENT SATISFACTION OF ANTENATAL CARE SERVICE IN HEALTH CENTERS IN WET-LET TOWNSHIP, MYANMAR NWAY EINT CHEI 5936924 PHMP/M M.P.H. THEMATIC PAPER ADVISORY COMMITTEE: NAWARAT SUWANNAPONG Ph.D., MATHUROS TIPAYAMONGKHOLGUL, Ph.D. ABSTRACT Client satisfaction is an important commonly used indicator for measuring the quality of health care service. Wet-Let Township was affected by cyclone Komen floods in July and August 2015. Despite the efforts by the stakeholders and policy makers to improve the quality of antenatal care services, there still were major challenges in the service quality which required ensuring holistic work performance. Therefore, this cross-sectional study aimed to assess the client satisfaction with antenatal care service in the health centers in Wet-Let Township and to analyse the associations among general characteristics, antenatal care service quality, accessibility to antenatal care service and client satisfaction among pregnant women. Data were collected from 246 pregnant women at the health centers using a questionnaire and interview. Descriptive statistics and chi-square were used for data analysis with the level of significance set at p<0.05. The results showed that 80.1% of the pregnant women had moderate and 17.5% had low satisfaction levels while 78.9% had low level of overall antenatal care service quality. Chi-square test revealed that four variables: education, parity, antenatal care service quality and accessibility, were associated with the client satisfaction (p<0.05). To improve the satisfaction of pregnant women, authorities have to enhance the quality of antenatal care service by providing patient-centered care, development of the standards and accompanying guidelines, reducing the prolonged waiting time with the aid of advanced technology, coordination with nongovernmental organization and stakeholder for geographic prioritization and encouraging community involvement. KEY WORDS: CLIENT SATISFACTION/ ANTENATAL CARE SERVICE/ HELATH CENTERS/ MYANMAR 116 pages v CONTENTS Page ACKNOWLEDGEMENTS iii ABSTRACTS iv LIST OF TABLES viii LIST OF FIGURES ix LIST OF ABBREVIATIONS x CHAPTER I INTRODUCTION 1 1.1 Rationale and background 1 1.2 Objectives 5 1.3 Hypotheses 6 1.4 Variables of the study 6 1.5 Operational definitions 6 1.6 Conceptual framework 9 CHAPTER II LITERATURE REVIEW 10 2.1 Client satisfaction 10 2.2 Health service system in Myanmar 15 2.3 Antenatal care service quality 16 2.4 Accessibility to antenatal care service 22 2.5 Wet-Let Township, Myanmar 24 2.6 Related studies 26 CHAPTER III MATERIALS AND METHODS 32 3.1 Research design 32 3.2 Study site and study population 32 3.3 Sample size calculation 33 vi CONTENTS (cont.) Page 3.4 Sampling procedure 34 3.5 Research instrument 34 3.6 Data collection 35 3.7 Content validity and reliability 36 3.8 Data analysis 36 3.9 Ethical consideration 37 38 CHAPTER IV RESULTS 4.1 General characteristics 38 4.2 Level of client satisfaction, service quality and accessibility 40 4.3 Antenatal care service quality 41 4.4 Accessible to antenatal care service 47 4.5 Client satisfaction of pregnant women 51 4.6 Associations between general characteristics and client 53 Associations between antenatal care service quality and client 55 satisfaction 4.7 satisfaction 4.8 Associations between accessibility to antenatal care service and 55 client satisfaction CHAPTER V DISCUSSION 58 5.1 Client satisfaction on antenatal care service at health centers 58 5.2 General characteristics and client satisfaction 60 5.3 Antenatal care service quality and client satisfaction 62 5.4 Accessibility to antenatal care service and client satisfaction 64 vii CONTENTS (cont.) Page CHAPTER VI CONCLUSION AND RECOMMENDATIONS 66 6.1 Conclusion 66 6.2 Recommendation for the implementation 67 6.3 Recommendation for further studies 69 REFERENCES: 70 APPENDICES 79 Appendix A Questionnaire – English version 80 Appendix B Questionnaire – Myanmar version 91 Appendix C Certificate of approval ethical review committee 103 Appendix D Information sheet – English version 104 Appendix E Information sheet – Myanmar version 108 Appendix F Informed consent form – English version 112 Appendix G Informed consent form – Myanmar version 114 BIOGRAPHY 116 viii LIST OF TABLES Table Page 3.1 Possible scores and classification of all study variables 37 4.1 General characteristics of 246 pregnant women 39 4.2 Level of client satisfaction, service quality and accessibility of 246 41 pregnant women 4.3 Antenatal care service quality of 246 pregnant women 44 4.4 Accessibility to antenatal care service of 246 pregnant women 48 4.5 Client satisfaction towards antenatal care service of 246 pregnant 51 women 4.6 Associations between general characteristics to antenatal care service 54 and client satisfaction 4.7 Associations between level of antenatal care service quality and client 55 satisfaction 4.8 Associations between level of accessibility to antenatal care service and client satisfaction 56 ix LIST OF FIGURES Figure 1.1 Page Conceptual framework of Client Satisfaction of Antenatal Care 9 Service in Health Centers in Wet-Let Township, Myanmar 2.1 SERVQUAL Model 13 2.2 Map of Wet-Let Township 26 x LIST OF ABBREVIATION ANC Antenatal Care ASEAN Association of Southeast Asian Nations BHS Basic Health Staff HA Health Assistant HCP Health Care Personnel IEC Information, Education and Communication IMR Infant Mortality Rate LHV Lady Health Visitor MCH Maternal and Child Health MDGs Millennium Development Goals NICE National Institute for Health and Clinical Excellence PHC Primary Health Care PHS Public Health Supervisor RHC Rural Health Centers SDGs Sustainable Development Goals TMO Township Medical Officer TBAs Traditional Birth Attendants U5MR Under 5 years Mortality Rate UN United Nations WHO World Health Organization Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 1 CHAPTER I INTRODUCTION 1.1 Rationale and Background Millennium Development Goals (MDGs) was set at 1990 and related targets for realization 2015. MDGs are the world's time-bound and quantified targets for tackling extreme poverty in its many dimensions such as income poverty, hunger, disease, lack of adequate shelter and exclusion when promoting gender equality, education and environmental sustainability. They are basic human rights in the world to health, education, shelter and security (1). An important framework for development and significant progress is provided by these goals. However by the year 2015, most of the developing countries were not still achieving to meet some of the MDGs especially in maternal, newborn, child health and reproductive health. The aim of MDG-4 is to improve maternal health. So the new Agenda (the 2030 Agenda for Sustainable Development) was announced. This Sustainable Development Goals (SDGs) and targets were built on MDGs to complete where did not achieve (2). About 287,000 women yearly die of causes associated with childbirth (3). According to the report of World Health Organization and the Institute for Health Metrics and Evaluation, about 830 women die daily from preventable causes related to pregnancy and childbirth. 99% of these maternal deaths are taking place in developing countries (4). In the developing countries, reproduction related mortality is one of the five leading causes of death for women in the 15-45 year age group. This mortality accounts for one-fourth of all deaths in the developing countries (5). According to the World Health Organization, for every 100,000 live births in the country in 2015, 138 women died due to pregnancy and childbirth complications. The childbearing years are the highest risk. Some of the immediate causes of maternal mortality are: antepartum and postpartum hemorrhage, eclampsia, sepsis, and toxemia. The high prevalence of maternal death associates with the barriers to access antenatal care (ANC) services. The high quality ANC is essential for Nway Eint Chei Introduction / 2 reproductive, maternal, newborn and child health continuum of care. Globally, 81% of women receive some form of ANC, 76% in the South-East Asia region attending at least one antenatal visit. It has been estimated that an additional 160,000 newborn lives could be saved through the achievement of 90% coverage of ANC (5). Women who did not receive ANC were more likely to have pregnancy complications. Lack of ANC is a main factor in many developing countries. In general, high maternal mortality rates in developing countries can be due to lack of adequate ANC and home delivery, in combination with low socio-economic status, women perception and satisfaction. However increasing antenatal attendance due to available ANC facilities in some developing countries still requires high quality of care and increased client satisfaction to health service (6). ANC is an accessible and cost-effective system to improve maternal and newborn health outcomes. ANC gives pregnant women to introduce the health system, promote healthy behaviors, identify and treat health problems and raise awareness of danger signs of pregnancy. Most traditional birth attendants (TBAs) do not take proper training and they deliver over half of the infants born in developing countries. In developed countries, ANC is characterized by high numbers of antenatal visit and early attendance but in developing countries there is fewer or no and late ANC visits. Because there are many factors that influenced on accessibility of ANC service, availability of service and women perception and satisfaction. These could be health seeking behavior of pregnant women, customer satisfaction to provided services, availability of ANC service and socio-demographic characteristics of pregnant women. The study in Pakistan said that the accessibility of ANC service depends on distant location of facilities, a lack of transport, inconvenient facility working hours, socio-cultural factors such as low levels of pregnant woman’s awareness, a lack of decision-making by pregnant women, the quality of service, the quality of service provider and the influence of spiritual healers and quacks (7). WHO recommends that for healthy pregnant women with no underlying medical problems should take at least 4 ANC visits with specific intervals. The optimum number of ANC visits depends on not only effectiveness but also costs and other barriers to ANC access and supply. ANC improves directly the health outcome of newborn babies by reducing stillbirths and neonatal deaths and indirectly by Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 3 providing health contacts with the pregnant women in the continuum of care. If 90 percent of pregnant women received ANC, up to more than 160,000 newborn lives could be saved in Africa (8). Developing countries focus on increasing service availability and maintaining acceptable quality standards due to considerable gaps in services. Understanding maternal perception of care and satisfaction with services is important as perceived quality is a key factor of service utilization (3). In recent years many developing countries have become increasingly interested in assessing the quality of their health care. Quality assessment is measured by one of three types of outcomes such as medical outcomes, costs and client satisfaction. For the client satisfaction, clients are asked not only their own health status after receiving care but also their satisfaction with the services delivered. Recently the World Bank has been giving advice to developing countries to ensure that the limited resources have both an optimal impact on the population’s health at affordable cost and that health services are client-oriented (9). The customer satisfaction towards provided services determines the willingness to follow-up and accessibility to services. Therefore service quality improvement inspires customer satisfaction and a good image of the health facility. The Republic of the Union of Myanmar is one of the developing countries which situated in South-East Asia. It is bordered by Laos and Thailand to the east, India and Bangladesh to the west and China to the north. Based on January 12, 2017 report the United Nations estimates the current population of Myanmar is 54,615,065 (10). About 70 percent of the total population resides in rural areas and remote areas with difficult and limited health service facilities (11). Myanmar is committed to achieving the Millennium Development Goal 4. Maternal deaths due to child-bearing are 282 for every 100,000 live births. These maternal deaths are higher than national target, 130 per 100,000 live births, and also the Southeast Asia average which is 140 maternal deaths (12). The infant mortality rate is high at 62 per 1000 live births. This rate is higher in rural areas than in urban areas. Maternal mortality ratio and under-five and infant mortality rate is still high. So to reduce U5MR and IMR, maternal health takes part in important role. Because fetus is the part of mother, healthy mother can birth healthy baby and mother is also the first teacher of the baby (13). Nway Eint Chei Introduction / 4 While declining in rates of maternal and newborn mortality over 20 years ago in Myanmar, the country did not meet the 2015 targets for the United Nations (UN) Millennium Development Goals (MDG) 4 and 5. The MDG target for maternal mortality was 130 per 100,000 live births by the year 2015. Infant mortality rate is 43 per 1,000 live births which represents about 70% of under 5 mortality rate (14). According to Countdown to 2015-Myanmar, the ANC coverage with 4 times antenatal visits is about 72 % for the whole country (15). Antenatal care coverage of the world is 72%, for developing countries 68%, and for industrialized countries 98% (16). However, there are barriers to access to ANC service such as lack of knowledge, poverty, hard to reach geographical areas, socio-cultural belief and etc. Antenatal care is a main role of preventive medicine and reduction of the risk of complications through education, counseling and various interventions with professionals providing services (17). When global efforts reduce maternal mortality, it is important to look at not only availability, accessibility, affordability, acceptability of antenatal care service but also maternal satisfaction and its determinants on provided service. Satisfaction is considered ‘patient’s judgment on the quality and goodness of care’ (3). Pendleton (18) defined client satisfaction is an important intervening variable between service provision and its desired outcomes. Pascoe (19) defined client satisfaction as the recipient’s reaction to the context, process, and result of their service experience. Satisfaction is generally a main factor of health service utilization. Lack of satisfaction with quality of care could be a major discouraging factor in the use of antenatal care facility (20). Satisfied pregnant women are willing to come back for the ANC services. Several factors such as attitude of staff, cost of care, time spent at the ANC service and doctor communication influence on client satisfaction in previous studies (17). Client who doesn’t satisfy to the ANC service quality is likely to seek care and this can cause complications in pregnancy and increasing maternal mortality. Wet-Let Township which is located in upper part of Myanmar is one of the hard to reach areas for many years. In rural community lack of knowledge, using herbal medicine, culture and belief and traditional perception are still remaining. Although antenatal care coverage at least one visit in 2013 is about 87%, there are Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 5 increasing in malnutrition and severe malnutrition under 5 year and low birth weight rate (21). Poor socio-economic condition, culture, belief and lack of knowledge could be barriers to access the quality antenatal care service. These barriers and quality of ANC service can dissatisfy pregnant women to come for continuum of care. Moreover, this township was affected by floods of cyclone Komen in July and August 2015. Despite the efforts by the stakeholders and policy maker to improve the quality of antenatal care services, there was still major challenge in quality deficiencies which require ensuring holistic work performance. In Myanmar woman satisfaction towards antenatal care was assessed at the year 1998 (22). Later there are a few studies in assessments about patient satisfaction to health care. Client satisfaction of antenatal care service in health centers in Wet-Let Township, Myanmar was used as base line information for concerned governmental and nongovernmental organizations or health service providers to plan, to improve ANC procedures and management and act in motivating our pregnant women to use antenatal care service. 1.2 Research Objectives 1. To assess the client satisfaction on antenatal care service in Wet-Let Township 2. To describe the general characteristics i.e. age, ethnic, religion, marital status, education, occupation, family income, family size, gravida, parity 3. To assess the antenatal care service quality i.e. registration, history taking, physical examination, laboratory investigation, pharmacy unit, health education, follow up in Wet-Let Township 4. To determine the accessibility to antenatal care service i.e. distance, transportation, travelling, affordable, information about ANC service, provider’s manner, facilities in Wet-Let Township 5. To analyze the associations between general characteristics, antenatal care service quality, accessibility to antenatal care service and client satisfaction in Wet-Let Township Nway Eint Chei Introduction / 6 1.3 Hypotheses 1. There are associations between general characteristics and client satisfaction. 2. There are associations between antenatal care service quality and client satisfaction. 3. There are associations between accessibility to ANC service and client satisfaction. 1.4 Variables of the study  Dependent variable Client satisfaction on antenatal care service  Independent variables General characteristics i.e. age, ethnic, religion, marital status, education, occupation, family income, family size, gravida and parity Antenatal care service quality i.e. registration, history taking, physical examination, laboratory investigation, pharmacy unit, health education and follow up Accessibility to ANC service i.e. distance, transportation, time, cost, information, provider’s manner and facilities 1.5 Operational definitions Client satisfaction means evaluation based on the fulfillment of needs and expectations of pregnant woman who comes for antenatal check-up after booking visit at the health service in Wet-Let Township. Client satisfaction on antenatal care service quality is measured by five dimensions through service quality received including tangibles, reliability, responsiveness, assurance and empathy.  Tangibles refer to physical facilities, equipment and appearance of health personnel.  Reliability means the ability to perform the promised service dependently and accurately. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 7  Responsiveness refers to the willingness to help the client’s problem and complaint rapidly and increase the speed of services.  Assurance means the skill and qualification of health personnel creates confidence and trust in client.  Empathy refers to paying attention and understanding to the customer. Ethnic means Myanmar, Chin, Kachin and others. Family size means both parents and children. Gravida refers to total number of the pregnancy. Primigravida means a woman who has the first time pregnancy. Multigravida is a woman who has been pregnant more than one time. Parity refers to number of child birth with a gestational age of 24 weeks or more, regardless of whether the child was born alive or stillbirth. Nullipara means a woman who has never given birth beyond 20 weeks of gestational age. Primipara is a woman who has given birth once. Multipara means a woman who has given birth more than one time. Antenatal care means that the care given to the woman during pregnancy to detect and prevent possible pregnancy related complications. Antenatal care service means that proper ANC service includes identification of pre-existing health conditions, early detection of complications arising during pregnancy, health promotion and disease prevention and birth preparedness and complication planning. Antenatal care service quality means the difference between the clients received antenatal care at health service and the recommended antenatal care guideline. It will be assessed by using routine procedures of antenatal care service quality such as registration, antenatal history taking, physical examination, laboratory investigation, pharmacy unit, health education and follow-up. On the other hand the antenatal care service procedure received by pregnant women will not complete this recommended guideline, this service will be regarded as poor or fair in quality.  Registration includes filling a registration form and taking ANC record book.  