Women's satisfaction with maternity care is essential to health care professionals, and it is related to midwifery care. High-quality midwifery care is delivered when that care is safe, effective, and results in a positive experience for women. It is a fundamental concept. As women's experiences are now regarded as an integral part of assessing the quality of maternity care, women's views of their care must be recorded and used for quality improvement [17].

The women's perception of care and satisfaction with services is essential, and apparent quality is crucial for service application. Users, who deem the quality of care in a health center to be good, are more likely to return, increasing demand for the service. Service operation and positive maternal and neonatal outcomes can be significantly enhanced by improving the quality of facility provisions and making them more acceptable to women [18].

Few studies have been conducted in Saudi Arabia (KSA) to assess the quality of generic and routine healthcare for childbirth. In addition, few instruments are available to assess the postnatal mother's satisfaction with nursing care. It is crucial for healthcare professionals to understand women's satisfaction with their childbirth experience. Therefore, there has been a growing interest in Saudi Arabia in identifying factors associated with maternal satisfaction at the primary health care level. Maternal health care in Saudi Arabia is developing fast with multiple governmental and independent service providers. So, it is essential to look at maternal satisfaction and its determinants [19]. Evidence on women's perception and satisfaction with the quality of care received aids in identifying other aspects of care that are essential to strengthening and developing the nation's health frameworks. In addition to sustaining long-term requirements, creating healthy changes in the field of maternity care, and identifying blockages, ongoing evaluations should be performed [20].

It is hoped that the present study will provide an adequate evaluation of the quality and satisfaction of maternity care and special postnatal care in the studied hospital, which could help its administrators to identify the gaps in this service and accordingly develop appropriate improvement strategies [21].

The main objective of this study was to evaluate the gap between the quality of maternity care and women's satisfaction with postnatal care at the King Khalid Hospital-Jeddah, Saudi Arabia

• How do women evaluate the quality of maternity care in KKH?
• Does a gap exist between the actual perception and expectation of maternity service quality using SERVQUAL?
• What is the degree of women's satisfaction with postnatal care in KKH?
• Does postnatal care quality relate to women's satisfaction with postnatal care?

A cross-sectional descriptive design was used to include the population at a single point in time. The study was conducted at the King Khalid Hospital (KKH), Jeddah, affiliated with the National Guard Health Care Agency (NHGA), Saudi Arabia. It is a 751-beds tertiary care hospital accredited by the Joint Commission International (JCI). Maternity services are provided in three wards. (Prenatal Ward 1, Postnatal Ward 2, and Labour & Delivery (L&D). The study setting area was a Postnatal (Ward 2), which contained twenty beds, divided into eight rooms, each of which had four beds, and four other isolation rooms, each of which had one bed.

This study included a convenient sample of Saudi women who delivered in the postnatal ward (2). These women admitted receiving either the care associated with the delivery or postnatal care. The sample size was determined using the G-POWER software application. The sample was 300 participants to achieve the power of 0.80%. The sample size was based on an accuracy level of 5%, where the confidence level was 95%, and it is considered significant if P < 0.05. The inclusion criteria included women, who were ≥18 years old and undergoing immediate care following a spontaneous vagina delivery (SVD). Mothers who had undergone cesarean section (CS) and mothers who refused to participate in this study were excluded.

Three tools were used to measure the study variables.

Tools were reviewed by a jury of Academic experts of the nursing department at the College of Nursing. Few amendments were made. The current study's reliability was tested using Cronbach's alpha correlation coefficient with a value equal to 0.876 for SERVQUAL and 0.903 for JPSNQ, indicating good reliability for both questionnaires.

The Statistical Package for Social Sciences (SPSS) version 21 was used in the data analysis. Frequencies and percentages were used to present demographic characteristics. Mean and Standard Deviations were used to calculate average scores of care qualities and the women's satisfaction questionnaires. Pearson Correlation Coefficient (r) was used to measure the linear correlation between the quality of maternity care and women's satisfaction. Multiple Linear Regression (R²) was used to describe the women's satisfaction concerning the quality of maternity care as a predictor variable. P ≤ 0.05 was set as the level of statistical significance.

The study maintained ethical considerations and obtained approval from the King Abdullah International Medical Research Centre (KAIMRC). The final approval of the institutional review board (IRB) was received: SP18/131/j. Informed consent was obtained before the patients were interviewed. The researcher clarified the purpose of the study to every woman to obtain consent for participation in the study. Approval from the hospital to progress with the data collection strategy was also obtained to meet the ethical consideration of the study. Permission was obtained from the postnatal care manager, and the information collected in this research project was kept confidential.

Table 1 shows that the highest percentage of participants (41.7%) were aged between 23 to 26 years. More than half of women (60.3%) had a collegiate education degree. In the obstetrical data, gravidity ranged between 1 to 8, with a mean value of 2.43 ± 1.529, and the range of parity ranged between 1 to 8, having a mean of 2.29 ± 1.365. About two-thirds of women (61.1%) were not in the labor force, while 38.9% had work. 48.6% were admitted to the hospital in the last five years, while 12.9% were admitted in six months. The main reason behind the choice of hospital was the availability of good doctors (44.0%). However, the lowest reason for choosing this hospital was staff nurses (2.9%).

