Maternal Satisfaction and Associated Factors with Postcesarean Section Pain Management: A Cross-Sectional Study

Background Maternal satisfaction with pain management after cesarean delivery serves as an indicator of the quality of care. Assessing the level of satisfaction with postcesarean delivery pain management is paramount for both the mother and the healthcare institution. This study aimed to assess maternal satisfaction with postcesarean section pain management and associated factors at the Comprehensive Specialized Hospital in Northwest, Ethiopia, in 2023. Methods An institution-based cross-sectional study was conducted from April to June 2023, involving 424 study participants. A consecutive sampling method was utilized for participant selection. Data were entered into Epidata and then exported to SPSS version 25 for analysis. Descriptive and analytic statistics were employed. Both bivariable and multivariable logistic regression analyses were conducted to identify factors associated with maternal satisfaction regarding postcesarean section pain management. Variables with a p value of <0.2 in the bivariable analysis were included in the multivariable analysis. In the multivariable analysis, variables with a p value of <0.05 were considered statistically significant. Crude odds ratio and adjusted odds ratio with 95% confidence intervals were calculated to demonstrate the strength of the association. Results A total of 424 participants were included in the study with a response rate of 97.8%. The overall maternal satisfaction with postcesarean section pain management was 80.2% (95% CI: 76.1%–83.8%). Urban residence, elective cesarean section, mild pain, two and above previous history of cesarean section, and waiting less than 30 minutes to get analgesia were associated with maternal satisfaction with postcesarean section pain management. Conclusion The overall maternal satisfaction with postcesarean section pain management was promising. Urban residence, elective cesarean section, previous history of cesarean section, mild pain, and waiting less than 30 minutes to get analgesia were predictor factors for maternal satisfaction with postcaesarian section pain management. We recommend that the stakeholders should give attention to enhancing maternal satisfaction.


Introduction
Cesarean section is one of the most common and important surgeries performed when vaginal birth poses a health risk to the mother or fetus [1].Te global cesarean section (CS) rate was 18.6% on average; however, rates in the least and most developed regions range from 6.0 to 27.2%, respectively [2].In Ethiopia, the recent overall rate of cesarean deliveries was 29.55% [3].
Pain is the most common complaint among women having a cesarean section [4].A study conducted at the University of Gondar Comprehensive Specialized Hospital reported that 85.5% of parturient delivered by cesarean section experienced moderate to severe postoperative pain in the frst 24 postoperative hours [5].If postcesarean pain is not managed properly, it can put mothers into a period of depression, afecting mother-child bonding and delaying recovery and returning to normal day-to-day activities [6].
Early recovery is important especially for a mother who has delivered via cesarean section to take care of her newborn shortly after an operative procedure [7].
Patient satisfaction is an essential component for assessing the quality of care and evaluating performance [8].High satisfaction with healthcare is considered a desired outcome and may infuence decisions to seek care, change providers or medical plans, and adhere to prescribed treatment plans [9].
If accurately measured, maternal satisfaction with postcesarean pain management can be a useful indicator of the quality of care in healthcare settings [10].Health personnel play a major role in perioperative patient care, including assessment and treatment of postoperative pain [11].
Efective pain management depends not only on medication choices but also on the patient's expectations for pain management, which in turn infuences satisfaction [12].Satisfaction with pain management is the result of contentment with the care process and outcomes, including waiting time, access, and adequacy of care [13].In healthcare settings, patient satisfaction typically includes both psychosocial and technical components of care, both of which are closely related to efcient pain management [14].
Despite the high number of cesarean births, no studies have been conducted to ascertain maternal satisfaction with pain management after cesarean section in our hospital.Terefore, this study aimed to assess maternal satisfaction with postcesarean section pain management and its associated factors at our institution.