Antenatal history taking includes gestational age at 1st antenatal booking, number of antenatal visit, last menstrual period, expected date of delivery, history of twin pregnancy, smoking, betel chewing, drug allergy and underlying illness, family planning method and voluntary confidential counseling and testing of blood. Nway Eint Chei Introduction / 8  Physical examination includes measurement of blood pressure, routine measurement of height and weight, measurement of symphysio-fundal height and auscultation of fetal heart sound.  Laboratory investigation includes testing of urine for infection and albumin, blood test for syphilis and severe anaemia.  Pharmacy unit includes injecting 2 Tetanus toxoid vaccine and supplementation of iron, folic acid and vitamin B1 tablets.  Health education includes warning signs found in antenatal, perinatal and postnatal period, balance diet, physical activities and sleeping pattern.  Follow-up means continuing antenatal care as 1st visit as early as possible (within 13 weeks), 2nd visit monthly up to 28 weeks, 3rd visit every 2 weeks up to 32 weeks and 4th visit weekly until delivery. Accessibility to ANC service means how easy the pregnant woman to get the antenatal care facilities whenever she needs the service. It is the ability of pregnant women to obtain equally the ANC service quality. These will be assessed by seven components such as distance, transportation, time, cost, information, provider’s manner and facilities.  Distance to ANC service center means travelling distance from the residence of pregnant woman to ante-natal care service center.  Transportation to ANC service center means how pregnant women come to ANC service i.e. by walking, riding motor-cycle or tuk-tuk or car etc.  Time means travelling time to go to health care service from their home and waiting time at the ANC service.  Cost refers to pregnant women who have to pay money for taking ANC at ANC service and personal cost i.e. transportation charges and cost for foods.  Information means that the pregnant women can get information from various sources such as health care provider, family member, friends, mass media and others.  Provider’s manner means ANC receipt i.e. type of health worker such as nurse, midwife and skill birth attendant, communication of health provider.  Facilities means place of ANC receipt, toilet, water and electricity. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 9 1.6 Conceptual framework Independent variables Dependent variable General characteristics           Age Ethnic Religion Marital status Education Occupation Family income Family size Gravida Parity Client Satisfaction on Antenatal Care Antenatal Care service quality        Registration History taking Physical examination Laboratory investigation Pharmacy unit Health education Follow up Service      Tangibles Reliability Responsiveness Assurance Empathy Accessibility to Antenatal Care service        Distance Transportation Time Cost Information Provider’s manner Facilities Figure 1.1 Conceptual framework of Client Satisfaction of Antenatal Care Service in Health Centers in Wet-Let Township, Myanmar Nway Eint Chei Literature Review / 10 CHAPTER II LITERATURE REVIEW The study on “Client Satisfaction of Antenatal Care Service in Health Centers in Wet-Let Township, Myanmar” consists of the following topics: 2.1 Client satisfaction 2.2 Health service system in Myanmar 2.3 Antenatal care service quality 2.4 Accessibility to antenatal care service 2.5 Wet-Let Township, Myanmar 2.6 Related studies 2.1 Client satisfaction Definitions: The definition of client satisfaction has a wide variance. Client is defined as a patient who accesses to health care facility. Satisfaction can be defined as the extent of one‟s experience with expectations (23). Aday (24) defined consumer satisfaction as “the attitudes toward the health care system of those experienced a contact with it”. Risser (25) defined patient satisfaction as “the degree of congruency between a patient‟s expectations of ideal nursing care and his perception of the real nursing care he receives”. Swan, et. al.(26) defined patient satisfaction as “a positive emotional response that is desired from a cognitive process in which patients compare their individual experience to a set of subjective standards”. Koontz, et. al.(27) stated that “satisfaction refers to the contentment experienced when a want is satisfied”. Webster (28) recorded as “satisfaction implies complete fulfillment of one‟s wishes, needs, expectations and etc”. Kotler, Armstrong and Kotler (29) defined client satisfaction as a comparison of resulting person‟s feelings of pleasure or Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 11 disappointment to a product‟s perceived performance in relation to expectation. Hoyer and MacInnis (30) defined satisfaction as a feeling of acceptance, happiness, relief, excitement and delight. Theory and Concept on Client Satisfaction Client or patient is considered as consumer. The consumer satisfaction is a response such as emotional or cognitive and that response refers to a particular focus: expectations, product, and consumption experience occurring at a particular time such as after consumption, after choice and based on accumulated experience. On the other hand, the consumer dissatisfaction is described as the bipolar opposite of satisfaction (31). Oliver (32) stated the word “satisfaction is derived from the Latin satis (enough) and facere (to do or make). A related word is satiation which loosely means enough or enough to excess. These terms illustrate the point that satisfaction implies a filling or fulfillment. So consumer satisfaction can be regarded as the consumer‟s fulfillment response”. Client satisfaction is one of the commonly used indicators for quality of healthcare and healthcare performance. Client satisfaction is also an important factor of health service utilization. Client satisfaction is influenced by many factors which are quality of health services provided, availability of medicine, behavior of doctors and health staff, cost of services, health care service infrastructure, physical comfort, emotional support, and respect for patient preferences (23). Satisfaction is generally a broader concept when service quality focuses particularly on dimensions of service. In contrast satisfaction is more inclusive and it is influenced by perception of service quality, product quality, prices, situational and personal factors (33). The consumer satisfaction or dissatisfaction obtained from a product purchase is through equity theory of consumer satisfaction. This theory shows that people analyze the ratio outcomes and input to the ratio of the outcomes and inputs of the partner an exchange. People examine the exchange between themselves and other parties to conclude the extent that it is equitable or fair (34). Teijlingen et al. (35) stated that patient satisfaction is a constituent of quality of health care. Lack of satisfaction with quality of care was chiefly discouraging the use of antenatal care service facilities. Nway Eint Chei Literature Review / 12 Although customer satisfaction is influenced by perceptions of service quality, it includes perceptions of product quality, price of services, personal factors, uncontrollable situational factors and experiences motivating to and from the services (36). Parasuraman et al. (37) defined service quality as the ability of the organization to meet or exceed customer expectations. Service quality was defined as the discrepancy between consumers‟ perceptions of services provided and their expectations about that service. Zeithaml (36) defined perceived quality as “the consumer‟s judgment about an entity‟s overall excellence or superiority”. Quality is an overall evaluation of a product similar to attitude. The best perspective value of the measurement of service quality should take into account customer expectations of service as well as perceptions of service. The expectation is the consumers‟ desire or want. Ten service-quality dimensions such as tangibles, reliability, responsiveness, communication, credibility, security, competence, courtesy, understanding or knowing the customer and access were used to assess the service quality. Far ahead, Parasuraman et al. (37) modified this model into multiple encounter models and produced SERVQUAL, a 22 item scale for measuring service quality, because of overlapping dimensions. The measurement of service quality includes customer expectations of service and perceptions of service. It has five dimensions such as: 1. Tangibles refer to physical facilities, equipment and appearance of personnel. 2. Reliability refers to ability to perform the promised service dependably and accurately. 3. Responsiveness means willingness to help customers and provide prompt service. 4. Assurance includes competence, courtesy, credibility and security. The employees of knowledge and courtesy and their ability to stimulate trust and confidence. 5. Empathy includes access, communication, understanding the customer. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 13 Figure 2.1 SERVQUAL Model [Accessed on June 8, 2017] (38) Available from: https://www.google.co.th Locker and Dunt (39) stated that evaluation of quality of care is one of the purposes of consumer satisfaction which is considered as a prescription for the action for improving services in some way that is beneficial to patients. The 8-domain WHO Responsiveness model (40) refers to satisfaction with the quality of health care system from the perspective of patient experience. Maslow‟s hierarchy of five human needs fulfillment theory described as the proposition of satisfaction-causes-performance concept in management. While not satisfying for enough length of time and threatening our human lives, the needs are powerful factors of human behavior. Patients or clients are coming to seek or obtain services at health care facilities and to meet their needs related to health. The clients perceive the exceeded satisfaction when they need their want and expectations for health services are met. If clients satisfy the health services, they have improved compliance‟s, continuity of care related hospitalization and length of stay (41). Cleary (42) considered patient satisfaction as the quality of patient care. It included two main criteria for evaluation of satisfaction to health care services. Firstly client satisfaction is influenced by types of organization manipulated by policy changes. The second criteria related to subsequent patient behavior. Nway Eint Chei Literature Review / 14 Jarrett (43) showed five common misconceptions about customer satisfaction that doom a company‟s customer satisfaction initiatives: the customer satisfaction represents an objective reality, the simple tasks to measure customer satisfaction, the customer attitudes can be accurately measured, the satisfaction will quickly effort to change and all customers are alike. Williams (44) found that valueexpectancy model. In this model the satisfaction is measured by positive attitude relating to both one‟ beliefs the care possesses certain attributes and one‟ evaluation of those attributes. Stallard (45) found the discrepancy between expectation and experience, “the Gap model”. Discrepancy approach is implicitly used by most satisfaction studies. In health care sector clients are typically thankful for what they receive. In any case unqualified service is better than no service which is a common situation of the developing countries. According to the various theories in previous studies, client satisfaction in this study is defined as evaluation based on the fulfillment of needs and expectations of pregnant women who come for antenatal check-sup after booking visit at the health service in Wet-Let Township. Client satisfaction of antenatal care service quality is measured by using SERVQUAL produced by Parasuraman. It has five dimensions through service quality received including tangibles, reliability, responsiveness, assurance and empathy.  Tangibles refer to physical facilities, equipment and appearance of health personnel.  Reliability means the ability to perform the promised service dependently and accurately.  Responsiveness refers to the willingness to help the client‟s problem and complaint rapidly and increase the speed of services.  Assurance means the skill and qualification of health personnel creates confidence and trust in client.  Empathy refers to paying attention and understanding to the customer. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 15 2.2 Health service system in Myanmar The Republic of the Union of Myanmar is the second largest country in South East Asia region. It is bounded by People‟s Republic of China to the north and east, Lao People‟s Democratic Republic and the Kingdom of Thailand to the east, and Republic of India and People‟s Republic of Bangladesh to the west. Myanmar has14 States and Regions consisting of 74 Districts, 330 Townships, 398 Towns, 3065 Wards, 13,619 Village Tracts and 64,134 Villages. According to the 29th March 2014 census the population of Myanmar was 51,419,420 persons. Around 70 percent of the population resides in rural areas where benefits of health care services are much less than the urban areas. The Ministry of Health and Sports is the main role in the health sector as a governing agency and a provider of comprehensive health care such as promotive, preventive, curative and rehabilitative health care. It is not only the major organization responsible for raising the health status of the people but also responsible for planning, financing, administrating, regulating and providing health care. The Ministry of Health and Sports has seven departments, each under a director general: Department of Medical Care, Department of Public Health, Department of Medical Research, Department of Health Professional Resources Development and Management, Department of Food and Drug Association, Department of Sport and Department of Traditional Medicine (46). Ministry of Health and Sports is responsible for providing health care services to the entire population of country. The basic health staff (BHS) down to the grass root level are providing comprehensive health care through primary health care (PHC) approach. Health infrastructure of Myanmar is based upon sub-rural health center and rural health center where midwives (MW), Lady health visitors (LHV) and health assistants (HA) are the responsible person for rural community. Primary medical care is provided at the grass root level by these staffs and those who need special care are being referred to station hospital, township hospital and to the specialist hospital sequentially. At state and regional level, the state and regional health department is responsible for planning, coordinating, training, technical support, close supervision, monitoring and evaluating of district and township health department. At the peripheral level, the township level actual Nway Eint Chei Literature Review / 16 implementation of health services to the community is undertaken. The township medical officer (TMO) is responsible for all centers and voluntary village health posts proving health care at rural level. In each township, there is a township hospital which may have 16 or 25 or 50 beds according to the population of the township. Each township has at least one or two station hospital and 4-7 rural health centers (RHC). Each RHC has 4 sub centers covered by MW and public health supervisor-2 (PHS-2) at the village level. Regarding maternal and child health (MCH) care service, “Ministry of Health and Sports had been implementing the interventions based on the National Reproductive Health Policy developed in 2002 supported by two consecutive reproductive health strategic plans” (47). The organization and implementation of MCH services at various levels are township health department, MCH centers, MCH and school health teams, urban health center, RHC and sub-rural health center. The main activities of MCH are antenatal care, safe and aseptic delivery, post natal care, under five child health care, nutritional development of mother and children and immunization (46). Limitation in resources, ineffective referral system, managerial skill and utilization of health information for decision making, inadequate laboratory services and lack of inter-sectoral coordination are still major challenges for quality of service, customer expectation, customer perception and customer satisfaction towards the health care service. 2.3 Antenatal care service quality Antenatal care is the care provided by midwives, nurses or doctors to check that the pregnant woman and her growing baby are healthy. Quality antenatal care means that the health staff is qualified and trained to provide antenatal care, have all the essential equipment and drugs they need and there is enough staff so that the appointment is not rushed and the pregnant woman can ask questions (48). Antenatal care is the care that a woman experiences during pregnancy. ANC helps to ensure healthy outcomes for women and newborns. Antenatal care is a major element of Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 17 comprehensive maternal health care. ANC involves monitoring of the progress of the pregnancy to assess fetal and maternal health, offering preventive treatment such as immunization against tetanus or iron for anemia and advising women on a range of important health subjects such as identification of warning signs in pregnancy and when to seek care (49). The World Health Organization (WHO) new antenatal care model recommended that the healthy pregnant women with no underlying medical problems should take booking visit within 12 weeks, first visit at 20 weeks, second visit is 26 weeks, third visit is 32 weeks and fourth visit is 36 weeks (50). According to WHO guideline, ANC includes risk identification, prevention and management of pregnancy-related or concurrent diseases, health education and health promotion. ANC reduces maternal and perinatal morbidity and mortality both directly with detection and treatment of pregnancy-related complications and indirectly with the identification of women at increased risk of developing complications during delivery and ensuring referral system to an appropriate care (51). There are two new WHO models of antenatal care: routine antenatal care and special care. Routine antenatal care is needed by 75% of the total population of pregnant women. Although 25% of pregnant women need special care, they have specific health conditions or risk factors and signs and symptoms of complications of pregnancy (52). Rooney (49) claimed that a question „whether can ANC prevent maternal mortality and morbidity‟ is difficult to solve. In contrast, it is important to reduce the possibility that a pregnant woman will experience a serious complication of pregnancy or childbirth for reducing maternal mortality (53). Nevertheless the complications of pregnancies frequently occur among women with no risk factors. Therefore some complications cannot be expected although most of those may be prevented (54). The use of ANC is dependent on the actual needs and health status of women as well as influencing by how women perceive her own health status (55). Moreover the type and quality of ANC that women receive is important for safety outcomes. Poor ANC is an important risk factor for adverse pregnancy outcomes among women who are easily accessible to health care service (56). During the period of 2000-2008, less than half of pregnant women globally received the recommended minimum 4 antenatal visits despite of having 78% at least Nway Eint Chei Literature Review / 18 one antenatal visit. However there is only 39% of pregnant women received four or more antenatal visits in low income countries. Even in developing countries in Africa, Americas and Asia, the richer urban women are more likely to access to antenatal care service than the poor (53). WHO estimated that 25 % of maternal deaths occur during pregnancy. This maternal death varies between different countries and disease depending on the prevalence of unsafe abortion, violence. Between a third and a half of maternal deaths due to hypertension such as pre-eclampsia and eclampsia and antepartum haemorrhage are ranging one-third from a half which are directly related to inadequate antenatal care. ANC provides women and their families with appropriate information and advice for a healthy pregnancy, safe delivery and postnatal care with care of the newborn, promotion of early exclusive breastfeeding and support with decision on future pregnancies in order to improve pregnancy outcomes. An effective ANC package depends on skilled health care providers with referral services and adequate supplies and laboratory support (8). It is important to monitor pregnancy by skilled provider during antenatal care and to reduce morbidity and mortality risks for the mother and child during pregnancy, at delivery and during the postnatal period which is within 42 days after delivery. According to 2015-16 Myanmar Demographic and Health survey 81 % of women received antenatal care from a skilled provider at least once for their last birth. Although 94% of urban women received ANC from a skilled provider, rural women only received 77%. Percentage of Women who had four or more ANC visits is 59. However 84% is in urban and 51% in rural (57). In developing countries, women of child bearing age and children under 12 years account for 60-70% of total population. In Myanmar women and children constitute about 60% of total population and they are major consumer of health services. They are also vulnerable or special risk groups. The risk is connected with child bearing in women and growth, development and survival in infants and children. Not only doctors and nurses but also midwives and auxilary midwives provide maternal care especially antenatal care throughout the nation to reduce and prevent the risk (58). The aim of antenatal care in Myanmar is to prevent or to minimize the complications of pregnancy and to make the mother fit to endure stress and strain. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 19 Routine procedure for antenatal service quality 1. Registration 2. Antenatal record book 3. Obstetric history -date of 1st antenatal visit -number of antenatal visit -last menstrual period -expected date of delivery -gravida and parity -education of pregnant woman -history of twin pregnancy -smoking, betel chewing -drug allergy -regular taking drugs -underlying illness (TB, heart disease, chronic renal disease, hypertension, diabetes, fits, thyroid, syphilis, malaria and hepatitis) and other diseases -family planning method -voluntary confidential counseling and testing for HIV and syphilis 4. Examination -measurement of height and weight -measurement of blood pressure -measurement of symphysio-fundel height (the size of the uterus corresponds with the period of amenorrhea) -presentation and position of fetus -auscultation of fetal heart sound 5. Laboratory testing -blood test for blood grouping, haemoglobin, random blood sugar level and syphilis -urine test for infection and albumin 6. Immunization -tetanus toxoid injection (2 times) Nway Eint Chei Literature Review / 20 7. Drug supplement -anti-helminth drug, iron and folic acid tablets 8. Antenatal information -folic acid supplementation, lifestyle advice (smoking cessation), balance diet (having 3-4 times a day of rice, fruits and vegetables, meat, fish, bean, egg, milk and oatmeal), physical activity for 10 minutes, sleep in daytime for 2 hour and 8 hour at night, using bed net while sleeping, wearing suitable cloth, warning signs about prenatal, perinatal and postnatal period, preparation for birth, newborn care and breast feeding The Ministry of Health and Sports, Myanmar prepared for antenatal care guideline and recommended that antenatal care service must be given at health centers according to the guideline. The first antenatal visit should be either within 13 weeks of gestational age or as early as possible. During 1st visit, taking history, doing general medical check-up, measuring blood pressure, height and weight, testing blood for anaemia and syphilis, asking history of TB, giving 1st dose of tetanus toxoid vaccine, iron, folic acid supplement and multivitamin, doing voluntary confidential counseling and testing for HIV, giving health knowledge about HIV transmission from mother to child, balance diet, physical activities, sleeping and dressing pattern and warning signs of antenatal, perinatal and postnatal period are given. The second visit should be within 28 weeks or monthly up to 28 weeks after taking 1st ANC visit. During 2nd visit, the health personnel gives measuring blood pressure and weight, doing obstetric examination and testing urine for infection and albumin, giving anti-helminth drugs, iron and folic acid supplement and injecting 2nd dose of tetanus toxoid vaccine. The third visit should be within 32 weeks or 2weekly from 28weeks to 32 weeks. During 3rd visit, the pregnant women will be provided measuring blood pressure and weight, doing obstetric examination, testing urine for infection and albumin, testing blood for anaemia and syphilis and giving iron and folic acid supplement. The forth visit should be weekly starting from 32 weeks until delivery. During 4th visit, the health personnel provide measuring blood pressure and weight, doing obstetric examination, testing urine for infection and albumin, giving iron and folic acid, giving vitamin B1 supplement needed to take up to 3 months after birth and providing health knowledge Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 21 about warning signs of delivery. (Available source: Maternal and child health guide book, Department of Health, Myanmar) In this study of client satisfaction of antenatal care service in health centers antenatal care service quality means the difference between the clients received antenatal care at health service and the recommended antenatal care guideline. It will be assessed by using routine procedures of antenatal care service quality such as registration, antenatal history taking, physical examination, laboratory investigation, pharmacy unit, health education and follow-up. On the other hand the antenatal care service procedure received by pregnant women will not complete this recommended guideline, this service will be regarded as poor or fair in quality.  Registration includes filling a registration form and taking ANC record book.  Antenatal history taking includes gestational age at 1st antenatal booking, number of antenatal visit, last menstrual period, expected date of delivery, history of twin pregnancy, smoking, betel chewing, drug allergy and underlying illness, family planning method and voluntary confidential counseling and testing of blood.  Physical examination includes measurement of blood pressure, routine measurement of height and weight, measurement of symphysio-fundal height and auscultation of fetal heart sound.  Laboratory investigation includes testing of urine for infection and albumin, blood test for syphilis and severe anaemia.  Pharmacy unit includes injecting 2 Tetanus toxoid vaccine and supplementation of iron, folic acid and vitamin B1 tablets.  Health education includes warning signs found in antenatal, perinatal and postnatal period, balance diet, physical activities and sleeping pattern.  Follow-up means continuing antenatal care as 1st visit as early as possible (within 13 weeks), 2nd visit monthly up to 28 weeks, 3rd visit every 2 weeks up to 32 weeks and 4th visit weekly until delivery. Nway Eint Chei Literature Review / 22 2.4 Accessibility to antenatal care service Definition of Accessibility The World Health Organization (59) defined accessibility as “the continuing and organized supply of care that is geographically, financially, culturally and functionally within easy reach of the whole community. The care has to be appropriate and adequate in content and in amount to satisfy the needs of people and it has to be provided by methods acceptable to them. Timmreck (60) defined accessibility as “the degree to which system inhibits or facilitates the ability of an individual to gain entry and to receive services. Accessibility includes geographic, architectural, transportation, social, temporal, and financial considerations. Peters et al. (61) implied accessibility as „the timely use of service according to need‟. Penchansky and Thomas (62) defined access as “factors that affect entry into the health system. Access is a measure of the fit between characteristics of providers and health services and characteristics and expectations of clients. Five dimensions of access are availability, geographic accessibility, accommodation, affordability and acceptability.” Theory and concept Although there is no universally accepted definition of access to antenatal care service, the best way to measure access is outcomes including utilization rates and satisfaction (59). Utilization of antenatal care service is used as an operational proxy for access to health care. Aldana et al. (9) stated that satisfaction is a key determinant of health service utilization. Use of ANC is influenced by accessibility of the ANC services chiefly place of residence, distance and transport to the healthcare facilities. Access is a function of availability of health services and acceptability of the patients. Access has four dimensions: availability, geographic accessibility, affordability and acceptability. These factors influence the poor women living in rural, the remote and hard-to-reach areas to access antenatal care services (35). Peters et al.(61) identified the analytical framework for assessing access barriers to health services and a rudimentary framework by Ensor and Cooper (63) on supply-side and demand-side barriers. These two frameworks were combined for finding the hinder access to antenatal care service. In that framework service location Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 23 and household location are considered as distance. Availability means the sufficient supply and adequate number of health workers to match the health needs of the target population (64). WHO proposed framework of access to health care including geographic accessibility, financial accessibility, cultural accessibility and functional accessibility. Geographic accessibility refers to the distance, travelling time and acceptable transportation. Financial accessibility refers to affordable method of payment and services. Cultural accessibility means that using technical and managerial methods with cultural patterns of a community. Functional accessibility is having the right kind of care available on a continuing basis to those in need when they need it (59). During the period of 2000-2008, less than half of pregnant women globally received the recommended minimum 4 antenatal visits despite of having 78% at least one antenatal visit. However there is only 39% of pregnant women received four or more antenatal visits in low income countries. Even in developing countries in Africa, Americas and Asia, the richer urban women are more likely to access to antenatal care service than the poor (53). WHO estimated that 25 % of maternal deaths occur during pregnancy. This maternal death varies between different countries and disease depending on the prevalence of unsafe abortion, violence. Between a third and a half of maternal deaths due to hypertension such as pre-eclampsia and eclampsia and antepartum haemorrhage are ranging one-third from a half which are directly related to inadequate antenatal care. ANC provides women and their families with appropriate information and advice for a healthy pregnancy, safe delivery and postnatal care with care of the newborn, promotion of early exclusive breastfeeding and support with decision on future pregnancies in order to improve pregnancy outcomes. An effective ANC package depends on skilled health care providers with referral services and adequate supplies and laboratory support (8). Geographical location, distance from health facilities, availability of transportations, economically affordability and culturally acceptability have strong effect on the accessibility to ANC services. In Myanmar 53% of pregnant women visited to skilled personnel at least three times during their pregnancy. The proportion is lower in rural areas (48.2%) which are compared to 69.8% in urban areas. Pregnant Nway Eint Chei Literature Review / 24 women from poor households have lower access to ANC service than those from rich households with 44.5% and 57.7% each (65). In this study accessibility to ANC services means how easy the pregnant woman to get the antenatal care facilities whenever she needs the service. It is the ability of pregnant women to obtain equally the ANC service quality. It is measured by using framework for access to health care offered by WHO. It has four parts such as geographic, financial, cultural and functional accessibility. Geographic accessibility means location of service, travelling time and transportation. Financial accessibility refers to affordable services. Cultural accessibility is enhanced by the characteristic of provider. Functional accessibility is the availability of the continuous care when the patient needed. These will be assessed by seven components such as distance, transportation, time, cost, information, provider‟s manner and facilities.  Distance to ANC service center means travelling distance from the residence of pregnant woman to ante-natal care service center.  Transportation to ANC service center means how pregnant women come to ANC service i.e. by walking, riding motor-cycle or tuk-tuk or car etc.  Time means travelling time to go to health care service from their home and waiting time at the ANC service.  Cost refers to pregnant women who have to pay money for taking ANC at ANC service and personal cost i.e. transportation charges and cost for foods.  Information means that the pregnant women can get information from various sources such as health care provider, family member, friends, mass media and others.  Provider’s manner means ANC receipt i.e. type of health worker such as nurse, midwife and skill birth attendant, communication of health provider.  Facilities means place of ANC receipt, toilet, water and electricity. 2.5 Wet-Let Township, Myanmar Wet-Let Township is situated at the upper part of Myanmar and bounded by Ayeyarwaddy river to the east, Mu river to the west, Sagaing township to the south Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 25 and Shwe-Bo township to the north. The area is about 514.58 Sq-Mile. The total population is about 207334 with approximately 95% of rural population and the population density is 55.41 Sq-Mile. There are about 222 villages and 72 village tracts. As health facilities there is one 25-bedded township hospital, two 16-bedded station hospital, one maternal and child health clinic, eight rural health centers. Doctorpopulation ratio is 1: 25916, Lady health visitor-population ratio is 1: 51833 and midwife-population ratio is 1: 4411. Antenatal care coverage at least one antenatal visit is 87%. ANC coverage 4+ data is not available. Maternal mortality ratio is 1.4 per 1000 live births. Infant mortality rate is 23.6 per 1000 live births (21). This study was done in rural area of that township because of the followings:  Geographic location – it is located in the plain between two rivers. So most of the rural areas are not easily to access the health center.  Population – majority are rural population.  Midwives are essential for providing basic maternal health care to pregnant women and newborns. Health personnel to population ratio are quite different from WHO recommended health personnel - population ratio (23: 10000 population). Source: National policy and strategy for nursing and midwifery services report 2011-2015 (66)  Although ANC coverage is relatively higher than union level (82%), this township was affected by floods of cyclone Komen and heavy monsoon rain in July and August 2015. According to report of rural health center, ANC coverage reduced from 77.89% to 12.3% and IMR increased from 11.23 per 1000 live birth to 19.23 per 1000 live birth. Moreover there was increasing about 2 times in referral rate.  After recovery from floods, there has still problem in health service quality especially in rural areas. Consumer satisfaction is not only a vital indicator for quality of health service but also important outcome for health service.  Recent years, a study on client satisfaction and quality of health service is still rare. Due to these reasons the researcher selected as research area. Nway Eint Chei Literature Review / 26 Figure 2.2 Map of Wet-Let Township (67) Source: Map data of Google [Accessed on December 25, 2016] 2.6 Related studies Client satisfaction The study in Nigeria concluded that patient satisfaction linked to the provided quality of services and 85.6% satisfied with the antenatal care services and good attitude of nurses at the clinic (17). The research done in Nepal showed that clients satisfied with maternity care received at the facility (86%), provider‟s skills (85%), politeness of health care personnel (83%), waiting time (80%), cleanliness (70%), antenatal information received (69%) and assured confidentiality (67%) (68). The study conducted in Malawi concluded that 99.1% of patients had good relationship with the health care provider. 97.3% of the women were satisfied with the received antenatal care (69). The research on determinants of women‟s satisfaction with maternal health care showed that more than 75% of women were satisfied with the provided service (3). A survey conducted in women satisfaction on antenatal care services in Sarawak, Malaysia found that 24.6% had poor satisfaction with ANC, 51% had average satisfaction and 24.6% had high satisfaction (70). Turk and Avoilar (71) Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 27 stated that there was a strong and significant link between the quality of service and client satisfaction. The study of satisfaction among expectant mothers with antenatal care services in the Musandam region of Oman found that 59% of the respondents had excellent grade of over satisfaction (72). The research on clients' satisfaction towards health care services at outpatient department, Pimlon hospital, Yangon, Myanmar stated that 79.7% of the respondents attending OPD are highly satisfied with the service given in private hospital (73). General characteristics The research accompanied in India showed that the individual characteristics such as age, education, health status, race, marital status and social class positively associated with patient satisfaction (74). The study in Gambia and India found that maternal characteristics affected women‟s perceived satisfaction with antenatal care. Maternal age and education was directly associated with maternal satisfaction due to greater experience and maturity (75). The study of mothers‟ utilization of antenatal care and their satisfaction with delivery services in selected public health facilities of Wolaita zone, southern Ethiopia found that patient satisfaction levels varied with age and there were significant association between age of mother, education level and satisfaction to the health services (76). The study conducted in Kenya that maternal satisfaction is influenced by socio-economic, cultural factors and ethnicity. A study in Nigeria showed that religion is also significant (77). Respondents' socio-economic status is expressed in their general inability to pay for health care. The study about 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 showed that socio-demographic variables which were average monthly family income, educational level of pregnant women significantly predicted the level of satisfaction with antenatal care service (78). The study conducted in India that in recent years patients are more educated and much richer (79). Studies in Nigeria found multiparous women were more satisfied with antenatal care than primiparous women (80). There is a difference between primiparous and multiparous women with Nway Eint Chei Literature Review / 28 significant satisfaction of antenatal care to health education. The multiparous women were more satisfied than the primiparous mothers with health education shown in Indian study (81). Antenatal care service quality The client satisfaction was influenced by the available health service quality. The study in Ghana listed that the quality of antenatal care service included attitude of staff, time spent at the health center, availability of health personnel and the communication between health personnel and patient (6). Overcrowded service and unnecessary prolonged facility affect to maternal satisfaction on antenatal care service in survey of Ghana and Malawi (69). The study in Bangladesh found that clients considered reducing waiting time more important than increasing consultation time (9). The study on assessment of quality of antenatal care services in Nigeria showed that timing of first antenatal visit, adequacy of number of ANC visit, skill of health care provider, type of helath facilities, for example blood pressure measurement, receiving iron supplement, education on prevention of mother to child transmission, tetanus toxoid vaccine injection, were significant factors for desirable quality of ANC (82). For physical examination separate room and privacy is a main requirement for women utilization of antenatal care services. The surveys in Bangladesh and India showed that maintaining a separate room and privacy for examination is a significant determinant for satisfaction to ANC service (9). The study conducted in India showed that 95% of the women satisfied with the number of antenatal visits and the consultation time with midwives. 