Table 2 illustrates that 68% of participants perceived maternity care as high quality, represented by mean ± SD (3.73 ± 0.466). Participants reported high-quality assurance (4.39 ± 0.571), followed by tangible and reliable quality (4.22±0.557, 3.93±0.589), respectively. However, participants rated both responsiveness and empathy as moderate (3.13±0.807, 3.09 ± 0. 907, respectively).

Table 2 shows a gap between the expectations and the perception of the participant's quality of care. This gap was found to be lower than expected quality of maternity care by -1.27. The same trend of the result was reflected in all the dimensions of quality, where there was a gap between the expected and perceived quality of Tangible (-0.78), Reliability (-1.07), Responsiveness (-1.87), Assurance (-0.61), and Empathy (-1.91). The highest gap value was related to Empathy (-1.91), while the lowest gap was related to Assurance (0.61).

The overall women's satisfaction with postnatal care was above average, with a mean ±SD of 3.20±0.511. The participated women were highly satisfied with the value and preference dimension (4.76 ± 0.775) and comfort and care (3.77 ± 0.854). While they were moderately satisfied with communication skills, orientation, and information dimension (3.34±0.743, 3.07±0.813, 3.02±0.767), respectively, they were less satisfied with the dimension of postnatal care (2.73±0.775) (Table 3).

Table 4 shows a significant strong positive linear correlation between the overall quality of maternity care and ‎women's satisfaction with postnatal care at r = 0.622, p=0.000. The regression analysis showed a ‎statistically significant effect of quality of care in achieving women's satisfaction, where R² = 0.387, indicating that the quality of maternity care could be explained for about 38.7% of the variation in women's satisfaction. ‎Where the value of F=219.483 and the p=0.000 were statistically significant.‎

The individual effect of different dimensions of quality of maternity care on women's satisfaction revealed that Responsiveness, Assurance, and Empathy dimensions had a significant ‎impact on women's satisfaction with postnatal care ‎ (t=4.404,5.712,6.955 and P=0.00). On the other hand, both the Tangible and Reliability dimensions had no significant impact or effect ‎on the women's satisfaction, where P = (0.515, .057).‎

The findings of the current study revealed a significant moderate positive correlation between the quality of maternity care and women's satisfaction with postnatal care. The quality of maternity care predicted 38% of the variation in women's satisfaction, indicating that the quality of maternity care for postnatal women in KKH affected women's satisfaction, and the higher the quality of maternal care, the higher the women's satisfaction. These findings were in agreement with the results of a study reported by Atiya‎ [23], demonstrating a statistically significant relationship between women's satisfaction and the quality of maternity care.

Furthermore, thirty-eight postgraduate nursing programs were implemented in the 2017-2018 academic year; one of these was the midwifery program [30]. However, there is a lack of national nursing scope of practice, which the Saudi Commission mandates for Health Specialties (SCFHS) [31]. Therefore, the lack of a national scope of nursing practice may lead to alterations in learning outcomes of adopting different international scopes; there is no assurance that nursing graduates of midwifery programs will practice midwifery, including the childbirth process. These issues also work against Saudi nurses, who graduate from international nursing schools, including advanced nursing practitioners, who are not guided by clear nursing practice regulations [32].

In the same line [33], a study reported that maternal satisfaction is one of the most frequently reported outcome measures for quality of care, the quality improvement and efficiency of health care to provide quality maternal-friendly services. Also, another study [27] found that maternal satisfaction with healthcare services is increasingly recognized as an essential outcome for the healthcare system. Moreover, another study [34] reported that the quality of the service facility is enhanced by assessing patients’ satisfaction with provided care, consequently leading to progress and perfection of nursing care based on patients' outlooks.

Our findings reported that women became more satisfied with maternal health care services when they perceived good technical quality of care and competency of providers. However, good care is perceived through receiving complete procedures, proper medication, and information [20]. In the same line, a study conducted in Iraq [35] reported that discripency between the predictable and delivered care affected women's satisfaction and reflected that the empathy, responsiveness, assurance, reliability, and tangibles were explained by one-quarter only of the total variance of customer satisfaction. Among five factors, responsiveness, reliability, and tangibles significantly impacted customers’ satisfaction, and the remaining two factors (empathy and assurance) did not significantly affect customers’ satisfaction. While a study [36] indicated that empathy, reliability, responsiveness, assurance, and tangibles are the significant determinants of service quality that positively affect customers’ satisfaction.

Application of the “women-friendly” tactic established on suitable reaction to women's care requirements and during the postnatal care is essential to decline women's dissatisfaction. Similarly, a strategic approach for designating applicable quantity and quality of staff to suit the number of women looking for maternal care would be beneficial. There is also a need to apply individualized postnatal care based on age, rarity, condition, and culture to meet the various health needs and achieve satisfaction for mothers. The current study recommends providing educational programs for postnatal care skills. Besides, continuous training of the health care providers at maternal and child health units is recommended to improve their performance and raise the quality level. So, regular and continuous monitoring of women's satisfaction could improve the hospitalization services by using a program to evaluate the quality and satisfaction. Enhancing strategies to increase the health care worker's knowledge and providing training courses for providers to upgrade their communication and counseling skills are inevitable.

The current study is the first study conducted in the western region of Saudi Arabia to study the relationship between women's satisfaction and the quality of services provided at the postnatal care units. However, the results are limited only to the population of the King Khalid Hospital in Jeddah. The study cannot be generalized to other settings, so replicating the study with other settings and populations is recommended. Additionally, women's satisfaction could include more indicators for more holistic measurement.