Introduction

Provision of quality healthcare and utilization of health services during pregnancy, childbirth and in the post-natal period are important contributors to woman’s maternal health outcomes. There is growing consensus that much maternal and new-born mortality could be prevented with the provision of better quality care [1–4]. Numerous studies of maternal healthcare services in Asia have found that both public and private health facilities offer sub-optimal services, with short-comings in the physical facilities and the quality of maternal healthcare provided [5,6]. Disparities in services by healthcare providers are often reported [7], and the experience and perception of care may differ according to women’s background characteristics, previous exposure and expectations. There is also a growing body of evidence to show that women’s perception of quality of care is one of the key determinants of service utilization although this continues to be an often neglected aspect of assessing access to care in low and middle-income countries [8,9]. User’s perception could also be affected by their personal, social and cultural circumstances [10]. Similar findings are reported specifically from Nepal [11–13]. However, the experience of user’s perceptions when they are members of historically vulnerable subgroups and how these differ from the general population of women, has been little explored.

The literature reports that both women with disabilities—defined here as those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others [14], and Dalit women face numerous barriers in accessing maternal healthcare services due to their lower status in the society. ‘Dalits’ are considered ‘untouchables’ and are at the bottom of the caste hierarchy and the word literary means oppressed. In Nepal, women with disabilities and women from Dalit caste groups have low rates of maternal health service utilization [15,16]. This study attempts to better understand the perceived quality of care and experience of maternal healthcare services of these two groups both commonly regarded in Nepal as being socially discriminated and oppressed.

Background

Over the past two decades, Nepal has made good progress towards improving maternal health outcomes. There has been a significant increase in utilization of maternal healthcare services and the maternal mortality ratio has fallen dramatically to 258/100,000 in 2015 from 548/100,000 in 2000 [17]. However increases in utilisation have not been equitable, with persistent disparities in utilization among different population groups [11,15,18,19].

High coverage alone is not enough to reduce mortality and needs to be accompanied by improved quality throughout the continuum of care [3,4,20]. Good quality maternal healthcare in pregnancy and childbirth is a basic reproductive right that should be ensured by the state [21,22]. In recent decades, attempts have been made to drive more equitable improvement of maternal outcomes in low and middle-income countries, but substantial inequalities in care quality remain in many countries. Disproportionate resource allocation, poorly developed health systems and socio-cultural, economic and physical factors are all recognised as factors leading to health disparities and poor maternal outcomes [23,24].

Poor quality of care is a contributing factor in both public and private health facilities in low-income countries [12,25,26]. The capacity and number of health workers, quality and availability of drugs, low expectations of care, short opening hours and lack of privacy during antenatal care and delivery are frequently cited as maternity care concerns in Nepal; however, women with disabilities appear particularly vulnerable to experiencing distress caused by these factors [8,16,25].

Staff attitudes, demonstrated by being friendly, polite, welcoming, respectful, sympathetic, non-discriminatory and protecting the confidentiality of mothers are key factors affecting clients’ perceptions of care quality. Similarly, the competence and efficiency of health workers are reported to influence user’s perception of care; as do factors about the health facility environment such as accessibility, space, hygiene and sanitation, comfort and availability of supplies [27–29].

The experience of care can vary by the background characteristics of a woman and her family. Socio-demographic factors such as level of education, distance to a health facility and mode of transport to reach services are linked to a client’s perception of care [30,31]. Illiterate women with low social status and restricted personal freedoms are reported to have lower expectations of care quality than do their educated, higher status counterparts [32]. It is also reported that health providers sometimes fail to treat women from ‘lower’ social groups with respect during their labour and childbirth [33]. Further, disparities are reported between the information given to Muslim and Hindu women by health providers during their ante natal check-ups [26]. Poor quality of care in both government and private facilities was commonly reported by women with disabilities in health services [34], whilst others report no differences in services given to women with and without disabilities [35].

Quality of care is a complex and multidimensional concept [20] and there is no universally accepted definition. Some define ‘‘quality as excellence to expectations or goals, which have been met” [36]; others define it as ‘‘fitness-for-purpose” [37] or ‘‘the degree to which health services for individuals and population increase the likelihood of desired health outcome and are consistent with current professional knowledge” [38,39]. WHO defines quality of care as ‘‘the extent to which healthcare services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, healthcare needs to be safe, effective, timely, efficient, equitable and people-centred” [40]. Based on the WHO definition, quality of care in maternal healthcare considers two important components: the quality of provision of care and the experience of women, new-borns and their families.

The WHO recommended quality of care framework [4] contains eight dimensions of care and recognises quality of care as being a core component of the right to health. However, this study focused on user’s experience and is limited to four dimensions. Few studies about women’s perspective of health services have been undertaken in Nepal and even less is known about the experience of maternal healthcare services of vulnerable populations such as women with disabilities and Dalit women.

Methods

Results

Discussion

Women with disabilities were more positive about factors relating to ‘the Health Facilities’ (such as availability of staff and equipment, opening times, facilities and cleanliness), than women without disabilities (mean score of 7.68 compared to 6.61); but this was the only difference in perceived quality across the four dimensions of ‘Health Facility’, ‘Healthcare Delivery’, ‘Interpersonal Aspects’, and ‘Access to Services’. There was a significant difference in the perception of cleanliness, with women with disabilities rating this more highly. The reasons for this more favorable perception are unclear, but the evidence suggests that women with disabilities may be at increased risk of being socially excluded and vulnerable, which may affect their confidence to criticize services. Those with disabilities may be more reliant upon the help of the health facility and thus may also be less likely to be overtly critical. Recent research into ‘‘why health service users in Nepal do not complain” also found that despite being aware of major weaknesses, very few people complained or were openly critical, and that poorer and less empowered groups were least likely to complain [44]. Women with disabilities are frequently poorer than women without disabilities and as a result may live in worse housing conditions with which to compare the health facility. Studies in India, Nigeria, Tanzania, Ghana and Zambia have also found that women’s increasing education levels negatively affect their satisfaction with maternal care; and women with disabilities are frequently less educated than the mainstream population, so this may also contribute to their expectations and more positive satisfaction with services [45].