98% were satisfied with the explanation given and the examination done by midwives (81). Availability of prescription drugs and adequate and well-functioning of essential equipment such as sphygmomanometers, stethoscope, weighing machine, thermometers, lab services and clean delivery kits significantly associated with satisfaction of antenatal care service in studies in India, Oman, Nigeria, Gambia and Uganda (3). The studies in developing countries showed that the interpersonal aspects of care were the determinants of maternal satisfaction. The interpersonal aspects of care include therapeutic communication like listening, politeness, prompt pain relief, kindness, approachability and smiling demeanor, caring behavior such as attentive to Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 29 needs, making clients feel accepted and coaxing clients and interpersonal skills of staff for example staff confidence and competence. These aspects were significantly influencing client‟s satisfaction with antenatal care service in the studies of Ghana, Lebanon and Gambia (77). Client satisfaction also associated with perceiving of the technically good quality of care and technically competent health care provider. The essential aspects of cognitive support are counseling by the provider, the process of imparting information, consultation in decisions regarding care, and transparent mechanisms for registering patient feedback. The study in Oman found that client satisfaction associated with the content of messages such as the provider‟s commitment, availability of time and overcoming any language barrier (72). The study in Ethiopia found that the antenatal care contents such as parity, type of pregnancy, focused antenatal care (ANC) history and number of visit and client knowledge about importance of focused antenatal care (FANC) were significantly associated with satisfaction with focused antenatal care services (78). The research in Thailand found that patient with good experience to the service provided had high satisfaction. The factors influenced on patient satisfaction were registration counter, laboratory, pharmacy, length of consultation time, ensuring privacy when needed, physical examination, information on the health problem and advice given by the health care provider. This study suggested that poor quality leads to loss of lives and public confidence, wastage of limited resources such as time, money, materials and low staff morale (83). Accessible to antenatal care service Many studies in developing countries concluded that convenience of access to maternal health care is an important factor of maternal satisfaction. Access included not only the distance and time but also mode of transportation such as availability of public transport between residence and facility and social support. The nearer the availability of antenatal service and the more convenient timing, the greater the satisfaction of pregnant women (3). The study in India found that the waiting time includes a lot of factors such as the doctor's working style, the kindness to the patient, the locality where the doctors‟ practices, and the efficacy of the supportive staff. The waiting time plays an important role in determining the patient satisfaction (79). The Nway Eint Chei Literature Review / 30 study in Myanmar concluded that waiting time to get ANC service by medical doctors was longer than the contact time and most patients did not receive any advice from examination and investigation results (22). The availability of medicines at health center significantly associated with women satisfaction with antenatal care in the study conducted in Gambia (75). The study in India, Kenya and Pakistan found that maternal satisfaction to ANC service is strongly associated with affordable care. Moreover overall cost of care, affordable drugs for antenatal care also influenced maternal satisfaction with care in the studies of Nigeria, Gambia and Ghana (17, 77). The study in Malaysia found that patient who did not need to pay for service charges was 1.935 times higher satisfied than those who paid for ANC service cost (70). In one study conducted in Ethiopia recorded that most of the patient (80.7%) satisfied with the interpersonal skill on focused antenatal care service at health center (78). The research of patient satisfaction towards Out-Patient department services of medicine department in Banphaeo community hospital Samut Sakhon Province, Thailand found that there was association between accessibility and satisfaction. The higher the accessibility to health service, the higher the level of the patient‟s satisfaction. 64.89% of the respondents had good accessibility and 35.11% had poor accessibility to the services (84). There are many studies confirming the association between accessibility level and the satisfaction level. One study in Myanmar also showed that there was highly significant association between accessibility and the level of satisfaction. High level of accessibility 92.5% had high level of satisfaction (73). In client satisfaction of antenatal care service in health centers in Wet-Let Township, Myanmar most of the variables in conceptual framework was applied according to significant association with satisfaction towards health service in previous literatures. In spite of association with dissatisfaction on health service in previous studies, some variables which can have association in this study were used in conceptual framework. The variables of antenatal care service quality were used depending on the antenatal care guideline in Myanmar which is a little different from National Institute for Health and Clinical Excellence (NICE) clinical guideline for Antenatal care: routine care for the healthy pregnant woman. In this guideline, Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 31 although the antenatal information includes the supplementation of vitamin D3 and antenatal screening, these cannot be done in Myanmar. The study area, Wet-Let Township, is far from central part of Myanmar. It has faced the shortage of resources and different status of health service quality compared to other areas. Client satisfaction on antenatal care service at health centers in Wet-Let Township, Myanmar aims to evaluate the client satisfaction on antenatal care service in Myanmar through the service quality aspects because client satisfaction is an important indicator for measuring the quality of service. The client satisfaction towards antenatal care service quality was assessed by using SERVQUAL identified by Parasuraman. The associations between general characteristics, antenatal care service quality, accessibility to antenatal care service and client satisfaction on antenatal care service were analyzed. Nway Eint Chei Materials and Methods / 32 CHAPTER III MATERIALS AND METHODS 3.1 Research design A cross-sectional study was conducted to assess the client satisfaction on antenatal care services and also to analyze the associations between general characteristics, contents of antenatal care service, accessibility to antenatal care service and the level of client satisfaction on antenatal care service among pregnant women who come to antenatal care service at health centers in Wet-Let Township, Myanmar. 3.2 Study site and study population The study site was Wet-Let Township which is located 88.69 km far from Mandalay. It was bounded by Ayeyarwaddy river to the east, Mu river to the west, Sagaing township to the south and Shwe-Bo township to the north in Sagaing region, Myanmar. The total population was 207,334 and female population between 18-49 years was 54,799 (21). The married female population was approximately 46,845 (85). The study population was pregnant woman who came to antenatal care service at health centers in Wet-Let Township during April, 2017. Inclusion criteria 1. Pregnant women within the age of 18-49 years who received at least two antenatal visits in second trimester at health center 2. Pregnant women who can speak Myanmar language 3. Pregnant women who are willing to participate Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 33 Exclusion criteria 1. Pregnant women with psychological problem 2. Pregnant women who are not present at the health center during the study period 3.3 Sample Size Calculation Total number of pregnant women who took first booking ANC at health centers during October, November and December was 533 (21). The calculation for sample size was computed based on finite population of N= 533 by using finite population proportion formula (86). n= n = 224 = Estimated sample size = Standard normal score at 95% of confidence interval = 1.96 N = Total number of pregnant women who take ANC = 533 d = Allowance for error = 0.05 p = Proportion of client satisfied towards antenatal care service at health centers = 0.5 (The proportion of client satisfaction towards antenatal care service at health centers, Myanmar has not known in update, so 0.5 was taken for calculation.) To cover the non-respondent rate, 10% of calculated rate was added. Total sample size became 246. Nway Eint Chei Materials and Methods / 34 3.4 Sampling procedure Wet-Let Township has eight rural health centers. The researcher collected data from these health centers by using probability proportionate sampling method. When collecting data from each health center according to inclusion and exclusion criteria by using purposive sampling. The sample size for each health center was calculated by using the following formula: nv = (nc / Nt) × Nv nv = the number of sample of each health service nc = the calculated number of sample size for this study Nt = the number of total new pregnant women who come to ANC services during October, November and December, 2016 Nv = the number of new pregnant women who come to each ANC service during October, November and December, 2016 3.5 Research instrument The instrument of this study was interviewed questionnaire which prepared in English version initially and then translated into Myanmar language. The questionnaire was consisted of the close-ended and open-ended. The questionnaires composed of the following four sections to collect the data. Section 1 General characteristics The questions of this section consist of 12 items i.e. age, ethnic, religion, marital status, education, occupation, family income, family size, gravida and parity. Questions were both fill in the blank and multiple choice forms. Section 2 Antenatal care service quality This section was composed of 45 questions regarding to registration (2 items), history taking (16 items), physical examination (7 items), laboratory investigation (5 items), pharmacy unit (3 items), health education (10 items) and follow-up (2 item). Questions were both fill in the blank, close type questions and multiple choice forms. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 35 Section 3 Accessibility to antenatal care service In this section, 23 questions were asked related to accessibility to antenatal care services i.e. distance, transportation, time, cost, information, provider‟s manner and facilities. Questions were multiple choices, open-ended questions and close-ended questions with the respond by „Yes, Always‟, „Yes, Sometime‟, „No, Never‟. Section 4 Client satisfaction to antenatal care service For the section of client satisfaction to antenatal care service, SERVQUAL model was used to measure the service quality and to analyze the client satisfaction. 19 questions were asked. This SERVQUAL‟s five dimensions were identified by Parasuraman et al. with the aim of measuring client satisfaction and guidelines across the service quality. (37) 3.6 Data collection 1. The data collection process was carried out after getting approval from Ethical Committee of Mahidol University. The questionnaire was constructed in English and also translated into Myanmar language. Data was collected by using interview questionnaires, conducted by researcher and eight trained field assistants (interviewers). 2. Interviewers were trained by the researcher before data collection about objectives of the study and the meaning of each question in the questionnaire. 3. Before starting, the respondent was informed about the purpose of this study and was assured that the responses were confidential and could response the questions freely. 4. The respondents could ask the interviewers about the questions if they did not understand the questions properly. 5. The answering time was 20 – 30 minutes. Nway Eint Chei Materials and Methods / 36 3.7 Content validity and reliability 1. Questionnaire was developed according to conceptual framework and literature. For content validity it was approved by the academic supervisors. 2. For reliability the questionnaire was pretested with 30 pregnant women in Zigon Township which has same characteristic with this study to assess the participants‟ understanding and time spent on the research tools. Cronbach‟s alpha coefficient was used to examine the reliability of the questionnaire and those questions which had score 0.7, these were acceptable. Cronbach‟s alpha coefficient result for satisfaction on ANC service was 0.76. 3.8 Data analysis Data entry and editing After doing data collection, collected data was entered via Epidata statistical software (v.3.1) and the data was encoded, cleaned and analyzed by using SPSS version 18.0 (Patent of Mahidol University). Data analysis For descriptive study, frequencies, percentage, minimum, maximum, mean, median and standard deviation (SD) were calculated. Chi-square test and Fisher‟s exact test were used to analyze the association between all the variables used in this study and satisfaction. . p-value at 0.05 is considered statistically significant. Scoring criteria Table 3.1 showed possible scores and classification of all study variables. More than or equal 80% was good, 60% to 79% was moderate and less than 60% was poor. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 37 Table 3.1 Possible scores and classification of all study variables Variables Min-Max Low Moderate High Client satisfaction 19 – 95 19 – 56 57 – 75 76 – 95 Tangibles 4 – 20 4 – 11 12 – 15 16 – 20 Reliability 3 – 15 3–8 9 – 11 12 – 15 Responsiveness 4 – 20 4 – 11 12 – 15 16 – 20 Assurance 4 – 20 4 – 11 12 – 15 16 – 20 Empathy 4 – 20 4 – 11 12 – 15 16 – 20 Antenatal care service quality 0 – 50 0 – 29 30 – 39 40 – 50 Accessibility to ANC service 0 – 21 0 – 12 13 – 16 17 – 21 3.9 Ethical consideration 1. Data collection was conducted with the permission of the “Documentary Proof of Ethical Clearance from the Research Ethical Committee” of Mahidol University. (COA. No. MUPH 2017-072) 2. The researcher got the permission and informed consent from the respondents after explaining about the objectives and benefits of this study. 3. The respondents was voluntarily allowed and to stop the participation during answering the questionnaire for any reasons. 4. The information of the respondent was kept confidentially and the respondent‟s name was not included in the questionnaire. The interviewees‟ answers were kept confidential and information obtained was used solely for research purposes. Nway Eint Chei Results / 38 CHAPTER IV RESULTS This study was conducted to assess the client satisfaction of antenatal care service in health centers in Wet-Let Township, Myanmar. The results were presented in the following parts: general characteristics, antenatal care service quality, accessibility to antenatal care service and client satisfaction on antenatal care service. The last part showed the associations between those factors and client satisfaction on antenatal care service. 4.1 General Characteristics Table 4.1 revealed that the mean age of clients was 29 years old. About three-fourth of clients (74%) were between 20 and 35 years old. All the pregnant women in this study are Myanmar and Buddhism. Majority of pregnant women (90.7%) were married. Regarding education status, nearly half of the respondents (44.7%) had middle school and upper level. Most of the clients (62.2%) were farmers followed by self-employed (19.5%) and government servant (4.5%). In term of average monthly family income, almost half of the respondents (45.5%) had monthly family income more than 160,000 Kyats. Majority of clients (88.6%) had three and less than three family members. Approximately half of the clients (55.7%) were first time pregnancy and 25.6% had given birth one time. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 39 Table 4.1 General characteristics of 246 pregnant women Variable Number Percentage 25 10.1 182 74.0 39 15.9 Age (Years) <20 20-35 >35 Mean± SD 28.5±6.057 (years) Min – Max 18 – 43 (years) Marital status Married 223 90.7 23 9.3 Primary school and lower level 136 55.3 Middle school and upper level 110 44.7 153 62.2 Self-employed 48 19.5 Housewife 34 13.8 Government servant 11 4.5 ≤ 160,000 134 54.5 >160,000 112 45.5 Separated Education Occupation Farmer Average monthly family income(Kyats) Median Min – Max 150000 (kyats) 45000 – 1050000 (kyats) Family members ≤3 218 88.6 >3 28 11.4 Median Min – Max 2 2–7 Nway Eint Chei Results / 40 Table 4.1 General characteristics of 246 pregnant women (cont.) Variable Number Percentage Primigravida 137 55.7 Multigravida 109 44.3 Gravida Min – Max 1–6 Parity (Number of childbirth) Nullip 137 55.7 Primipara 63 25.6 Multipara 46 18.7 Min – Max 0–5 *1 USD = 1372.85 Kyats (Cited on May 26, 2017, Available from: https://www.google.co.th/) 4.2 Level of client satisfaction, service quality and accessibility In table 4.2, level of client satisfaction, overall antenatal care service quality and overall accessibility to antenatal care service of 246 pregnant women were shown. In overall client satisfaction, the percentage was at moderate, low and high levels (80.1%, 17.5% and 2.4% respectively). Over one-third (35%) was the low level of responsiveness followed by tangible (33.3%), empathy (25.6%), assurance (24.4%) and reliability (21.2%). Regarding to overall service quality, the percentage was at low, moderate and high levels (78.9%, 17.9% and 3.3% respectively). In term of overall accessibility, the percentage was at moderate, low and high levels (58.9%, 24.4% and 16.7% correspondingly). Majority (81.7%) was the problem with the time consumption followed by distance (51.6%), information for public mobile phone system (50.8), facility for electricity (32.5%), distance (51.6%) and providers’ manner (24%). Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 41 Table 4.2 Level of client satisfaction, service quality and accessibility of 246 pregnant women Variable High Number Moderate % Number Low % Number % 6 2.4 197 80.1 43 17.5 Responsiveness 23 9.3 137 55.7 86 35.0 Tangible 30 12.2 134 54.5 82 33.3 Empathy 31 12.6 152 61.8 63 25.6 Assurance 37 15.0 149 60.6 60 24.4 Reliability 47 19.1 147 59.8 52 21.1 8 3.3 44 17.9 194 78.9 Overall Accessibility 41 16.7 145 58.9 60 24.4 Time 45 18.3 0 0.0 201 81.7 Distance 119 48.4 0 0.0 127 51.6 Information 121 49.2 0 0.0 125 50.8 61 24.8 105 42.7 80 32.5 184 74.8 0 0.0 62 25.2 24 9.8 163 66.3 59 24.0 193 78.5 44 17.9 9 3.7 Overall Client Satisfaction Overall Service Quality Facility Transportation Providers’ manner Cost 4.3 Antenatal care service quality It is worth considering the antenatal care service quality, there were seven parts such as registration, history taking, physical examination, laboratory investigation, pharmacy unit, health education and follow-up. Registration Among the 246 respondents, most of them (95.5%) were always convenient and easy to register and 88.2% got the antenatal record book. History taking Of the 246 pregnant women, majority of them (83.7%) remembered the gestational age of 1st antenatal visit and most of them (86.4%) had more than 12 weeks Nway Eint Chei Results / 42 gestational age. Three-fourth of the clients (76.8%) had less than four antenatal visits. Only 20.7% knew at least four antenatal visits needed to come to the health center. Most of them (86.3%) need four antenatal visits at health center. 81.7% of pregnant women were asked their last menstrual period and 68.3% were told their expected date of delivery. Only 38.2% of clients were asked the history of twin pregnancy. Almost half of the clients (45.5%) were asked about history of smoking and most of them (89.5%) were non-smokers. Nearly half of clients (44.7%) were asked the history of betel chewing and 64.3% of them were non-betel chewer. 49.2% of clients were asked about the history of drug allergies. 32.1% of respondents were asked about the history of taking medicines and 33.7% about the history of underlying illness such as heart disease (70%), hypertension (32%), malaria (22%), asthma (18%), diabetes (16%), TB (12%), chronic renal disease (2%), syphilis (2%), hepatitis (2%), and HIV (2%). 37.4% of clients had illness due to this pregnancy such as hypertension (12%) and heart disease (2.2%). 96.3% of pregnant women were asked regarding history of birth spacing: 78.5% of them used various contraception method, depo injection (71%) and oral contraceptive pills (39.8%). The median month of taking contraception was 18 months and 82.8% of them used continuously. 