Design and
Setting.Tis hospital-based cross-sectional study was conducted between April and June 2023 at the University of Gondar Comprehensive Specialized Hospital, located in the Amhara regional state in Northwest Ethiopia.Te hospital serves as a teaching and comprehensive referral healthcare institution.Te hospital has two rooms for emergency cesarean section and one room for elective cesarean section.Te hospital has 14 beds for the admission of pregnant women for elective cesarean section and 24 beds for emergency elective cesarean section.Data from the hospital operation register logbook indicated that around 4500-5000 cesarean deliveries were done annually.During the study period, a total of 1054 elective and emergency cesarean sections were performed.We included women who underwent caesarean section and stayed for 24 hours after cesarean section.Mothers under the age of 18 years, patients with lower levels of consciousness, and those unwilling to provide informed consent for the study were excluded from participation.
In our setting, unless contraindicated, spinal anesthesia is the preferred anesthetic choice, administered with 1.8-2 ml of 0.5% bupivacaine alone or with the addition of 25 μg of fentanyl or 25 mg of pethidine to enhance analgesia for cesarean sections.Following surgery, our standard postoperative analgesic regimen includes an abdominal feld block (Transversus abdominis plane block with 15−20 ml of 0.25% bupivacaine bilaterally), followed by systemic analgesic medication (50−100 mg of IV tramadol or 75 mg of IM diclofenac) as needed based on pain assessment using the numerical rating scale.

Study Variables.
Te outcome variable of this study was maternal satisfaction with pain management after a cesarean section.Te independent variables were sociodemographic, clinical, and analgesic-related factors.
Maternal satisfaction with postoperative pain management after cesarean section was measured via a 5-point Likert scale.Te maternal satisfaction scale was dichotomized into satisfed and dissatisfed groups based on the demarcation threshold formula (highest value-lower value/2) + lower value [15][16][17].Mothers who scored less than 28 out of 45 were considered dissatisfed, whereas those who scored 28 and above were considered satisfed.
Neonatal outcome is categorized and defned using the APGAR score, which stands for appearance (skin color), pulse (heart rate), grimace (refex irritability), activity (muscle tone), and respiration.Tis scoring system provides a quick assessment of the health of all neonates at 1 and 5 minutes after birth and in response to resuscitation eforts.A neonate is considered "alive and well" if they have an APGAR score of 7-10.Conversely, a neonate with an APGAR score of less than 7 is categorized as live but ill.

Sample Size Determination.
Te sample size of the study was determined by using a single population proportion formula.Te size of the study participants was calculated using a 95% level of confdence and a 5% margin of error.No similar study was conducted in Ethiopia to assess maternal satisfaction with postoperative pain management after cesarean delivery.Tus, the 0.5 proportion assumption was applied.With a 10% nonresponse rate, the fnal sample size was 424.

Sampling Technique. A consecutive sampling technique
was used to select the study participant.Participants who fulflled the criteria were included in the study until the required sample size was achieved.

Data Collection and Quality
Control.Data were collected 24 hr after the operation through chart review and interviews.Te questionnaire was translated into the local language (Amharic).Te questionnaire had the following four sections: sociodemographic characteristics, clinical-related factors, analgesia-related factors, and the Pain Treatment Satisfaction Scale (PTSS).PTSS is a valid assessment tool for pain treatment satisfaction with Cronbach's alpha of 0.87 [18].Te PTSS has the following fve dimensions: information on pain, pain medication, medical care, impact of current pain medication, side efects of pain medication, and satisfaction with pain medication and care.Te frst four dimensions were rated on a fve-point Likert scale.Only the side efects of pain medication were rated on a six-point Likert scale (0 � no experience and 5 � extremely bothered).Te last subsection of the Pain Treatment 2 Anesthesiology Research and Practice Satisfaction Scale (PTSS), which assesses satisfaction with pain treatment and care, was used to assess the respondents' satisfaction with pain management [19][20][21].Te nine items are rated on a fve-point Likert scale (1 � very dissatisfed and 5 � very satisfed).
To ensure the quality of data, a pretest was conducted on 5% of the mothers after cesarean section.Te accuracy, completeness, and consistency of the data collection were cross-checked before the analysis.
2.6.Data Analysis and Interpretation.Te data were entered using Epidata version 4.6 and then exported to SPSS version 25 for data analysis.Descriptive statistics were performed, and the results were presented using text, tables, and graphs.Multicollinearity among independent variables was assessed using the variance infation factor (VIF) and a tolerance test.Te goodness of ft of the logistic regression model was evaluated using the Hosmer-Lemeshow test, which indicated a good ft.Te normality of continuous variable distributions was assessed using the Shapiro-Wilk test.
A binary logistic regression analysis model was employed to determine the presence of statistically signifcant associations between maternal satisfaction with postcesarean section pain management and independent variables, with a 95% confdence interval (CI).All variables with a p value <0.2 in the bivariable analysis were included in the multivariable logistic regression analysis, and signifcance was determined at a p value <0.05.Te strength of association between dependent and independent variables was assessed using the adjusted odds ratio [22].