There were no differences in perceived quality of care between Dalit and non-Dalit women, except in relation to cleanliness and facilities’. Dalit women perceived the quality of this as being lower than non-Dalit women (0.79 vs 1.04). It is possible that the health facilities attended by more Dalit women were lower level facilities in poorer communities, that may have had limited utilities and sanitation. There were no differences in the perceived quality of ‘Healthcare Delivery’, which included items such as staff skills and training, drugs and supplies, dignity and privacy. Perceptions of ‘Inter-personal Aspects’ of care were different between women with and without disabilities in relation to individual items but not once collated at the overall ‘dimension level’; whilst the difference in perceptions of being ‘Open and Friendly’ and ‘Compassionate and Kind’ were highly significant and health worker’s attitude and behaviour seemed to have an impact on user’s perception of quality of care.

Interestingly, service users may interpret health worker’s attitudes and behaviours towards them as proxies for quality, rather than their actual knowledge and competence, an acknowledgment perhaps that clinical knowledge and competence is unlikely to translate into optimal quality of care (or outcome) in the absence of positive attitudes and supportive behaviours. This is also recognised in new global frameworks for improving quality of maternal and newborn care, that increasingly focus equally on the ‘provision of care’ and the ‘experience of care’ [4]. Women with disabilities rated health worker attitudes and behaviours more positively than women without disabilities, which is contrary to findings of previous studies reporting disparities in experiences and negative attitudes towards women with disabilities, as well as evidence of abuse and disrespect by healthcare workers. Some studies have also found that women with disabilities are not alone in reporting such violations and this phenomena was not necessarily related to disability [16].

It may also be that the positive perceptions and healthcare experiences of women with disabilities in the study could be the result of benevolent paternalism of local health providers rather than a reflection of equality, respect or positive regard. The fact that all participants with disabilities lived in rural areas may have influenced their positive perception, as more may have received care from local facilities where health workers already know them, rather than in larger urban centers where pre-existing relationships between health worker and patient are less likely. It is also possible that the relative positivity of service users with disabilities could be due to lower expectations, the result of limited exposure to alternatives and poor previous experiences.

There was no tangible difference in the Access dimension and this was the lowest rated by all groups, concurring with a previous study in Nepal [16]. However, there was a significant difference relating to ‘travel reimbursement and delivery incentives’. Women without disabilities perceived and rated this item more highly than women with disabilities. This may be because even with travel incentives, the transportation costs for women with disabilities were greater than the funds available. For example, women with physical disabilities unable to take the bus, may have to pay for more costly taxi services.

Although it was anticipated that there would be significant differences in perceptions of quality of care between vulnerable and non-vulnerable groups, there were in fact only a limited number of differences reported between women with and without disabilities, and even fewer between Dalit and non-Dalit women. The study found fewer associations between socio-demographic factors and perceived quality of care than studies in other settings [46,47]. However, it is important to note that all groups rated many aspects of care very low and thus the findings in this study reflect overall dissatisfaction with the quality of care. Also few of the women in this study had other experiences with which to compare the care they received locally upon which to base an informed view about the adequacy of equipment, staff skills or training; or to set their levels of expectation of services.

Poor experiences of care can deter use of health services [29], so if Nepal is to build on the progress made in recent years to increase utilization and reduce mortality, then quality and experience of care need to be better understood and improved upon, including indirect factors that may impact this such as transportation, distance to facilities or the preparation, pay and working conditions for health workers. Health provider’s (nurse’s) job satisfaction may also be related to service user’s perception of quality of care [48]. In the Nepali context, low pay and poor working conditions including inadequate physical infrastructure, erratic supplies of equipment and drugs, inequitable management approaches and poor housing, have been found to affect the job satisfaction of health providers and thus may contribute to adverse experiences and perceptions of quality of care [49].

Conclusion

Perceived quality of care differed significantly in several dimensions between women with and without disabilities, however little difference was found between women of different castes. Across the four dimensions and twenty items, women rated their experience of care as being low in almost all aspects, irrespective of caste or disability. This could have an impact on the progress Nepal has made in increasing utilization of health services and reducing maternal mortality, and prevent consolidation of these trends. Further research is necessary to explore differences and consistencies in perceptions and experiences of care across other regions and between different social groups and service users, and future research which combines the satisfaction tool with a Likert tool would provide further insight into quality of care.

Positive experiences of care are associated with greater willingness to use health facilities again in future [29]. It is vital therefore, that efforts are made to better understand the causes of poor experiences and quality of care, and comprehensive steps taken to address these.

Declaration: The views expressed in this article are those of the authors and do not necessarily represent the views of agencies supporting this study.

Supporting information

Acknowledgments

Big Lottery Fund UK through Kidasha in Nepal funded the study. The authors acknowledge the support and contribution of Kidasha and the colleagues–Janice Miller, Shanti Shrish, Ishwar Mainali and Tanka Shrestha, for the implementation of this study, data collection and analysis. In addition, the authors wish to acknowledge the support provided by Disabled People’s Organizations (DPOs) and the local partner—NAMUNA and its staff in Rupandehi. The authors are grateful to the women who shared their views and personal experiences.