65.6% remembered the time taken to stop contraceptive use before getting pregnancy and majority of them (78.7%) stopped more than 6 months. Only 19.5% of the respondents had voluntary confidential counseling and testing (VCCT) for HIV and syphilis. Majority (91.1%) got tetanus toxoid vaccine injection and 79.5% of them had completed dose. Physical examination Concerning about the physical examination, 72.4% were always measured their weight and 12.6% were measured their height. Although 97.6% of the respondents were measured blood pressure, only 21.7% of them knew their blood pressure. While majority of the clients (96.3%) were examined obstetric examination, symphysio-fundal height (93.2%), fetal heart sound (54.9%) and position of fetus (47.3%) included. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 43 Laboratory investigation Regarding laboratory investigation, only 39.8% of pregnant women received blood tests at health center and most of them (96.9%) were tested one time. Less than one-fifth of respondents (13%) received random blood sugar test. 8.5% of the pregnant women were merely tested their blood group. About half of the clients (54.9%) received urine test however only 8.9% of them tested four times. 5.7% of pregnant women were always explained about laboratory tests. Pharmacy unit In term of pharmacy unit, 74% of pregnant women knew the prescribed medicines such as folic acid (79.7%), iron (27.5%), multivitamin (23.1%), vitamin B1 (14.3%) and anti-helminth (4.4%). Majority of them (86.2%) always got prescribed medicines at health centers. About half of the clients (51.6%) got anti-helminth drug at 2nd trimester. Health education Regarding health education, more than half of pregnant women (60.6%) had been explained about antenatal information by HCP. 44.3% of the respondents were explained about danger signs of pregnancy such as bleeding per vagina and abdominal pain. 11% of clients were merely explained about danger signs of pregnancy induced hypertension such as swollen face and legs (92.6%), headache (70.4%), convulsion (33.3%), blurred vision (25.9%) and severe nausea and vomiting (7.4%). Only 4.1% of respondents were explained about danger signs of gestational diabetes including tiredness (100%), thirsty (60%) and dry mouth (20%). HCP explained 55.7% of the pregnant women about taking iron, folic acid and multivitamin supplement, 37.8% about balanced diet, 22.4% about sleeping pattern, 21.5% about physical activities, 18.3% about wearing suitable dress and 45.9% about taking ANC at least 4 times and plan for birth. Follow up Of the 246 pregnant women, majority of them (89%) got the date for follow up visit and 84.6% will come back for next antenatal visit. Nway Eint Chei Results / 44 Table 4.3 Antenatal care service quality of 246 pregnant women Variable Number Percentage Registration Convenient and easy registration No, never 3 1.2 Yes, sometimes 8 3.3 Yes, always 235 95.5 Received ANC record book 217 88.2 206 83.7 <4 189 76.8 ≥4 57 23.2 History taking Remember Gestational age of 1st ANC visit Number of AN visits Min – Max Know ANC visits needed 2–9 51 20.7 Have history of last menstrual period 201 81.7 Know expected date of delivery 168 68.3 94 38.2 History of smoking 112 45.5 History of betel chewing 110 44.7 History of drug allergies 121 49.2 79 32.1 Heart disease 35 70.0 Hypertension 16 32.0 Asthma 9 18.0 Diabetes 8 16.0 Chronic renal disease 1 2.0 No disease 77 83.7 Hypertension 11 12.0 Heart disease 2 2.2 History of twin pregnancy History of consuming medicines History of underlying illness (n=83) Illness due to pregnancy (n=92) Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 45 Table 4.3 Antenatal care service quality of 246 pregnant women (cont.) Variable Number Percentage History of birth spacing (n=237) Depo injection 132 71.0 Oral contraceptive pills 74 39.8 Not use contraception 51 21.5 Implant 4 2.2 Intrauterine device 1 0.5 48 19.5 178 79.5 No, never 33 13.4 Yes, sometimes 35 14.2 178 72.4 31 12.6 230 95.8 Hypertension 10 4.2 Always show high blood pressure 10 4.2 Symphysio – fundal height 221 93.2 Fetal heart sound 130 54.9 Position of fetus 112 47.3 Receive blood tests 98 39.8 Receive random blood sugar test 32 13.0 Receive blood grouping 21 8.5 135 54.9 208 84.6 Yes, sometimes 24 9.8 Yes, always 14 5.7 History of VCCT for HIV and Syphilis Tetanus toxoid vaccine injection 2nd dose (n=224) Physical examination Weight measured Yes, always Height measured Blood pressure measured (n=240) Normal Obstetric examination (n=237) Laboratory investigation Receive urine test Explanation about laboratory test No, never Nway Eint Chei Results / 46 Table 4.3 Antenatal care service quality of 246 pregnant women (cont.) Variable Number Percentage Pharmacy unit Know prescribed medicines (n=182) Folic acid 145 79.7 Iron 50 27.5 Multivitamin 42 23.1 Vitamin B1 26 14.3 8 4.4 No, never 15 6.1 Yes, sometimes 19 7.7 212 86.2 127 51.6 Explanation about antenatal information 149 60.6 Explanation about danger signs of pregnancy 109 44.3 Anti-helminth Getting prescribed medicines (n=231) Yes, always Getting anti-helminth drug Health education Explanation about danger signs of pregnancy induced hypertension (n=27) Swollen face and legs 25 92.6 Headache 19 70.4 Convulsion 9 33.3 Blurred vision 7 25.9 Severe nausea and vomiting 2 7.4 137 55.7 Balanced diet 91 97.8 Having 3-4 times a day 18 19.4 Sleep on side position (Left side) 52 94.5 Using bed net while sleeping 18 32.7 Sleeping 2 hours in daytime 17 30.9 Sleeping 8 hours at night 15 27.3 53 21.5 Explanation about taking vitamin supplement Explanation about balanced diet (n=93) Explanation about sleeping pattern (n=55) Explanation about physical activity Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 47 Table 4.3 Antenatal care service quality of 246 pregnant women (cont.) Variable Explanation about wearing suitable dress Number Percentage 45 18.3 113 45.9 219 89.0 No 19 7.7 Uncertain 19 7.7 208 84.6 Explanation about plan for delivery Follow up Getting follow up date Coming back for next ANC visit (n=227) Yes 4.4 Accessible to antenatal care service Table 4.2 shows that 58.9% of the pregnant women had moderate accessible to antenatal care service, 24.4% had a low accessibility and 16.7% had a high accessibility. In table 4.4, almost half of the clients (48.4%) were living less than 3 miles far from nearest health center. About two-third of them (61%) went to health centers by own transportation such as motorcycle, tuk-tuk and car. 44.7% of the respondents spent less than 15 minutes to come to health center. Almost three-fourth of the pregnant women (74.8%) said that they were convenient to come to ANC service center. Most of the respondents (75.6%) thought that health services were always available and less than a quarter (23.6%) assumed that they were sometimes available. The median of the waiting time at health center was 30 minutes and over three-fourth of respondents (79.3%) said that they were acceptable in waiting time at health center. All clients had consultation time with HCP less than 30 minutes and the median consultation time were 15 minutes. Almost all the respondents (95.5%) assumed they could afford the transportation cost. 67.5% of the service costs and 69.9% laboratory cost were free of charge. Four-fifth of the pregnant women (80.1%) though that they were always affordable of overall service cost. Most of them (75.7%) cost less than 1500 kyats for personal expense. Nway Eint Chei Results / 48 Regarding ANC service information, the respondents knew via friends/relatives (66.7%), health care personnel (25.2%), parent (20.7%), billboard (17.5%), television (11.4%), pamphlet (8.1%) and sister (2.8%). A majority (85.4%) of respondents always had opportunity for asking questions to HCP while only 73.2% of HCP had good communication and 69.1% of clients were feeling always welcomed by HCP. Only 4.9% of the pregnant women were always explained procedures before starting by HCP. In terms of facility, there were availability of drinking water (97.6%), toilet (67.1%), mobile phone communication system (57.7%), water for hand washing (48.4%) and electricity (23.6%). Table 4.4 Accessibility to antenatal care service of 246 pregnant women Variable Number Percentage Distance of health center from home (miles) <3 119 48.4 3-5 40 16.3 >5 87 35.4 Median Min – Max 3miles 0.25 – 40miles Transportation method Own transportation 150 61.0 Walk 80 32.5 Public transport 16 6.5 110 44.7 15-30 69 28.0 >30 67 27.2 Travelling time (minutes) <15 Median Min – Max Convenience to come to ANC service 20 min 3 – 210 min 184 74.8 2 0.8 58 23.6 186 75.6 Availability of service No, never Yes, sometimes Yes, always *1 mile = 1.60934 km (Available from: https://www.google.co.th/) Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 49 Table 4.4 Accessibility to antenatal care service of 246 pregnant women (cont.) Variable Number Percentage Waiting time at health center (minutes) (n=172) <30 54 31.4 ≥30 118 68.6 Median Min – Max Acceptability of waiting time 30 min 0 – 240 min 195 79.3 217 100.0 Consultation time (minutes) (n=217) ≤30 Median Min – Max Affordability of transportation cost 15 min 10 – 30 min 235 95.5 166 67.5 1 – 1500 57 23.2 >1500 23 9.3 ANC service cost (Kyats) Free of charge Median Min – Max 0Kyat 0 – 15000Kyats Laboratory cost (Kyats) Free of charge 172 69.9 1 – 1500 27 11.0 >1500 47 19.1 Median Min – Max 0Kyat 0 – 15000Kyats Affordability of overall service cost No, never 3 1.2 46 18.7 197 80.1 1 -1500 106 75.7 >1500 34 24.3 Yes, sometimes Yes, always Personal cost (Kyats) (n=140) Median 1000 Kyats *1 USD = 1372.85 Kyats (Cited on May 26, 2017, Available from: https://www.google.co.th/.) Nway Eint Chei Results / 50 Table 4.4 Accessibility to antenatal care service of 246 pregnant women (cont.) Variable Min – Max Number Percentage 200 – 20000 Kyats Information about ANC service (n=246) Friends/Relatives 164 66.7 Health care Personnel 62 25.2 Parent 51 Billboard 43 Television 28 11.4 Pamphlet 20 8.1 7 2.8 No, never 14 5.7 Yes, sometimes 22 8.9 210 85.4 No, never 23 9.3 Yes, sometimes 53 21.5 170 69.1 Bad 24 9.8 Uncertain 42 17.1 180 73.2 216 87.8 Yes, sometimes 18 7.3 Yes, always 12 4.9 Drinking water 240 97.6 Toilet 165 67.1 Communication i.e. public phone 142 57.7 Water for hand washing 119 48.4 58 23.6 Sister Opportunity for asking questions to HCP Yes, always Welcome by HCP Yes, always Communication of HCP Good Explanation of procedures (n=30) No, never Available facility (n=246) Electricity for light Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 51 4.5 Client satisfaction of pregnant women Table 4.5 showed that client satisfaction towards antenatal care service. Regarding to tangibles, about three-fourth of pregnant women (77.2%) satisfied to neatness and well-dressing of HCP, just over a half (52.5%) satisfied to cleanliness of health center, 47.9% satisfied to convenience of waiting room, nearly a third (30.9%) satisfied on equipment for examination room is in good condition. In term of reliability, 65.8% of the client satisfied to HCP provides service on time, over half of the respondents (54.4%) satisfied to health personnel’s skill in providing ANC and 44.7% also satisfied to availability of clear information about ANC at health center. Concerning about responsiveness almost half of respondents (52.5%) satisfied to giving ANC on time, 45.9% satisfied to willingness of HCP on helping pregnant woman, 37.4% also satisfied to availability of HCP in providing ANC and just about a third (34.9%) satisfied towards rapidity of HCP in solving problem of pregnant woman. Of the 246 pregnant women whom interviewed about assurance, 65.1% satisfied to feeling of safety and trust in ANC, 54.1% satisfied to timeliness of HCP in giving ANC, 52.9% satisfied to management of HCP on your problem and exactly a half satisfied to knowledge of HCP for answering their questions. Regarding empathy, 71.1% of respondents, 43.1%, 42.3% and 34.9% satisfied to privacy of examination room, trying of HCP on giving best service, attention of HCP on their feelings and understanding of HCP on their needs respectively. Table 4.5 Client satisfaction towards antenatal care service of 246 pregnant women Percentage Items Very satisfied Satisfied Uncertain Dissatisfied Very dissatisfied Tangibles Neatness and well-dressing 14.6 62.6 8.5 8.5 5.7 Cleanliness of health center 4.1 48.4 13.8 26.4 7.3 Convenience of waiting 2.0 45.9 20.7 23.6 7.7 of HCP room Nway Eint Chei Results / 52 Table 4.5 Client satisfaction towards antenatal care service of 246 pregnant women (cont.) Percentage Items Very satisfied Equipment for examination Satisfied Uncertain Dissatisfied Very dissatisfied 3.3 27.6 30.9 28.9 9.3 9.3 56.5 10.2 17.5 6.5 8.9 45.5 28.0 9.3 8.1 4.9 39.8 27.6 19.9 7.7 Giving of ANC on time 3.7 48.8 13.0 26.8 7.7 Willingness of HCP on 2.8 43.1 25.6 21.1 7.3 1.6 35.8 28.9 28.9 4.9 1.6 33.3 40.2 17.5 7.3 9.8 55.3 17.9 14.2 2.8 3.7 49.2 23.6 14.2 9.3 9.8 40.2 37.8 8.1 4.1 6.1 48.0 7.7 28.0 10.2 room is in good condition Reliability HCP provides service on time Health personnel’s skill in providing ANC Availability of clear information about ANC at health center Responsiveness helping pregnant women Availability of HCP in providing ANC Rapidity of HCP in solving problem of pregnant women Assurance Feeling of safety and trust in ANC Management of HCP on her problem Knowledge of HCP for answering her questions Timeliness of HCP in giving ANC Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 53 Table 4.5 Client satisfaction towards antenatal care service of 246 pregnant women (cont.) Percentage Items Very satisfied Satisfied Uncertain Dissatisfied Very dissatisfied Empathy Privacy of examination 13.4 57.7 7.7 15.9 5.3 4.9 38.2 35.8 18.3 2.8 6.9 35.4 31.3 19.5 6.9 2.0 32.9 32.5 28.5 4.1 room Trying of HCP on giving best service Attention of HCP on your feelings Understanding of HCP on her needs 4.6 Associations between general characteristics and client satisfaction Table 4.6 showed the associations between the general characteristics i.e. age, marital status, education, occupation, average monthly family income, family members, gravida and parity towards client satisfaction. Education and client satisfaction had significant association (p=0.013) that who had middle school and higher level education were good in satisfaction in compared to those who had primary school and lower level. It was found that there was associations between parity and client satisfaction (p=0.022). Those who had more than one time child birth had moderate satisfaction of 89.1% compared to those who had one time child birth and no child birth. The study revealed that there were no associations between age group, marital status, occupation of pregnant women, family income, family member, the number of times a woman has been pregnant and client satisfaction (p>0.05). Nway Eint Chei Results / 54 Table 4.6 Associations between general characteristics to antenatal care service and client satisfaction (n=246) Level of overall client satisfaction Variable Total High Moderate Low n % n % n % p value Age <20 years 87 2 2.3 73 83.9 12 13.8 20-35 years 120 2 1.7 94 78.3 24 20.0 >35 years 39 2 5.1 30 76.9 7 17.9 Married 233 6 2.7 179 80.3 38 17.0 Separated 23 0 0.0 18 78.3 5 21.7 0 0.0 114 83.8 22 16.2 110 6 5.5 83 75.5 21 19.1 Housewife 34 1 2.9 29 85.3 4 11.8 Occupation 212 5 2.4 168 79.2 39 18.4 0.523 Marital status 0.766 Education ≤ Primary school ≥Middle 136 0.013 school Occupation 0.6341 Average monthly family income(Kyats) ≤ 160,000 134 3 2.2 105 78.4 26 19.4 >160,000 112 3 2.7 92 82.1 17 15.2 ≤3 218 4 1.8 175 80.3 39 17.9 >3 28 2 7.1 22 78.6 4 14.3 Primigravida 137 2 1.5 114 83.2 21 15.3 Multigravida 109 4 3.7 83 76.1 22 20.2 Nullip 137 2 1.5 114 83.2 21 15.3 Primipara 63 3 4.8 42 66.7 18 28.6 Multipara 46 1 2.2 41 89.1 4 8.7 0.678 Family member 0.212 Gravida 0.278 Parity 1 p-value by Chi-square test 0.022 Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 55 4.7 Associations between antenatal care service quality and client satisfaction Concerning about the service quality, there was significant association between the antenatal care service quality and the client satisfaction (p=0.003), there was 9.6% in high service quality with a high level of client satisfaction and 18.6% in low service quality with a low level of client satisfaction. Table 4.7 Associations between level of antenatal care service quality and client satisfaction (n=246) Level of overall client satisfaction Overall ANC service quality Total High Moderate n % n % Low n value % Good 52 5 9.6 40 76.9 7 13.5 Poor 194 1 0.5 157 80.9 36 18.6 p -value by Fisher’s Exact test p 0.003 p<0.05 is significant. 4.8 Associations between accessibility to antenatal care service and client satisfaction Regarding the accessibility to antenatal care service, the findings stated that there were statistically significant associations between accessibility to health service and client satisfaction on antenatal care service which p value was less than 0.001. 14.6% of the respondents who had high accessibility to ANC service had high level of client satisfaction. 20% of the poor accessibility had poor level of client satisfaction. Associations were found between distance and client satisfaction (p=0.047) with 4.2% of the pregnant women lived near to the health center had good satisfaction to ANC service. There were no associations between transportation and client satisfaction which p value was 0.135. The study showed that there was significant association between time consumption at health center and client satisfaction (p=0.002), 20.9% of the respondents had prolonged waiting time and short Nway Eint Chei Results / 56 consultation time. The association was also found between cost and client satisfaction with the p value of 0.006, 32.1% of poor satisfaction to health service had to pay for service fee. It was found that there was no associations between information and client satisfaction (p=0.144). The study revealed that there was association between providers’ manner and client satisfaction (p<0.001) and 16.7% of pregnant women who had good communication with HCP had good level of client satisfaction. There was no statistical association between facilities and client satisfaction. (p=0.07). Table 4.8 Associations between level of accessibility to antenatal care service and client satisfaction (n=246) Level of overall client satisfaction Accessibility to ANC service Total High n % Moderate p Low n % n 33 80.5 2 value % Overall accessibility 4.9 <0.0011 Good 41 6 14.6 Poor 205 0 0.0 164 80.0 41 20.0 Easy to access 119 5 4.2 99 83.2 15 12.6 Poor 127 1 0.8 98 77.2 28 22.0 Easy to access 184 6 3.3 150 81.5 28 15.2 Poor 62 0 0.0 47 75.8 15 24.2 Acceptable 45 2 4.4 42 93.3 1 2.2 Poor 201 4 2.0 155 77.1 42 20.9 Affordable 193 6 3.1 161 83.4 26 13.5 Can’t afford 53 0 0.0 36 67.9 17 32.1 Easy to get 121 2 1.7 103 85.1 16 13.2 Poor 125 4 3.2 75.2 27 21.6 Distance 0.047 Transportation 0.135 Time 0.002 Cost 0.006 Information 1 p-value by Chi-square test 94 p-value by Fisher’s exact test 0.144 Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 57 Table 4.8 Associations between level of accessibility to antenatal care service and client satisfaction (n=246) (cont.) Level of overall client satisfaction Accessibility to ANC service Total High n % Moderate p Low n value n % % 19 79.2 1 4.2 Providers’ manner Good 24 4 16.7 Poor 222 2 0.9 178 80.2 42 18.9 Good 61 4 6.6 48 78.7 9 14.8 Poor 185 2 1.1 149 80.5 34 18.4 <0.001 Facilities 1 p-value by Chi-square test p-value by Fisher’s exact test 0.07 Nway Eint Chei Discussion / 58 CHAPTER V DISCUSSION This study aimed to assess the client satisfaction of antenatal care service in health centers. The discussion is based on the findings collected from 246 pregnant women who come to antenatal care service at health centers in Wet-Let Township, Myanmar by using interview questionnaires. The discussion was presented by the following topics: 1. Client satisfaction on antenatal care service at health centers 2. General characteristics and client satisfaction 3. Antenatal care service quality and client satisfaction 4. Accessibility to antenatal care service and client satisfaction 5.1 Client satisfaction on antenatal care service at health centers From the survey, it was found that 80.1% of total pregnant women who come to antenatal care service at health centers had moderate satisfaction level, 17.5% had low level and 2.4% had high level. The higher the perceived service quality in five aspects: Tangible, Reliability, Responsiveness, Assurance and Empathy, the higher the level of client satisfaction. The perception of service was a critical determinant of client satisfaction. Regarding tangibles 38.2% of pregnant women were dissatisfied about equipment condition for examination room. It could be absence or inadequacy or poor condition or no latest model of equipment. For example equipment in some health center was in poor condition and some didn’t have weighing machines, as well as no establishment of corporate health centers equipped with the up to date facilities. About a third (33.7%) was dissatisfied to cleanliness of health centers, the problem may be due to policies, work culture and attitude. Although being