Ethics Approval and Consent to Participate.
Ethical approval was obtained from the Ethical Review Board of the School of Medicine, College of Medicine and Health Sciences, University of Gondar, with registration number SOM 06/01/584/2023.Written informed consent was obtained from each participant, and confdentiality was maintained at all levels of the study.

Sociodemographic Characteristics of the Respondents.
A total of 424 participants were recruited with a 97.8% (415) response rate.Nine participants were excluded from the analysis due to incomplete data.Te age range of 26-33 years old comprised the majority of participants (50.6%), with a median age of 28.Of the 216 participants, 52% were from rural locations (Table 1).

Pain Treatment Satisfaction Scale.
Te majority of participants preferred to have information about their injury or illness and understood the cause of their pain.In addition, the majority of mothers (86.1%) indicated a preference to know nothing about potential adverse efects of analgesics.Conversely, only 4.8% of the participants expressed a preference for substantially more information regarding their pain treatment options (Table 3).
In response to medical care questions, more than half of the participants somewhat agreed that it was easy to ask questions to medical staf (n � 220, 53%).Nearly half of the mothers believed that medical staf were willing to provide pain medication that they felt they needed (n � 205, 49.4%).A greater number of participants strongly agreed that medical staf provided adequate follow-up care (n � 42, 10.1%) (Table 4).
Most participants either agreed or strongly agreed with all statements regarding pain medication, improving their health, function, participation, mood, and cognition (Table 5).However, most participants did not experience these negative side efects.Some participants experienced bothersome side efects including nausea, vomiting, excessive fatigue, and inability to concentrate (Table 6).

Satisfaction Related to Postcesarean Section Pain
Management.In this study, satisfaction with postcesarean section pain management was dichotomized as satisfed and dissatisfed.Nine items of the PTSS were used to measure maternal satisfaction (Table 7).Using a demarcation threshold method, scores between 28 and above indicated satisfaction and scores below 28 indicated dissatisfaction.Overall, 80.2% (CI: 76.1%-83.8%) of the participants expressed satisfaction with the pain management following a cesarean section (Figure 3).In multivariate binary logistic regression analysis, certain factors were identifed as signifcantly associated with maternal satisfaction with postcesarean section pain management.Urban residence, elective surgery, mild pain intensity, two or more previous cesarean sections, and waiting for less than 30 minutes to receive analgesia were signifcant of maternal satisfaction with postcesarean section pain management (Table 8).
Participants living in urban areas were 1.7 times more satisfed with postcaesarean section pain management than those in rural areas (AOR � 1.799, 95% CI: 1.064-3.042).Te odds of maternal satisfaction with postcesarean section pain management were 2.2 times higher in the elective procedure group compared to the emergency group (AOR � 2.227, 95% CI: 1.1-4.511)(Table 8).
Maternal satisfaction with postcesarean section pain management was shown to be 2.7 times greater in those who had two or more previous cesarean sections than in those who did not (AOR � 2.766, 95% CI: 1.023-7.479).When analgesia was obtained quickly (less than 30 minutes), maternal satisfaction with postcesarean pain management was 1.8 times higher than when it took longer (more than 30 minutes) to obtain analgesia (AOR � 1.811, 95% CI: 1.073-3.057)(Table 8).