different geographic location, same policy was set up for infrastructure, health workforce and management. Some health center were facing space limitation, for instance using only one space for Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 59 various functions as registration unit, laboratory unit, pharmacy unit and health education unit. Neither enough resource nor job satisfaction may cause over workload, stressful condition and no responsibilities of giving hotel service health care. Not only limitation of space and human resource but also poor facilities and communication within organization could lead to less than ideal patient expectation. However, using one space for discrete functional service can save the budget, from client’s point of view, it could not be convenient and could dissatisfy because they have to pay service fee at some health centers. Chauhan (23) found out that client satisfaction is influenced by many factors which are quality of health services provided, availability of medicine, behavior of doctors and health staff, cost of services, health care service infrastructure, physical comfort, emotional support, and respect for patient preferences. In term of reliability, about one-fourth of respondents were dissatisfied to availability of clear information about ANC and providing service on time. It could be health care personnel (HCP) were not always present at health centers because sometimes they attended the training course and while going to attend training, they didn’t inform the pregnant women. Even though ANC was free at the point of care once a week, some HCP didn’t give ANC if the pregnant women couldn’t pay service fee. As there was no establishment of effective communication system like mobile phone service, the pregnant women cannot be availability of clear ANC information. When pregnant woman did not get the promised service dependently and accurately, she could dissatisfy to service unlike a normal woman because they are high priority group and dependent to others to come to health centers. Markovie` (87) reported that the reliability had the most significant impact on overall client satisfaction (p=0.013). Concerning about responsiveness, just over one-third of pregnant women were dissatisfied to giving ANC on time, availability of HCP followed by willingness of HCP on helping pregnant women and rapidity of HCP in solving problem. It could be due to interpersonal skills of health care providers. Due to resource scarcity, HCP provided not only health care but also vaccination program with door-to-door service which caused unavailability of health care provider and the health service on time. Insufficient communication, for example prescribing more and talking less to the pregnant women, led to dissatisfaction with the antenatal care service. Sometimes Nway Eint Chei Discussion / 60 HCP delay to make decision for quick solutions to the problems of respondents and therefore they were more likely to be dissatisfied. The study in Nigeria concluded that patient satisfaction linked to the provided quality of services and 85.6% satisfied with the antenatal care services and good attitude of nurses at the clinic (17). Regarding assurance and empathy, poor communication, lack of empathy led to dissatisfaction. Mood is one of the issues that could influence the behavior. The positive mood could influence the behavior like recognizing that the pregnant women expect personal relationship, showing compassion and care, vice versa, shortages of human resources, inappropriate balance and mix of skills, inequitable distribution and difficulties in rural retention led to negative mood with the results of dissatisfaction to the pregnant women. Low salary, over workload, lack of clear recruitment and deployment policies could affect the role and responsibilities of health care personnel. They were not interested in their job and also what the pregnant women need, the clients’ feeling and problem, bring on dissatisfaction. The research done in Nepal showed that clients satisfied with antenatal care received provider’s skills (85%), politeness of health care personnel (83%) and assured confidentiality (67%) (68). It can be seen from this study that client satisfaction varies in different health facilities and circumstances. This disparity may be due to provided antenatal care service quality differences or different expectations of the pregnant women. 5.2 General characteristics and client satisfaction Regarding the general characteristics, the age range of the pregnant women was less than 20 years, from 20 to 35 years and over 35 years. Among married pregnant women only 2.7% had good client satisfaction. However there is no one among separated women had good client satisfaction. It could be explained by respondents cannot get money and companion and those living with husband may have social support toward their antenatal care compared to those who are separated. The finding showed majority of the pregnant women (86.2%) had various types of occupation such as farmer, general worker, self-employee and government servant. 13.8% were housewife with dependent. Among the pregnant women who had Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 61 occupation 2.4% and 2.9% of housewife had good level of satisfaction in this study. One explanation could be that the health center could not be opened 24 hour, the unavailability of health care personnel, the pregnant women were working at outside and the same time of working hour and health centers opening hour. Oliaee (88) found out that there were no significant associations between maternal characteristics like age, marital status, occupation and client satisfaction. Nearly half of pregnant women (45.5%) had more than 160,000 kyats of monthly family income and 54.5% had lower than 160,000 kyats. The high income group (2.7%) and 2.2% of low income group had good satisfaction level because the high income group did not need to worry about the service cost and they said that the more they can pay for the service, the more the health care personnel take care them. However, the study which conducted by Pascoe (19) explained that pregnant women with higher incomes tend to be less satisfied. Majority of the respondents (88.6%) had at most three family members and 11.4% had more than three family members. The more family members group (7.1%) and the less family member group (1.8%) had high satisfaction level. Similar to the married group, pregnant women with many family members may have social support toward their health care. However the median family member was 2, in accordance with the declining fertility rate as well as findings from the literature concerning about reducing the fertility rate in Malaysia (89). 3.7% of multigravida group (has been pregnant for at least a second time) and 1.5% of primigravida group (pregnant for the first time) had high satisfaction level. It could be clarified that the primigravida group did not know well about the antenatal service compared to the multigravida group. The number of primary school and lower education level and middle school and higher education level in this study was nearly the same. This was due to the researcher’s desire to avoid the selection bias because of unequal participation of the different education background. Two variables from general characteristics were significantly associated with client satisfaction and supporting first hypothesis. Among them, it was found that there were statistical significant associations between the education level and client satisfaction. The P value was 0.013. The almost half of the respondents had middle school and upper education level 44.7% compared with 55.3% Nway Eint Chei Discussion / 62 for primary school and lower education level. Among the 110 high educated respondents, 5.5% of them were at high and 75.5% were at moderate satisfaction level. The variable was also mentioned in previous study conducted in India that the individual education positively associated with patient satisfaction (74). It might be due to if the pregnant women had the higher level of education, they can read the information written in the antenatal record book. So they can know whether the health care personnel follow the protocol in record book or not. The parity was also found associated with the client satisfaction which P value as 0.022. The multiparous women (given birth more than once) consist of 46 respondents, the primiparous women (given birth only once) consist of 63 respondents and the nulliparous women (never given birth) consist of 137 respondents. The multiparous women were at 8.7%, the primiparous women were at 28.6% and the nulliparous women were at 15.3% of the poor level of satisfaction respectively. This finding was same as the study conducted in Nigeria that multiparous women were more satisfied with antenatal care than primiparous women (80). The remaining variables of the general characteristics such as age, marital status, occupation, average monthly family income, family member and gravida were found no statistically significant associations with the client satisfaction. 5.3 Antenatal care service quality and client satisfaction According to the results, the percentages of low, moderate and high overall service quality were 78.9%, 17.9% and 3.3% respectively. There is statistical significant finding between the service quality and client satisfaction (p=0.003). 9.6% of respondents perceived good service quality had high level of client satisfaction. It was confirmed by the study in Ethiopia that antenatal care contents were significantly associated with client satisfaction (78). Antenatal care service delivery relies on a mix of public, private for-profit, private not-for-profit and ethnic health organization. The problem within these organizations is poor alignment leading to timeliness of unavailability of resources such as technical support, antenatal record book. Unequal distribution of resources can Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 63 cause different types of service quality affecting the expectation of pregnant women and also satisfaction to the provide service. Overcrowded service and unnecessary prolonged facility affect to maternal satisfaction on antenatal care service in survey conducted by Changole (69). Lack of well-developed health information system, advanced technology brought on unavailability of important information like booking visit should be within 12 weeks of gestational age, in time. Most of the respondents didn’t know how many antenatal visits do they need and is antenatal care important for their pregnancy. Some said they are taking antenatal care to get the governmental support, not for their prenatal health. This kind of lack of health knowledge depends on both supply and demand sides. The supplier faces many challenges relating to availability and distribution of inputs, weakness in key functions and public financial management, on the other hand, the demand side had poor literacy, no right for decision to take ANC, poverty and no interested in health knowledge. These could affect the outcome of pregnancy and satisfaction toward the antenatal service. The studies in developing countries showed that the interpersonal aspects of care were the determinants of maternal satisfaction (3). Changole (69) explained client satisfaction also associates with perceiving of the technically good quality of care and technically competent health care provider. Without the development of the minimum quality standards guideline could affect the quality of health care. Poor health seeking behavior of pregnant women can give rise to ignore the quality of health care, for example what is the minimum standard of antenatal service quality, what is the role and responsibilities of health care provider. Moreover, one of the main issues is misunderstanding. Majority of the pregnant women satisfied about receiving ANC from health care personnel because of shortage of health care personnel at rural area. Typically, today’s patients are more educated and much richer, they could expect the different types of antenatal care similar to the care given at specialist hospital and private hospital although they don’t know the minimum quality of antenatal care at health center. In spite of getting iron and folic acid medicines freely at health centers, some respondents want to take vitamin and mineral supplement prescribed in private centers. Similarly, blood test and urine test can be done at health centers, but pregnant women want to take ultrasound. A huge Nway Eint Chei Discussion / 64 gap between the service provider and the service seeker could lead to decrease client satisfaction. Even though the majority of the pregnant women said that they were moderately satisfied with the antenatal care service, they might have various reasons for saying this way and might not reflect their true opinions. The majority of them, in point of fact, did not get any feedback from the health care personnel as regards what their examination and investigation results were. 5.4 Accessibility to antenatal care service and client satisfaction According to the answers of the respondents, 58.9% were moderate accessibility, 24.4% were low and 16.7% were high accessibility to antenatal care service. The findings stated that there was statistical significant association between accessibility to antenatal care service and client satisfaction (p<0.001). Additionally, 14.6% of highly accessible respondents were at the high client satisfaction level. Therefore, it can be inferred that the higher the accessibility to antenatal care health services, the higher the level of client satisfaction. This finding was same as the study conducted in Thailand which has the relationship between accessibility and satisfaction (84). This study showed that there was association between distance and satisfaction (p=0.047). Aldana et al. (9) stated that satisfaction is influenced by accessibility of the ANC services chiefly place of residence, distance and transport to the healthcare facilities. But the result showed that there was no association between transportation and satisfaction. Although there is availability of health service once a week, some pregnant women had inconvenience to come to health center because of living far from health center, asking for help to send and come along with her and the same working time at outside and opening hours of health center and also poverty. Misunderstanding upon the in service training can cause the dissatisfaction. When they came to the health centers, the HCP were going for training. So they thought that they cannot always get the HCP provided service and only can always get the traditional birth attendants (TBA). Some said the HCP gave only health care, but the TBA carried Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 65 out not only the care but also the house keeping. This misinterpretation between the provider and the pregnant women create dissatisfaction. There was no association between information and satisfaction. In determining the outcome of client satisfaction, the amount of time the pregnant women spent in the waiting at health center played a very important role. This may be due to the working style of health care personnel, the kind of respondents she sees, the locality where she practices and the efficacy of the supportive environment. In this study associations were found between time consumption, costs, providers’ manner at health center and client satisfaction (p<0.05). The study in Malaysia found that patient who did not need to pay for service charges was higher satisfied than those who paid for ANC service cost (70). However, there is no association between facilities and satisfaction (p>0.05). Bart (90) also reported that there were access barriers to health centers. It could be explained by prolonged waiting time, consultation time, personal cost and lack of electricity. In addition, the barriers for accessing antenatal care service can be removed with some technical assistance from stakeholders, local health authorities and community. They play a pivotal role with helping the pregnant women to access the antenatal care services. Despite the fact that only 16.7% was highly accessible, unequal distribution of resources and affecting from natural disaster were still far from satisfactory. Limitation of Study Asking about the satisfaction towards antenatal care service was sensitive top which could lead to confused or falsified responses. Moreover, the respondents might get difficulty to answer dissatisfaction in front of interviewer. The respondents’ opinions may be covered by the feeling afraid of health care personnel and there could have bias because this study was done within the boundary of health center. However, the interview was conducted as exit interview to minimize the bias. Nway Eint Chei Conclusion and Recommendations / 66 CHAPTER VI CONCLUSION AND RECOMMENDATIONS This cross-sectional study was conducted to assess the client satisfaction of antenatal care service in health centers in Wet-Let Township, Myanmar. The research was to find out the association between the general characteristics, antenatal care service quality, accessibility to antenatal care service and client satisfaction on antenatal care service. The study population was the pregnant women who come to antenatal care service at health center in Wet-Let Township, Myanmar. A total number of 246 respondents were interviewed by using the structured questionnaire from the duration of 1st April to 30th April. Chi-square and Fisher’s exact test were used for data analysis. 6.1 Conclusion Among the 246 pregnant women in Wet-Let Township, Myanmar, the average age was 28.5 years old with majority of low risk group. Almost all (90.7%) were married and lived in this township together with husband. Nearly half of them (44.7%) had middle school and upper level of education. Only 13.8% of respondents were housewife with dependent and the monthly family more than 160,000 kyats per month in 45.5% of respondents. Most of them (88.6%) had highest through three family members. The 44.3% have been pregnant at least one time and 18.7% had given birth more than once. Regarding antenatal care service quality, only 3.3% of the respondents perceived the good quality antenatal care. 95.5% of pregnant women said that they were convenient and easy to register and 88.2% of them got antenatal record book. Majority of them (86.4%) came to the health center for booking visit at after 12 weeks of gestational age. Only 23.2% had completed antenatal visits according to the Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 67 recommended guideline and 20.7% knew how many antenatal visits they need during their antenatal period. 81.7% of respondents were asked about the history of last menstrual period and 68.3% were said the expected date of delivery by the health care personnel. Nearly half of the clients were asked about the history of smoking (45.5%) and history of betel chewing (44.7%). The 37.4% of pregnant women were said the illness due to pregnancy such as pregnancy induced hypertension. Majority of the respondents 96.3% were asked about the history of birth spacing. Only 19.5% of pregnant women were counseled for PMCT. The 79.5% got completed doses of tetanus toxoid vaccine injection. According to the survey, health care personnel always measured weight (72.4%) and height (12.6%) of pregnant women. Blood pressure was commonly checked (95.8%). Although obstetric examination to 96.3% of pregnant women was done, 47.3% were merely said their position of fetus. 39.8% of respondents received blood test and 54.9% got urine tests. Most of them (86.2%) got the prescribed medicines at health centers. Over half of the respondents (60.6%) were explained about the antenatal information such as danger signs of pregnancy, pregnancy induced hypertension, gestational diabetes, balanced diet and physical activity by the health care personnel. Majority of them (89%) got the follow up date for next antenatal visit. The study revealed that 16.7% of the respondents were highly accessible to antenatal care service, 58.9% were moderately accessible and 24.4% were poor accessible to antenatal care service. In overall client satisfaction, 2.4% of total respondents were at a high level, 80.1% at a moderate level and 17.5% had a low level. There were significant associations between the education level, parity, overall service quality, accessibility to antenatal care service and client satisfaction (p <0.05). 6.2 Recommendation for the implementation Recommendations for implementation are as follows: 1. The findings indicated that there were associations between education level of pregnant women, parity and client satisfaction. The activities such as antenatal Nway Eint Chei Conclusion and Recommendations / 68 information, health promotion program related to point out the danger signs of pregnancy related complications and health risk behavior like smoking and betel chewing habit to enhance the knowledge and the encouraging programs should be implemented at health center. The health care personnel should encourage not only the multiparous women but also the nulliparous women to maintain regular antenatal visit by creating peer group with IEC (Information, Education and Communication) approach like word of mouth approach. Community awareness and female education, especially in health literacy should be increased for sharing information, previous experience on antenatal care and child birth to ensure continuum of care. 2. The study showed that the only 3.3% of respondents had received high level of overall service quality. The survey assessment for health care quality should be done for situational analysis and according to this result, the project should be implemented within the scarcity of resources, however, all the implementation program must be patient-centered need care. The existing program should be strengthened and expanded, especially in relation to private sector with the development of private-public partnership. Not only monitoring and evaluation but also national accreditation for quality improvement should be established. Implementation research should be an integral part of the monitoring and evaluation. Supply-side readiness such as the development of the standards and accompanying guidelines to assess whether the standards are met, competency-based licensing and re-licensing of health care personnel and supportive environment like adequate policies including well-functioning institutions, strengthened leadership and enhanced accountability at health center level should be established. 3. The results showed 16.7% and 24.4% of pregnant women had high and low accessibility respectively. Prolonged waiting time at health center until the respondents meet the health care personnel is the barrier to access the antenatal care service and it should be lowered with the aid of advanced technology. For unequal geographic accessibility, geographical prioritization will help sequence efforts, establishment of mobile clinic team to improve service availability, readiness and equity. Well-developed health information system should be established with the help of multi-media to get clear information about antenatal care. Some implementation can’t be successful only with government supply. At that time encouraging community Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 69 involvement like social support, cultural acceptability of health care and coordination with non-governmental organization for supporting budget, risk pooling to help improve affordability of care and address the substantial barriers to seeking care and health volunteers should be carried out for home-based services. Community feedback mechanism should be developed. 6.3 Recommendation for further studies 1. This study assessed the client satisfaction based on the pregnant women’ opinion that attended the antenatal care service at health centers. Opinions from antenatal care service users who did not attend the service also would give better picture of satisfaction. It is presumed that satisfaction and dissatisfaction are not mutually exclusive issues. A study to find why the clients are dissatisfied is also important to maintain clients and explore factors influencing client satisfaction and dissatisfaction. 2. The sample of this study was antenatal care service users. It is an individual based assessment of service quality as client satisfaction. A community based non-users’ opinion and all potential antenatal care service users will give different result. Opinion of the mothers who have already given birth will add more insight about the client satisfaction because they knew the outcome of the pregnancy. 3. 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The role and use of consumer satisfaction surveys in mental health services. JMH. 1996;5(4):333-49. 46. Ministry of Health and Sports, Myanmar. Maternal and child health. 2015. Available from: http://www.moh.gov.mm 47. Ministry of Health and Sports, Myanmar. Health in Myanmar. 2012. Available from: http://www.moh.gov.mm 48. World Vision International. Intervention 7: access to quality maternal health services. 2016. Available from: http://www.wvi.org/health/intervention-7access-quality-maternal-health-services. 49. Rooney C. Antenatal care and maternal health: how effective is it? A review of the evidence by Cleone Rooney. Geneva: World Health Organization. 1992. 50. World Health Organization. Implementation of a new WHO antenatal care model in Thailand. 2014. [cited on 2017 Feb 2]. Available from: https://www.mhtf.org/2014/09/02/21626/ 51. World Health Organization. World Health Organization recommendations on antenatal care for a positive pregnancy experience. 2016. Available from: http://apps.who.int/iris/ bitstream/. 52. World Health Organization .Antenatal care in developing countries. Promises, achievements and missed opportunities: an analysis of trends, levels and differentials, 1990 – 2001. Geneva: 2003. Availabe from: http://www.who.int/ reproductivehealth /publications/ maternalperinatalhealth /9241590947/en/ 53. McCarthy J, Maine D. A framework for analyzing the determinants of maternal mortality. Stud Fam Plann. 1992;23(1):23-33. 54. Maine D, Rosenfield A. The safe motherhood initiative: why has it stalled? Am. J. Public Health. April 1999;89:480-2. 55. National health survey 2000. Health care utilization. The Gallup Organization: preliminary report. Hungarian Gallup Institute 2001. 56. Béatrice B, Barbara M. Poor antenatal care in 20 French districts: risk factors and pregnancy outcome. J Epidemiol Community Health. 1998;52:501-6. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 75 57. Ministry of Health and Sports, ICF International. Myanmar demographic and health survey: key indicators report. Nay Pyi Taw, Myanmar, and Rockville, Maryland, USA: 2015-16. Available from: http://www.moh.gov.mm/file/MDHS.pdf 58. Ministry of Health and Sports. Health in Myanmar, Nay Pyi Taw. 2010. Available from: http://www.moh.gov.mm/. 59. Gulzar L. Access to health care. Image J Nurs Sch. 1999;31(1):13-9. 60. Timmreck TC, editor. Dictionary of health services management. National Health Pub; 1987. 61. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann. N. Y. Acad. Sci. 2008;1136:161-71. 62. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127-40. 63. Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan. 2004 Mar 1;19(2):69-79. 64. What do we mean by availability, accessibility, acceptability and quality (AAAQ) of the health workforce? Global Health Workforce Alliance. 2016. Available from: http://www.who.int/workforcealliance/media/qa/04/en/. 65. Ministry of National Planning and Economic Development, United Nations Development Program: integrated household living condition survey in Myanmar: poverty profile report. June 2011. Available from: http://www.mm.undp.org/ihlca/01_Poverty_Profile/. 66. Ministry of Public Health. National policy and strategy for nursing and midwifery services report. 2011-2015. Available from: https://moph.gov.af/ NationalPolicyandStrategyforNursing andMidwiferyServices 67. Map data of Google. Map of Wet-Let Township (Accessed on December 25, 2016). Available from: https://www.google.co.th/maps/place/Wetlet 68. Paudel YR, Mehata S, Paudel D, Dariang M, Aryal KK, Poudel P, et al. Women’s satisfaction of maternity care in Nepal and its correlation with intended future utilization. J Reprod Med. 2015 Nov 8;2015. Nway Eint Chei References / 76 69. Changole J, Bandawe C, Makanani B, Nkanaunena K, Taulo F, Malunga E, et al. Patients’ satisfaction with reproductive health services at Gogo Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi. Malawi Med J. 2010 Mar 5;22(1):5-9. 70. Rahman MM, Ngadan DP, Arif MT. Factors affecting satisfaction on antenatal care services in Sarawak, Malaysia: evidence from a cross sectional study. SpringerPlus. 2016;5(1):725. 71. Turk Z, Avcilar MY. The effects of perceived service quality of audit firms on satisfaction and behavioural intentions: a research on the Istanbul stock exchange listed companies. RJBM. 2009;2(1):36-46. 72. Ghobashi M, Khandekar R. Satisfaction among expectant mothers with antenatal care services in the Musandam Region of Oman. Sultan Qaboos Univ Med J. 2008 Nov;8(3):325. 73. Aung Htet Win, Panzal A. Clients' satisfaction towards health care services at Outpatient Department, Pinlon Hospital, Yangon, Myanmar (Doctoral dissertation, Chulalongkorn University). 2009. 74. Naidu A. Factors affecting patient satisfaction and healthcare quality. Int J Health Care Qual Assur. 2009;22(4):366-81. 75. Jallow IK, Chou YJ, Liu TL, Huang N. Women's perception of antenatal care services in public and private clinics in the Gambia. Int J Qual Health Care. 2012;24(6):595-600. 76. Yohannes B, Tarekegn M, Paulos W. Mothers‟ Utilization of antenatal care and their satisfaction with delivery services in selected public health facilities of Wolaita Zone, Southern Ethiopia. Int J Sci Technol Res. 2013 Feb 25;2(2):74. 77. Bazant ES, Koenig MA. Women's satisfaction with delivery care in Nairobi's informal settlements. Int J Qual Health Care. 2009;21(2):79-86. 78. 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 Res Notes. 2014;7:164. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 77 79. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010;3(3):151-5. 80. Adewemimo AW, Msuya SE, Olaniyan CT, Adegoke AA. Utilization of skilled birth attendance in Northern Nigeria: A cross-sectional survey. Midwifery. 2014 Jan 31;30(1):e7-13. 81. Pricilla RA, David KV, Siva R, Vimala TJ, Rahman SP, Sankarapandian V. Satisfaction of antenatal mothers with the care provided by nursemidwives in an urban secondary care unit. J Family Med Prim Care. 2016 Apr;5(2):420. 82. Fagbamigbe AF, Idemudia ES. Assessment of quality of antenatal care services in Nigeria: evidence from a population-based survey. Reprod Health. 2015 Sep 18;12(1):88. 83. Ibrahim A. Patient satisfaction with health services at the outpatient department of Indira Gandhi Memorial hospital, Male’Maldives. Fac. of Grades. study, Mahidol Univ. MPHM. 2008. 84. Mandokhail AK, Keiwkarnka B, Ramasoota P. Patient satisfaction towards outpatient department (OPD) services of medicine department in Banphaeo community hospital Samut Sakhon Province, Thailand. J Public Health and Dev. 2007;5(3):98. 85. Ministry of Immigration and Population. Department of Population, Nay Pyi Taw. The 2014 Myanmar population and housing census: Sagaing region report. 2015;3-E:1-237. 86. Daniel WW, Cross CL. Biostatistics: basic concepts and methodology for the health sciences. 10th ed. Johnn Wiley and Sons Singapore: Pte. Ltd Publication; 2014:1-777. 87. Marković S, Lončarić D. Service quality and customer satisfaction in the health care industry-towards health tourism market. Tourism and Hospitality Management. 2014;20(2):155-70. 88. Oliaee Z, Jabbari A, Ehsanpour S. An investigation on the quality of midwifery services from the viewpoint of the clients in Isfahan through SERVQUAL model. Iran J Nurs Midwifery Res. 2016;21(3):291. 89. Yadav H. A review of maternal mortality in Malaysia. IeJSME. 2012;6(Suppl 1):S142-S51. Nway Eint Chei References / 78 90. Jacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan. 2012;27(4):288-300. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 79 APPENDICES Nway Eint Chei Appendices / 80 APPENDIX A QUESTIONNAIRE CLIENT SATISFACTION OF ANTENATAL CARE SERVICE IN HEALTH CENTERS IN WET-LET TOWNSHIP, MYANMAR Instruction 1. Client used in this study are pregnant women within the age of 18-49 years who received at least one time antenatal visit in the past 3 months came to antenatal care service at health center This questionnaire consists of 4 parts: Part 1 General characteristics Part 2 Antenatal care service quality Part 3 Accessibility to antenatal care service Part 4 Client Satisfaction 2. The information will be kept confidentially. The finding from this research will be useful to improve the antenatal care service quality at health center in Wet-Let Township, Myanmar. Thank you for your participation! Name- Nway Eint Chei Researcher Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 81 QUESTIONNAIRE ID: ---------------Client satisfaction of antenatal care service in health centers in Wet-Let Township, Myanmar Date……………… Village……………………… ฀1. No Is your antenatal care visit 2nd or onward? ฀2. Yes Who is your antenatal attendant? ฀1. Midwife ฀2. Health assistant ฀3. Lady health visitor Section 1 General characteristics Instruction: Please write down in the blank space where provided or put a tick (√) in the box ฀ for your answer. 1.1 How old are you? 1.2 Ethnic 1.3 Religion 1.4 Marital status 1.5 Education 1.6 Occupation ฀3. Farmer ……………….years ฀1. Myanmar ฀2. Chin ฀3. Kachin ฀4. Others…………………. ฀1. Buddhism ฀2. Christian ฀4. Hindu ฀5. Others………………….. ฀1. Married ฀2. Divorced ฀3. Separated ฀4. Widow ฀1. Illiterate ฀2. Able to read and write ฀3. Primary school ฀4. Middle school ฀5. High school ฀6. College/University ฀1. Housewife ฀2. Laborers (General worker) ฀4. Self-employee ฀3. Muslim ฀5.Others……………. 1.7 Average monthly family income ……………..Kyats per month 1.8 How many family members do you have? ……………..people 1.9 How many times have you pregnant? ……………..times 1.10 How many living children do you have? ……………..child/children Nway Eint Chei Appendices / 82 ฀1. No 1.11 Did you have abortion? ฀2. Yes If Yes, do you know that you have abortion at which month of gestational age? ฀1. No ฀2. Yes If Yes, please specify ………months………. weeks ฀1. No 1.12 Did you have stillbirth? ฀2. Yes If Yes, do you know that you have stillbirth at which month of gestational age? ฀1. No ฀2. Yes If Yes, please specify ………months………. weeks Section 2: Antenatal care service quality Instruction: Please write down in the blank space where provided or put a tick (√) in the box ฀ for your answer. Registration 2.1 Is registration process convenient and easy? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always ฀1. No 2.2 Do you get the antenatal record book? ฀2. Yes History taking 2.3 In which month of pregnancy you came for the 1st antenatal visit at health center? ฀1. Do not remember ฀2. Remember If you remember, please specify ………..months/…………weeks 2.4 How many antenatal visits do you have? ……………..visits 2.5 Do you know how many times you need to visit health center during pregnancy? ฀1. No ฀2. Yes If Yes, please specify ………………times 2.6 Did the health personnel ask you about your last menstrual period? ฀1. No ฀2. Yes 2.7 Did the health personnel tell you about your expected date of delivery? ฀1. No ฀2. Yes 2.8 Did the health personnel ask you about your history of twin pregnancy? ฀1. No ฀2. Yes Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 83 2.9 Did the health personnel ask you about your smoking history? ฀1. No ฀2. Yes ฀1. Non-smoker If Yes, you are ฀2. Ex-smoker ฀3. Current smoker 2.10 Did the health personnel ask you about your betel chewing history? ฀1. No ฀2. Yes If Yes, you are ฀1. Non-betel chewer ฀2.Ex-betel chewer ฀3. Current betel chewer 2.11 Did the health personnel ask you about your drug allergies history? ฀1. No ฀2. Yes ฀1. No If Yes, do you know that you have allergic drugs? ฀2. Yes If Yes, your allergic drugs are ……………………………………. 2.12 Did the health personnel ask that you’ve consumed any medications during ฀1. No pregnancy? ฀2. Yes If Yes, do you know which kind of the drugs do you take? ฀1. No ฀2. Yes If Yes, please specify……………………………………. 2.13 Have health personnel asked your underlying illness related to pregnancy? ฀1. No ฀2. Yes If Yes, the illness that the health personnel asked are (You can choose more than one answer) ฀1. Don’t remember ฀2. TB ฀3. Heart disease ฀4. Chronic renal disease ฀5. Malaria ฀6. Syphilis ฀7. Hepatitis ฀8. Others…………….… 2.14 Did health personnel tell that you have illness due to pregnancy? ฀1. No ฀2. Yes (If No, please skip to question no: 2.16) If Yes, your illness is ฀1. Hypertension ฀2. Diabetes ฀3. Heart disease ฀5. Others…………………… ฀4. Fits 2.15 At which month of pregnancy did you get this disease? ฀1. Don’t remember ฀2 Remember If you remember, please specify ……….months…………weeks Nway Eint Chei Appendices / 84 2.16 Have health personnel asked your birth spacing method? ฀1. No ฀2. Yes If Yes, which type of methods did you use before getting this pregnancy? ฀1. Not use ฀2. OC pills ฀3. Depo injection ฀4. IUD ฀5. Implant ฀6. Condom ฀7. Others…………………. How long did you use this method? …………years…………months Did you use continuously? ฀1. No ฀2. Yes How long did you stop before getting pregnancy? ฀1. Don’t remember ฀2. Remember If you remember, please specify ………years………...months 2.17 Did you get voluntary confidential counseling and testing for HIV and Syphilis from the health personnel? ฀1. No ฀2. Yes 2.18 Have you been injected tetanus toxoid vaccine? ฀1. No ฀2. Yes If Yes, how many times have you been injected? ………………….times Physical Examination 2.19 Have you been measured weight? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always 2.20 Have you been measured height? ฀1. No ฀2.Yes 2.21 Have you been measured blood pressure? ฀1. No ฀2. Yes ฀1. Normal ฀2. Hypertension If yes, your blood pressure is Whenever you check your blood pressure, it shows high level? ฀1. No ฀2. Yes Do you know your blood pressure? ฀1. No ฀2. Yes If Yes, your blood pressure is …………/………..mmHg 2.22 Have you received obstetric examination such as measurement of symphysiofundal height, position of fetus and auscultation of fetal heart sound? ฀1. No ฀2. Yes 2.23 Did health personnel told the symphio-fundal height is fit for your gestational age? ฀1. No ฀2. Yes Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 85 2.24 Did health personnel tell you about the position of your fetus? ฀1. No ฀2. Yes 2.25 Did health personnel tell you about the fetal heart sound? ฀1. No ฀2. Yes ฀1. No ฀2. Yes Laboratory investigation 2.26 Have you done blood tests during pregnancy? ……………times If Yes, how many times have you done? 2.27 Have you checked your blood sugar level during pregnancy? ฀1. No ฀2. Yes Did you check your blood sugar level ever you come? ฀1. No ฀2. Yes If Yes, Do you know your blood sugar level? ฀1. No ฀2. Yes If Yes, your blood sugar level is …………...mg% 2.28 Was your blood group and Rh measured? If Yes, do you know your blood group and Rh? 2.29 Have you checked urine tests? ฀1. No ฀2. Yes ฀1. No ฀2. Yes ฀1. No ฀2. Yes ……………times If Yes, how many times have you done? 2.30 Have you explained about the laboratory tests before doing? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always If Yes, Please specify……………………… Pharmacy unit 2.31 Do you know which kinds of medicines the health personnel prescribed? ฀1. No ฀2. Yes If Yes, Please specify (You can choose more than one answer) ฀1. Iron ฀2. Folic acid ฀3. Multivitamin ฀4. Anti helminth ฀5.Others…………………. 2.32 Have you got the medicines as prescribed by the health care personnel? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always 2.33 Have you got anti-helminth drug at 2nd trimester (13-27 weeks)? ฀1. No ฀2. Yes Nway Eint Chei Appendices / 86 Health education 2.34 Have you been explained about the antenatal information? ฀1. No ฀2. Yes 2.35 Have you been explained about danger signs of pregnancy such as ฀1. No bleeding per vagina and abdominal pain? ฀2. Yes 2.36 Have you been explained about danger signs of pregnancy induced hypertension? ฀1. No ฀2. Yes If Yes, which of the followings have you been explained? (You can choose more than one answer) ฀1. Severe nausea and vomiting ฀2. Blurred vision ฀4. Swollen face and legs ฀5. Fits ฀3. Headache 2.37 Have you been explained about danger signs of gestational diabetes? ฀1. No ฀2. Yes If Yes, which of the followings have you been explained? (You can choose more than one answer) ฀1. Increased thirst ฀2. Dry mouth ฀3. Tiredness 2.38 Have you been explained about taking iron, folic acid and multivitamin ฀1. No ฀2. Yes supplement during pregnancy? 2.39 Have you been explained about balance diet during pregnancy? ฀1. No ฀2. Yes If Yes, which of the followings have you been explained? (You can choose more than one answer) ฀1. having rice, meat, fish, bean, egg, milk, fruit and vegetable ฀2. having 3-4 times a day 2.40 Have you been explained about sleeping pattern during pregnancy? ฀1. No ฀2. Yes If Yes, which of the followings have you been explained? (You can choose more than one answer) ฀1. 2 hours in daytime ฀2. 8 hours at night ฀3. sleep on side position ฀4. use of bed net while sleeping Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 87 2.41 Have you been explained about physical activities during pregnancy such as about 10 minutes for brisk walking? ฀1. No ฀2. Yes 2.42 Have you been explained about wearing suitable dress? ฀1. No ฀2. Yes 2.43 Have you been explained about taking ANC at least 4 times and plan for birth? ฀1. No ฀2. Yes Follow up ฀1. No 2.44 Do you have the date for follow-up visit? ฀2. Yes 2.45 Will you come back for next antenatal visit? ฀1.No ฀2. Uncertain ฀3. Yes If No and Uncertain, Why don’t you want to come back? Please specify…………………………………………………. Section 3: Accessibility to antenatal care service Instruction: Please write down in the blank space where provided. Please put a tick (√) in the box ฀ for your answer. 