Discussion
In this study, the overall results showed that 80.2% participants were satisfed with postcesarean section pain management in the frst 24 hours.Tese results were lower compared to other studies reported in Pakistan (91.6%),Kenya (85%), and Jordan (95%) [23][24][25].Te presence of institutional pain treatment policies, as described in these studies, engagement of anesthesiologists in pain management, and variations in evaluation techniques could be the cause of this discrepancy.However, this fnding was higher than the results of other studies conducted in Rwanda (76.1%),Uganda (68.0%), and Nigeria (60%) [26][27][28].Te inconsistent and insufcient availability of painkillers was cited as one explanation for this study's comparatively low satisfaction rate in Uganda.Consequently, the patients had to purchase their own drugs during the data collection period, as stated in the study [28].
Regarding the factors associated with maternal satisfaction with postcesarean section pain management, fve variables were statistically identifed.Te frst factor that was signifcantly associated with satisfaction with postcesarean section pain management was women who had elective versus emergency cesarean section.Tis fnding is supported by studies conducted in the USA and Germany.Tey stated that satisfaction with pain relief was provided following elective caesarean section with optimum pain management [29].Parturient of elective caesarean deliveries are psychologically prepared and counseled over time.
In the present study, urban residence was found to be signifcantly associated with satisfaction with postcesarean section pain management compared to rural residences.Tese fndings are consistent with a study conducted in Arba Minch, which also reported an increased likelihood of satisfaction among patients from urban residences compared to those from rural residences [30].
In contrast, a study conducted in US reported that compared to urban areas, rural areas were signifcantly more likely to be satisfed with pain management [31].Tis variation may be due to access to information, cultural diferences, and unrealistic expectations regarding care appropriateness.
Te current study also found an association between maternal satisfaction with postcesarean section pain management and having undergone two or more cesarean sections in the past.Tis result was in line with a study conducted in Mexico which indicated a positive correlation between the number of cesarean sections performed and maternal satisfaction with pain management [32].Tis indicates that women who had a higher number of cesarean sections reported statistically signifcant higher satisfaction on postcesarean section pain management.Tis might be due to their prior personal experiences, knowledge, and expectations of postsurgical pain as well as the relative change in pain from presurgical to postsurgical levels.
According to this study, there was a signifcant association between pain severity and maternal satisfaction with pain management after cesarean section.Compared to those with severe pain, those with mild pain were more satisfed with postcesarean section pain management.Tis fnding supported by other studies in which women who experienced severe pain had lower satisfaction than those who experienced moderate pain [33,34].Tis may be infuenced by patient expectations, individual pain thresholds, and efectiveness of pain management interventions.
Tis study also found an association between the amount of time she had to wait to receive analgesia and maternal satisfaction with postcesarean section pain management.Patients with less than 30 min of waiting time to receive analgesia had better satisfaction with postcesarean section pain management than those with a waiting time of 30 min or longer to obtain analgesia.Tis fnding is consistent with that of a study done in Tikur Anbessa Comprehensive Specialized Hospital in Ethiopia.Tey reported that waiting for a short time (<30 min) to receive analgesics to pain was positively associated with satisfaction [35].Tis fnding is consistent with other study where patients expressed dissatisfaction with pain management when experiencing longer waiting times for medication [36].Receiving timely pain relief can signifcantly improve the overall experience of patients, making them feel more comfortable.

Conclusion and Recommendation
Te overall score for maternal satisfaction with postcesarean section pain management was promising.Te study identifed several factors signifcantly associated with maternal satisfaction, including urban residence, elective surgery, two or more previous cesarean sections, mild pain intensity, and shorter waiting time (<30 min) for analgesia administration.
Clinicians should prioritize these factors when aiming to enhance maternal satisfaction with postcesarean section pain management.Particular attention should be directed towards mothers residing in rural areas and those undergoing emergency cesarean sections.In addition, it is crucial to conduct thorough assessments of pain severity when devising pain management interventions.Healthcare providers should prioritize eforts to minimize waiting times for receiving analgesia.Furthermore, special attention should be given to clients undergoing cesarean sections for the frst time, aiming to enhance their satisfaction with pain management aspects.

3. 6 .
Factors Associated with Maternal Satisfaction on Postcesarean Section Pain Management.Maternal satisfaction with postcesarean section pain treatment was found to be associated with several factors in bivariate logistic regression analysis.Tese factors included residence, monthly income, urgency of operation, pain severity, neonatal outcome, number of previous cesarean sections, and waiting time to obtain analgesia.

Figure 2 :
Figure 2: Type of analgesia given postcesarean section at University of Gondar Comprehensive Specialized Hospital in Northwest Ethiopia, 2023.

Table 1 :
Sociodemographic characteristics of participants who received pain management at University of Gondar Comprehensive Specialized Hospital in Northwest Ethiopia (n � 415).

Table 2 :
Clinical characteristics of postcesarean section mothers who received pain management at University of Gondar Comprehensive Specialized Hospital in Northwest Ethiopia, 2023 (n � 415).

Table 3 :
Information about pain medication.

Table 6 :
Side efect of pain medication.

Table 7 :
Satisfaction to pain treatment and care.