3.1 How far is the nearest antenatal care service center from your home? …………..miles 3.2 How do you go there? ฀1. Walk ฀2. Own transportation (motorcycle, tuk-tuk, car) ฀3. Public transport ฀4. Others……………………… 3.3 How long does it take to reach there? …….. hours………minutes 3.4 Do you think you are convenient to come to ANC service? ฀1. No ฀2. Yes 3.5 Is antenatal care service available all the time when you need? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always If No and Yes, sometimes, why ANC service is not available all the time? Please specify……………………………………………… 3.6 How long have you waited before getting ANC at ANC service? ฀1. No ฀2. Yes If Yes, please specify …….. hours………minutes 3.7 Is waiting time at ANC service to get ANC acceptable for you? ฀1. No ฀2. Yes Nway Eint Chei Appendices / 88 3.8 What was the consultation time with the health personnel during this visit? ฀1. No ฀2. Yes ……………minutes If Yes, please specify 3.9 Do you think the cost of transport to ANC service is affordable for you? ฀1. No ฀2. Yes 3.10 How much did you pay for taking ANC at health center? ฀2. …………………..Kyats ฀1. Free of charge 3.11 How much have you paid for other services such as antenatal record book, medicine, blood tests, urine tests and donation at health center? ฀2. …………………..Kyats ฀1. Free of charge 3.12 Do you think the cost of ANC service, drugs and laboratory investigation is affordable for you? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always 3.13 Is there other personal cost (transportation, food, phone) except ANC service cost while coming to ANC service? ฀1. No ฀2. Yes .……………….. Kyats If Yes, please specify 3.14 How do you know about the ANC service? (You can choose more than one answer) ฀1. Television ฀2. Pamphlet ฀3. Billboard ฀4. Friends/Relatives ฀5. Others………………… 3.15 Do you have opportunity to ask question to the health care provider? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always 3.16 Are you welcome by the health personnel? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always 3.17 How is the communication of the health personnel? ฀1. Bad ฀2. Uncertain ฀3. Good 3.18 Have you been explained procedure before the examination started? ฀1. No, never ฀2.Yes, sometimes ฀3. Yes, always 3.19 Was water for drinking available? ฀1. No ฀2. Yes 3.20 Is there water for hand washing? ฀1. No ฀2. Yes Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 89 ฀1. No ฀2. Yes 3.22 Was communication such as mobile phone available? ฀1. No ฀2. Yes ฀1. No ฀2. Yes 3.21 Was electricity available? 3.23 Was toilet available? Section 4: Satisfaction towards antenatal care service Instruction: Please put a tick (√ ) in the box for your answer. 5 = Very satisfied 4 = Satisfied 2 = Dissatisfied 1 = Very dissatisfied 3 = Uncertain Satisfaction towards ANC services 4.1 Tangibles 1 Cleanliness of health center 2 Convenience of waiting room 3 Equipment for examination room is in good condition 4 Neatness and well-dressing of health care personnel 4.2 Reliability 5 Health care personnel provides service on time 6 Health personnel’s skill in providing ANC 7 Availability of clear information about ANC at health center 4.3 Responsiveness 8 Giving of ANC on time 9 Willingness of health care personnel on helping pregnant women 10 Availability of health care personnel in providing ANC 11 Rapidity of health care personnel in solving problem of pregnant women 4.4 Assurance 12 Timeliness of health care personnel in giving ANC 13 Management of health care personnel on your problem Level of satisfaction 5 4 3 2 1 Nway Eint Chei Appendices / 90 Satisfaction towards ANC services 14 Knowledge of health care personnel for answering your questions 15 Feeling of safety and trust in ANC 4.5 Empathy 16 Privacy of examination room 17 Understanding of health care personnel on your needs 18 Attention of health care personnel on your feelings 19 Trying of health care personnel on giving best service “Thank you for your participation” Level of satisfaction 5 4 3 2 1 Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 91 APPENDIX B QUESTIONNAIRE – MYANMAR VERSION ………………………………………………………………………………………………………………… … ၁။ ။ ၃ ။ ၄ ။ ၁။ ၂။ ၃။ ၄။ ၂။ ။ ။ ။ Nway Eint Chei Appendices / 92 QUESTIONNAIRE – MYANMAR VERSION …………………… ………………………… …………………………….. ။ ฀၁ ฀၂ ฀၁ ฀၂ ฀၃ (၁) ฀ ။ (√ ၁.၁ ………………………. ၁.၂ ฀၁ ၁.၃ ฀၂ ฀၁ ၁.၄ ฀၃ ฀၄ ฀၂ ၶ ฀၄ ฀၅ ฀၁ ฀၂ ฀၃ ฀၄ …………………… ฀၃ …………………………….. ၁.၅ ฀၁ ฀၂ ฀၄ ฀၅ ၁.၆ ฀၃ ၊ ฀၃ ฀၆ ฀၁ ฀၂ ฀၄ ฀၅ ၊ ……………………………. ၁.၇ …………………………………. ၁.၈ …………………………………. ၁.၉ …………………………………. ၁.၁၀ …………………………………. Fac. of Grad. Studies, Mahidol Univ. ၁.၁၁ M.P.H. / 93 ။ ฀၁ ฀၂ ။ ฀၁ ฀၂ ………လ………… ပ ၁.၁၂ ။ ฀၁ ฀၂ ။ ฀၁ ฀၂ ………လ………… ပ (၂) ฀ ။ (√ ၂.၁ ။ ฀၁ ฀၂ ฀၃ ၂.၂ ။ ၂.၃ ฀၁ ฀၂ ฀၁ ฀၂ ၌ ။ ………….. ၂.၄ / ………… …………………. ၂.၅ ။ ฀၁ ฀၂ ………………. ၂.၆ ။ ฀၁ ฀၂ ၂.၇ ။ ฀၁ ฀၂ ၂.၈ ။ ฀၁ ฀၂ Nway Eint Chei Appendices / 94 ၂.၉ ။ ฀၁ ฀၂ ฀၁ ฀၂ ฀၃ ၂.၁၀ ။ ฀၁ ฀၁ ฀၂ ฀၂ ฀၃ ၂.၁၁ ။ ฀၁ ฀၂ ။ ฀၁ ฀၂ ………………………………. ၂.၁၂ ။ ฀၁ ฀၂ ။ ฀၁ ฀၂ ………………………………. ၂.၁၃ ။ ฀၁ ฀၂ ฀၁ ฀၂ ฀၄ ฀၅ ฀၆ ฀၇ ฀၈ ฀၃ …………………………….. ၂.၁၄ ။ ฀၁ ฀၂ ၂.၁၆ ( ฀၁ ฀၄ ฀၂ ၍ ) ။ ……… ฀၃ ……………………… ฀၅ ၂.၁၅ ) ฀၁ ฀၂ ………… ၂.၁၆ ။ ฀၁ ฀၂ ฀၁ ฀၃ ฀၄ ฀၆ ฀၇ ฀၂ ฀၅ ………………………….. Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 95 ……… ။ ။ ……...လ ฀၁ ฀၂ ။ ฀၁ ฀၂ ……… ) ၂.၁၇ ……...လ ( ) ။ (HIV) ฀၁ ฀၂ ၂.၁၈ ။ ฀၁ ฀၂ …………………. ၂.၁၉ ။ ฀၁ ฀၂ ฀၃ ၂.၂၀ ။ ၂.၂၁ ฀၁ ฀၂ ။ ฀၁ ฀၂ ฀၁ ฀၂ ฀၁ ฀၂ ฀၁ ฀၂ ။ ။ ………./……….mmHg ၂.၂၂ ။ ฀၁ ฀၂ ၂.၂၃ ။ ฀၁ ฀၂ ၂.၂၄ ။ ฀၁ ฀၂ ၂.၂၅ ။ ฀၁ ၂.၂၆ ฀၂ ၍ ฀၁ …………………. ฀၂ Nway Eint Chei Appendices / 96 ၂.၂၇ ။ ။ ฀၁ ฀၂ ။ ฀၁ ฀၂ ฀၁ ฀၂ …………………mg% ၂.၂၈ ၊ ฀၁ ။ ฀၂ ၊ ฀၁ ။ ฀၂ ၂.၂၉ ၍ ။ ฀၁ ฀၂ …………………. ၂.၃၀ ။ ฀၁ ฀၂ ฀၃ ။ ………………………………. ၂.၃၁ ။ ฀၁ ฀၂ ။ ၍ ( ) ฀၁ ฀၂ ฀၃ ฀၄ ฀၅ ……………………………. ၂.၃၂ ။ ฀၁ ၂.၃၃ ฀၂ ၃ ฀၁ ၆ ฀၃ (၁၃-၂၇ ။ ) ฀၂ ၂.၃၄ ။ ฀၁ ฀၂ Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 97 ၂.၃၅ ၊ ฀၁ ။ ฀၂ ၂.၃၆ ။ ฀၁ ฀၂ ။ ၍ ( ) ฀၁ ฀၂ ฀၃ ၊ ฀၄ ฀၅ ၂.၃၇ ။ ฀၁ ฀၂ ။ ၍ ( ) ฀၁ ฀၂ ฀၃ ၂.၃၈ ။ ฀၁ ฀၂ ၂.၃၉ ။ ฀၁ ฀၂ ။ ၍ ( ) ฀၁ ၊ ၊ ฀၂ ၃ ၄ ၊ ၊ ၊ ၊ ၂.၄၀ ။ ฀၁ ฀၂ ။ ၂ ฀၁ ฀၃ ( ฀၂ - ) ၈ ฀၄ ၂.၄၁ ၁၀ ။ ฀၁ ฀၂ Nway Eint Chei Appendices / 98 ၂.၄၂ ၍ ။ ฀၁ ฀၂ ၂.၄၃ ၄ ။ ฀၁ ฀၂ ၂.၄၄ ။ ฀၁ ฀၂ ၂.၄၅ ။ ၊ ฀၁ ။ ฀၂ ฀၃ ) ………………………………………………………….. (၃) ฀ ။ (√ ၃.၁ ။ ………………………… ၃.၂ ฀၁ ฀၂ ( ၊ - ၊ ၊ ฀၄ ……………………………. ) ฀၃ ၃.၃ …………. ………….. ၃.၄ ။ ฀၁ ฀၂ ၃.၅ ။ ฀၁ ฀၂ ฀၃ ။ ) ………………………………………………………….. ၃.၆ ฀၁ ) …………. ………….. ฀၂ Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 99 ၃.၇ ။ ฀၁ ฀၂ ၃.၈ ฀၁ ฀၂ …….………….. ) ၃.၉ ။ ฀၁ ฀၂ ၃.၁၀ ။ ฀၂ ….………………… ฀၁ ၃.၁၁ ( ၊ ၊ - ၊ ။ ฀၂ ….………………… ฀၁ ၃.၁၂ ။ ฀၁ ฀၂ ฀၃ ၃.၁၃ ( ၊ - ၊ ။ ) ฀၁ ฀၂ ………………………. ) ၃.၁၄ ။( ฀၁ ฀၄ ၊ ၍ ) ฀၂ ฀၃ ฀၅ ……………………………. ၃.၁၅ ။ ฀၁ ฀၂ ฀၃ ၃.၁၆ ။ ฀၁ ฀၂ ฀၃ ฀၁ ฀၂ ฀၃ ၃.၁၇ ၃.၁၈ ။ ၃.၁၉ ฀၁ ฀၂ ฀၃ ။ ฀၁ ฀၂ Nway Eint Chei Appendices / 100 ၃.၂၀ ။ ၃.၂၁ ။ ၃.၂၂ ။ ၃.၂၃ ။ (၄) (√ ၄.၁ ၁ ၂ ၃ ၄ ၄.၂ ၅ ၆ ၇ ။ ฀၁ ฀၂ ฀၁ ฀၂ ฀၁ ฀၂ ฀၁ ฀၂ Fac. of Grad. Studies, Mahidol Univ. ၄.၃ ၈ ၉ ၁၀ ၁၁ ၄.၄ ၁၂ ၁၃ ၁၄ ၁၅ ၄.၅ ၁၆ M.P.H. / 101 Nway Eint Chei Appendices / 102 ၁၇ ၁၈ ၁၉ ။ Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 103 APPENDIX C CERTIFICATE OF APPROVAL ETHICAL REVIEW COMMITTEE Nway Eint Chei Appendices / 104 APPENDIX D INFORMATION SHEET EC-3 Form 1. Title of project: Client satisfaction of antenatal care service in health centers in Wet-Let township, Myanmar 2. Study site: Antenatal care services in Wet-Let Township, Sagaing region, Myanmar 3. This project is conducted by Nway Eint Chei (MPH student of Faculty of Public Health, Mahidol University) under supervision of Major Advisor as follows: Assoc. Prof. Dr. Nawarat Suwannapong B.Sc. (P.H.N), M.S.W. (Medicine) Ph.D. (Population and Health) M.C.H Cert., TOT Cert 4. Brief Background, Rationale: (use simple word, understandable by volunteer participant) In Myanmar about 70 % of the total population resides in rural areas and remote areas with difficult and limited health service facilities. It has been estimated that an additional 160,000 newborn lives could be saved through the achievement of 90% coverage of antenatal care (ANC). Antenatal care coverage is influenced by many factors such as accessibility of ANC service, availability of service and women perception and satisfaction. ANC improves directly the health outcome of newborn babies by reducing stillbirths and neonatal deaths and indirectly by providing health contacts with the pregnant women in the continuum of care. The client satisfaction towards provided services determines the willingness to follow-up and accessibility to services. Therefore service quality improvement inspires customer satisfaction and a good image of the health facility. Satisfaction is generally a main factor of health service utilization. Client who Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 105 doesn’t satisfy to the ANC service quality is likely to seek care and this can cause complications in pregnancy and increasing maternal mortality. In Wet-Let Township although antenatal care coverage at least one visit in 2013 is about 87%, there are increasing in malnutrition and severe malnutrition under 5 year and low birth weight rate. There is no ANC coverage updated data after affecting by floods of cyclone Komen and heavy monsoon rain in July and August 2015. Poor socio-economic condition, culture, belief and lack of knowledge could be barriers to access the quality antenatal care service. These barriers and quality of ANC service can dissatisfy pregnant women to come for continuum of care. Despite the efforts by the stakeholders and policy maker to improve the quality of antenatal care services, there is still major challenge in quality deficiencies which require ensuring holistic work performance. 5. Objectives: To assess the client satisfaction and to analyze the associations between general characteristics, antenatal care service quality, accessibility to antenatal care service and client satisfaction on antenatal care service at health centers in Wet-Let Township 6. You are invited to be a volunteer/subject to participate in the project: The goal of this project is to assess the client satisfaction on antenatal care service at health centers in Wet-Let Township, Myanmar and also tries to identify the associations between general characteristics, antenatal care service quality, accessibility to antenatal care service and client satisfaction on antenatal care service at health centers. As you are a pregnant woman who come to health center, you can give all the necessary information, thus you are invited to participate in this project. 7. Research activities which involving you when you volunteer to participate in this research project will be as following: (focus on the parts that involve volunteers/subjects) If you voluntarily agree to be a respondent, I would like you to sign a written informed consent form and start to answer the questionnaire which will include questions about your general characteristics, antenatal care service quality, Nway Eint Chei Appendices / 106 accessibility to antenatal care service and client satisfaction on antenatal care service. 8. Period of time that you will be involved in this research activities (Treatment/data collection): The whole answering questionnaire will take around 20-30 minutes. 9. Expected benefits of the project to you and to others: This study will not directly benefit you, but the aim is to evaluate the client satisfaction on the antenatal care provided at health centers, to determine the gap and service quality and to analyze the impact of provided service quality on client satisfaction in health center. The result of this study will be used as base line information for improving the quality of the antenatal care service, increasing satisfaction of pregnant women and utilization of antenatal care service. 10. Risks or any undesirable that may occur to you caused by this research and measure or prevention and risk reclusion method which will be provided during participation in the project. There will be no foreseeable physical risks for you to participate in the study. However, the respondents may experience uncomfortable feelings from recalling the memories and answering to the questionnaire. Some questions may be unexpected. If you feel discomfort to answer the questionnaires and willing to stop, the researcher will let you stop at any time without hesitation. Your confidentiality and voluntary participation are the top priority to us. 11. How can you securely store the data and keep them confidential? (such as how to take care data, where are data storage who will access, and how to destroy data and when) You do not need to answer your name and it will be anonymous. All of respondents’ answers will be kept confidential. All questionnaires will be kept in locked cabinet. The only person who can access to the data is the researcher. After the collected data are entered into the database and analysis is finished and the report published, all of the answer sheets will be destroyed. In any sort of report Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 107 we might publish, we will not include any sort of information that can make possible to identify the respondent. 12. The right of the subject (he/she) to withdraw from the project. Your participation for the study is based on voluntarism. You have the right to refuse or withdraw at any time from the answering questionnaire. 13. Contact address of authorized persons in case of emergency. Nway Eint Chei Student ID: 5936924 Contact number: 09 53614750 Master of Public Health International Program Faculty of Public Health, Mahidol University 420/1 Rajvithi Road, Rajthevi, Bangkok 10400 Thailand Contact Address in Myanmar: 40, Pan Pin Gyi street, Kyee Myin Dine township, Yangon, Myanmar Contact Address in Bangkok: Mahidol University, Master of Public Health International Program Phayathai Campus Bangkok-Thailand. This research project will be approved by the Ethical Review Committee for Human Research, Faculty of Public Health, Mahidol University. Office address at Building 1, 4th Floor, 420/1 Rajvithi Road, Rajthevi, Bangkok 10400, Telephone: 02354-8543-9 Ext. 1127, 7404 Fax: 0-2640-9854 Nway Eint Chei Appendices / 108 APPENDIX E INFORMATION SHEET - MYANMAR VERSION သတငး့အခ္ကးအလကး စာမ္ကးႏြာ ှ၈ သုေတသန ေခါငး့စဥး ်မိ ု ံနယး နြငးံဆိုငး ေသာ မ္ာ့ကုိ ေလံလာ်ခငး့၈ ဿ၈ သုေတသနေနရာ စစးကိုငး့တိုငး့ေဒသၾကီ့၇ ်မိ ု ံနယး ၀၈ ဤေလံလာမႈကို တျဲဖကးပါေမာကၒ ေဒါကးတာနဝရ ဆူဝနပျနး့ ၏ ႀကီ့ၾကပးမႈ်ဖငးံ ၎ ေႏျ့အိမးံခ္ယး မြ်ပဳလုပး်ခငး့ ်ဖစးပါသညး၈ ၁၈ စာတမး့်ပဳစုရသညးံ အေ်ခခဵအေၾကာငး့အရငး့ ်မနးမာနိုငးင အာဆီီယဵႏိုငးငဵမ္ာ့အနကး မိခငးေသဆဵု့မြ ုတင ျ း ဒုတိယ အမ္ာ့ဆဵု့ ်ဖစးသညး၈ မိခငးေသဆဵု့မြ ုမ္ာ့ ်မငးံတကးေန်ခငး့သညး အရညးအေသျ့်ပညးံမြီေသာ မ္ာ့ကို လျယးကူစျာ လကးလြမး့မမြီ်ခငး့ႏြငးံ စပးဆကးလ္ကးရြိပါသညး၈ ်မိ ု ံ နယးတျငး အမ္ာ့စုမြာ ေက့္လကးတျငး ေနထိုငးၾက်ပီ့ အရညး အေသျ့ ်ပညးံမြီေသာ က္နး့မာေရ့ေစာငးံေရြာကးမုြ မ္ာ့ကို လျယးကူစျာ လကးလြမး့မမြီၾကပါ၈ ်မိဳံ၏ပထဝီ အေနအထာ့၇ အရညးအေသျ့ သဘာဝေဘ့အႏၲရာယးတို ံ ေၾကာငးံ ်ပညးံမြီေသာ း်မိ ု ံေန လူထုအတျကး အဓိက က္နး့မာေရ့ဆိုငးရာ ်ပသနာမ္ာ့ အနကးမြ တစးခု ရငးဆိုငးေနရေသာ ်ဖစးလ္ကး ရြိပါသညး၈ အရညးအေသျ့်မြငးံတငးရာတျငး အခ္ကးအလကး ်ဖစးပါသညး၈ ဤသုေတသနသညး ်မိ ု ံနယး Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 109 နြငးံ ၎နြငးံ ဆိုငးေသာ အခ္ကးအလကးမ္ာ့ကုိ သိရြိနိုငးရနး ရညးရျယးသညး၈ ဤသုေတသနမြ ေလံလာေတျ ံ ရြိခ္ကးမ္ာ့သညး ်ပညးသူလူထုအတျကး အရညးအေသျ့်ပညးံမြီေသာ နြငးံပကးသကးေသာ ေဆာငးရျကးခ္ကးအသစးမ္ာ့ လုပးေဆာငးရာတျငး အေထာကး အကူ်ပ ုနိုငးပါသညး၈ ထို ံအ်ပငး း်မိ ု ံနယး အတျငး့ တ်ခာ့ဆကးစပး လ္ကးရြိေသာ သုေတသနလုပးငနး့မ္ာ့ လုပးေဆာငး ရာတျငးလညး့ အက္ိ ု့ရြိေစနိုငးမညး ်ဖစးပါသညး၈ ၂၈ ဤသုေတသန၏ အဓိကရညးရျယးခ္ကး စစးကိုငး့တိုငး့ေဒသၾကီ့၇ း်မိ ု ံနယး အတျငး့တျငး တျငး ေလံလာ်ခငး့။ ၃၈ ယခု အစးမ၇ ညီမ၇ အနးတီတို႕ ကိုသုေတသနတျငး ပါွငးရနး ဖိတးေခ ပါသညး၈ ဤသုေတသန၏ အဓိက ရညးရျယးခ္ကးမြာ ၿမိဳ႕နယး အတျငး့ရြိ တျငး နြငးံဆိုငးေသာ ထိ႕ု ေၾကာငးံ အခ္ကးအလကးမ္ာ့ကို သိရြိရနး ရညးရျယးပါသညး၈ းၿမိဳ႕နယး အတျငး့တျငး ေနထိုငးသူ တစးဦ့အ်ဖစး ဤုသုေတသနတျငး ပါွငးရနးဖိတးေခၐပါသညး၈ ၄၈ ဤသုေတသနစာတမး့အတျကး မိမိဆႏၵအေလြ္ာကးပါွငးလြ္ငး ေအာကးေဖား်ပပါ အခ္ကး မ္ာ့ကို ကူညီေပ့ပါ ရြငး၈ အကယး၍ေ်ဖဆိုသူမ္ာ့ သေဘာတူလ္ြငးသေဘာတူညီမႈအသိေပ့စာတျငး လကးမြတး ထို့ ေပ့ပါရြငး၈ ်ဖစးပါတယး၈ ကၽျနးေတား/ကၽျနးမတို႕က ေမ့ချနး့မ္ာ့မြာေ်ဖဆိုသူ၏ လကၒဏာမ္ာ့၇ ဒီကေ်ဖဆိုသူကိုေမ့ချနး့အခ္ိဳ႕ကိုေပ့မြာ လူေနမႈႏြငးံ စီ့ပျာ့ေရ့ဆိုငးရာွိေသသ အရညးအေသျ့်ပညးံမြီေသာ ၊ ၊ မ္ာ့ႏြငးံ ပကးသကးေသာ အခ္ကးအလကးမ္ာ့ ပါွငးမညး ်ဖစးပါသညး၈ ၅၈ ဤသုေတသနေမ့ချနး့ေမ့ရာတျငး ၾကာ်မငးံမညးံအခိ္နး ေမ့ချနး့ေ်ဖဆိုရာတျငး မိနစးဿွ မြ ၀ွ ၾကာ်မငးံမညး ်ဖစးပါသညး၈ Nway Eint Chei Appendices / 110 ၆၈ ဤသုေတသနတျငး ပါွငးရ်ခငး့ အက္ိဳ့အ်မတး ယခုသုေတသနသညး သိ႕ု ေသား ေ်ဖဆိုသူမ္ာ့ကို တိုကးရိုးကးအက္ိဳ့်ပဳေစမညး သုေတသနမြရရြိလာေသာအေ်ဖမ္ာ့မြတဆငးံ မဟုတးပါ၈ းၿမိဳ႕နယးအတျငး့ရြိ ်ပညးသူ လူထု၏ နြငးံပကးသကးေသာ သေဘာထာ့ အ်မငးမ္ာ့ကိုသိရြိ်ပီ့ ထိုအေ်ဖမ္ာ့သညး အရညးအေသျ့်ပညးံမြီေသာ နြငးံပကးသကးေသာေဆာငးရျကးခ္ကးအသစးမ္ာ့ အေကာငးအထညး ေဖားရာတျငး အက္ို့ရြိနိုငး်ပီ့ အနာဂတးအတျကးမိခငးေသဆဵု့နြုနး့နြငးံ ေရာဂါ်ဖစးပျာ့နႈနး့မ္ာ့ကုိ ေလ္ာံခ္ေပ့ရနး အေထာကးအကူ်ပဳမညး ်ဖစးပါသညး၈ ှွ၈ သုေတသနတျငး ပါွငးေသာအခါ ရရြိလာမညးံ ဆို့က္ိဳ့မ္ာ့၇ မေမ္ြားလငးံထာ့ေသာ အေၾကာငး့အရာမ္ာ့ႏြငးံ ပကးသကးၿပီ့ တတးႏိုငးသမြြ္အနညး့ဆဵု့်ဖစးေစရနးအတျကး ်ပငးဆငး ေဆာငးရျကးေပ့မညး ်ဖစးပါသညး၈ ဤုသုေတသနတျငး ပါွငးေသာသူမ္ာ့သညး မိမိဆႏၵအေလ္ြာကး လိုလိုလာ့လာ့ ပါွငး သူမ္ာ့ ်ဖစးပါသညး၈ ဤုသုေတသနႏြငးံ ပကးသကး်ပီ့၁ငး့တို႕အာ့ တစးစဵုတစးရာ ထိခိုကး်ခငး့ မရြိႏုိငးပါ၈ သိ႕ု ေသား ေမ့ချနး့မ္ာ့ေ်ဖဆိုခ္ိနးတင ျ း ကိုယးေရ့ရာဇွငးႏြငးံ ပကးသကးေသာ၇ ခဏတာ စဥး့စာ့ရ မရေသာ အေၾကာငး့အရာမ္ာ့ ်ဖစးေနတတးပါသညး၈ တစးခ္ိဳ႕ေသာ ေမ့ချနး့မ္ာ့သညး မထငးမြတးေသာ ေမ့ချနး့မ္ာ့ ်ဖစးေနတတးပါသညး။ အကယး၍ ေ်ဖဆိုသူသညး ဆကးလကး ပါွငး ေ်ဖဆိုလိုသညးံ ဆႏၵမရြိလ္ြငး အခ္ိနးမေရျ့ ရပးတနး႕ႏိုငးပါသညး၈ ေ်ဖဆိုသူမ္ာ့၏ လိုလိုလာ့လာ့ ပူ့ေပါငး့ပါွငး ေဆာငးရျကး်ခငး့ကိုသာ အေလ့ထာ့ပါသညး၈ ှှ၈ ေ်ဖဆိုသူ၏ အခ္ကးအလကးမ္ာ့ကို လဵုလဵု်ခဵဳ်ခဵဳ တစးပါ့သူသ႕ို မေပါကးၾကာ့ေအာငး မညးသ႕ို ကာကျယး တာ့ဆီ့မညးနညး့၈ ေ်ဖဆုိသူ၏ အခ္ကးအလကးမ္ာ့ကို ေသခ္ာစျာ သိမးဆညး့ထာ့မညး ်ဖစးပါသညး၈ ေ်ဖဆိုသူ၏ နာမညးကို အေ်ဖလႊာတျငး မြတးသာ့ထာ့်ခငး့ မ်ပဳလုပးပါ၈ ေမ့ချနး့အာ့လဵု့ကို ေသခ္ာစျာ ခ္ိတးပိတးထာ့မညး်ဖစးၿပီ့ က္နးသညးံမညးသူမ္ြ အေ်ဖလႊာမ္ာ့ကို တာွနးခဵသုေတသန ယခုအခ္ကးအလကးမ္ာ့ကို ကျနးပ္ဴတာထဲသ႕ို ေမ့ချနး့မ္ာ့အာ့လဵု့ကို ဖတးရႈချငးံ၇ ပညာရြငးမြအပ ၾကညးံရႈချငးံ ေ်ပာငး့ေရျ႕မြတးသာ့ၿပီ့ေသာအခါ ဖ္ကးဆီ့ပစးမညး ်ဖစးပါသညး၈ အကယး၍ မရြိပါ၈ အေ်ဖလႊာႏြငးံ စာအုပးမ္ာ့ႏြငးံ Fac. of Grad. Studies, Mahidol Univ. ဂ္ာနယးတျငးေရ့သာ့ေသာအခါ M.P.H. / 111 ဘယးေသာအခါမြ ေ်ဖဆိုသူကို မညးသူမညးွါ မြတးမိေစႏိုငးေသာ အေၾကာငး့မ္ာ့ကို ထညးံသျငးံေဖား်ပမညး မဟုတးပါ၈ ှဿ၈ သုေတသနမြ ႏႈတးထျကးလိုမႈႏြငးံ ပကးသကးေသာ ေ်ဖဆိုသူ၏ လုပးပိုငးချငးံ အကယး၍ေ်ဖဆိုသူမ္ာ့သညး ေ်ဖဆိုရခကး်ပီ့ ေမ့ချနး့ကိုဆကးလကးမေ်ဖဆိုလိုရနး စိတးကသိကေအာကး်ဖစး်ခငး့ႏြငးံ ဆဵု့်ဖတး်ခငး့၇ ဆကးလကးပူ့ေပါငး့ေဆာငးရျကးလိုစိတး မရြိေသာအခါ မညးသညးံအခ္ိနးတင ျ းမဆို သုေတသနေမ့်မနး့်ခငး့မြ ႏတးထျကးႏိုငးပါသညး၈ ှ၀၈ အေရ့အေၾကာငး့ရြိေသာအခါ ဆကးသယ ျ းရနး တာွနးခဵပုဂၓိဳလး၏ လိပးစာ ေဒါကးတာေႏျ့အိမးံခ္ယး ေက္ာငး့သာအမြတးစဥး - ၂၆၀၃၆ဿ၁ - ၀၉ ၅၃၆၁၄၇၅၀ လူထုက္နး့မာေရ့မဟာသိပၸဵဘဲျ႕ လူထုက္နး့မာေရ့ဌာန၇ မဟီေဒါတကၑသိုလး ဘနးေကာကးၿမိဳ႕၇ ထိုငး့ႏိုငးငဵ ်မနးမာ်ပညးလိပးစာ အမြတး (၁ွ) ပနး့ပငးၾကီ့လမး့၇ ၾကညးံ်မငးတိုငး်မိ ု ံနယး၇ ရနးကုနးတိုငး့၈ ဘနးေကာကးလိပးစာ လူထုက္နး့မာေရ့ဌာန၇ မဟီေဒါတကၑသိုလး ဘနးေကာကးၿမိဳ႕၇ ထိုငး့ႏုိငးငဵ ယခုသုေတသနကို လူသာ့မ္ာ့ႏြငးံ ပကးသကးေသာ သုေတသနက္ငးံွတးေကားမတီ၇ ်ပညးသူလူထု က္နး့မာေရ့ဌာန၇ မဟီေဒါတကၑသိုလးမြ အတညး်ပဳၿပီ့်ဖစးပါသညး၈ လိပးစာမြာ တိုကးနဵပါတး ဿ၇ လႊာ၇ အမြတး ၁ဿှ/ှ ရာဗီသီလမး့၇ ရာဗီသီ၇ ဘနးေကာကး ှွ၁ွွ၈ ဖုနး့ ွ-ဿ၀၂၁-၅၂၁၀-၆ လိုငး့ချဲ ှှဿ၄၇ ၁၁ွ၁ ေၾက့နနး့ ွ-ဿ၃၁ွ-၆၅၂၁၈ Nway Eint Chei Appendices / 112 APPENDIX F INFORMED CONSENT FORM EC-4 Form Project Title: Client satisfaction of antenatal care service in health centers in Wet-Let township, Myanmar Responsible person(s) and institute: Nway Eint Chei Master of Public Health International Program Faculty of Public Health, Mahidol University Bangkok 10400 Thailand Date ………………………(day/month/year) I (Mr./Mrs./Ms.)……………….……………….….…………...………………………. Home address…………..… Street…….……… Village number……………………… Sub district…………. District…...……….. Province……….……. Postal code………. I have read and understood all statements in the information sheet. I have also been explained the objectives and methods of the study, as well as possible risks and benefits that may happen to myself upon the participation in the study. I understand that the information will be kept confidential and my name will not be declared in any case. I shall be given a copy of the signed informed consent form. I have the right to withdraw from the project at any time without any adverse effects upon myself. Signature…..…………………………….… (Respondent/informant) (……….…………………………..) Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 113 Signature…………………………………… (Researcher) ( Nway Eint Chei ) I cannot read but before having finger print on this informed consent form, the investigator/interviewer has read and explained to me in detail about the study, the information sheet and the informed consent form until I completely understood. Signature…………………………….… (Respondent/informant) (……………………………….) Signature…………………………….… (Researcher) ( Nway Eint Chei ) Nway Eint Chei Appendices / 114 APPENDIX G INFORMED CONSENT FORM – MYANMAR VERSION Fac. of Grad. Studies, Mahidol Univ. M.P.H. / 115 Nway Eint Chei Biography / 116 BIOGRAPHY NAME NWAY EINT CHEI NATIONALITY Myanmar DATE OF BIRTH 9th June 1991 PLACE OF BIRTH Myanmar EDUCATION 2007-2013 Bachelor of Medicine and Bachelor of Surgery (M.B; B.S) University of Medicine, Magway PERMANENT ADDRESS No. 40, Pan Pin Gyi street, Kyee Myin Dine Township, Yangon, Myanmar E- MAIL [email protected] PHONE +959 502 8505