DOES THE HEALTH CARE PROVIDER FULFILL THE NEEDS AND EXPECTATIONS OF WOMEN DURING INTRA-PARTUM AND IMMEDIATE POSTPARTUM PERIOD IN A SELECTED GOVT. HOSPITAL OF WEST BENGAL?

A descriptive study was conducted to assess the needs and expectations and fulfilment of needs and expectations of intra-partum and immediate post partum women. The findings revealed that in the area of esteem need all women (100%) wanted respectful maternity care. Intra-partum women had different types of need i.e. physiological need (92%) personal and psychological need (90%) social needs (98.61%) and safety needs (95%). Among various types of intra partum need 61.54% physiological needs were totally fulfilled. Pain relieving needs of immediate postpartum women were totally fulfilled (100%). Statistically significant association were found between educational status and fulfilment of personal & psychological need (χ2 = 5.257) and gravida and fulfilment of informational needs (χ2 = 14.920) at df 1, p <0.05 level of significance. There was a moderate negative correlation (‘r’ = -0.548) found between gravid and intra partum and immediate postpartum needs. There was a significant mean difference (t= 5.399, at df 118) between fulfilment of needs of primigravida and multigravida women at 0.05 level of significance. The study has a implication in nursing service by assessing the needs & expectations of intra partum and immediate postpartum women, the total needs can be fulfilled by health care provider.


Introduction
Normal labour is a spontaneous process of expulsion of the foetus and placenta. However, it is important to remember that the intra-partum and immediate postpartum women have some different kind of needs. Health care provider has the responsibility to assess the needs and provide frightening childbirth experiences and they are quite anxious about this1. So understanding women's need during intra-partum and immediate postpartum period is one of the first steps to help and support women to achieve the most satisfying experience.
Dr. Abdel GR, and Dr. Berggren V5 conducted a study on parturient needs during labour of Egyptian women. They identified twenty-two needs from the women's perspective. Among all of these needs the highest ranked needs for these women during labour were maintaining privacy through all procedures (86.5%), accessibility of nurses to demonstrate empathy (67.5%), availability to ventilate their feelings, fear and anxiety (57.5%), quick response on calling (67.5%), frequent monitoring (52.8%), accessibility of caring medical staff (47.2%) and short delivery (52.8%).
So, the investigator, by doing this research tries to help the women by identifying the needs and expectations during intra-partum and immediate postpartum period and helps to provide quality care to the women.
So, the investigator selected the study on does the health care provider fulfil the needs and expectations of women during intra-partum and immediate postpartum period in a selected Govt. hospital, West Bengal.
Purpose: The purpose of the study is to assess the care provided by the health care provider to fulfill the needs and expectations of women during intra-partum and immediate postpartum period. Problem Statement: Does the health care provider fulfil the needs and expectations of women during intra-partum and immediate postpartum period in a selected Govt. hospital of West Bengal?

Literature Related to Needs of Intra-Partum Women
Panda S, D'Sa J. and Rao AC6 conducted a descriptive study. The mean percentage distributions of scores under physical support needs were highest in needs (100%) as well as support (100%) for maintenance of hygiene and were lowest in needs (49.33%) in positioning and need for support (52.33%) in maintenance of hydration during labour.
A descriptive exploratory qualitative study was conducted by Iravani M, Zarean E, Janghorbani M, and Bahrami1 M. Study findings expressed that intervening to promote physiological needs can positively influenced on the women's sense of control and empowers during birthing. Some women were disappointed of restriction of eating and drinking during labour.
An analytic-cross sectional study was conducted by Dr Abdel GR and Dr Berggren V5 showed that twenty two need requirements emerged from women's perspective. 86.5% of women reported their needs for maintaining privacy through all procedure, 67.5% reported a need for qualified nurses offer help and demonstrate empathy.
A thorough systemic review was carried out by Iliadou M7 to identify practical points for supporting women in labour. Women during labour have a strong need for companionship, empathy and help. Continuous support appears to have a greater beneficial impact than intermittent support. Women's expectations of labour as a whole appear to be of more importance to their overall satisfaction with their labour experience than the perceived effectiveness of pain management.

Literature Related to Women's Expectations in Labour.
Zhang X and Lu H4 conducted a study on childbirth expectations. The total mean score of Childbirth Expectations Questionnaire was 4.14(SD=0.33) expectant mothers and 4.15(SD=0.30) for expectant fathers, revealed that couple's perceived a high level of childbirth expectations towards caring environment, spousal support, control and participation and medical support. Their expectations toward labour pain and their coping ability were relatively negative (M1=2.34, SD1=0.67; M2=2.46, SD2=0.65).
Pirdel M and Pirdel L8 conducted a descriptive-comparative study to compare women's expectations and experiences of childbirth. In the two groups, there was a negative significant relationship between the expectation and experience of childbirth in primiparas (r= -0.62,p<0.001) and multiparas (r= -0.69,p<0.001).

Final Study
Final study conducted from 15.10.2018 to 24.11.2018. The investigator herself collected the data. After obtaining formal administrative permission from concerning authorities subjects were selected according to the inclusion criteria by using non-probability purposive sampling technique. Self-introduction was given to the subjects and established rapport with them. Explained the purpose of the study to the subjects and addressed the terms of confidentiality. Then informed consent for the study was obtained from the subjects. Separate code number was given to each subject. At first demographic data collected from the intra partum women. Then needs and expectations during intra-partum and immediate postpartum period were assessed by using semi structured interview schedule at observation room of Labour room from the women. After normal vaginal delivery the women were sent to postnatal ward. The investigator again collected data to assess the care provided by the health care provider to fulfil the needs and expectations from the women as they felt by introducing 3 point rating scale at postnatal ward at the time of discharge. After collecting the data investigator left the subjects with thanks. Total time taken for one interview was approximate 25 minutes at intra partum period and 20 minutes at immediate postpartum period.

Plan for Data Analysis
Plan for data analysis was planned to analyse by using descriptive and inferential statistics. Data were analysed by using percentage frequency and chi square. Bar, Pie diagram and table were used to represent the demographic characteristics of women. Intra partum and immediate post partum needs were represented through bar, cone and column diagram separately for every area. Fulfilment of needs and expectation of intra partum and immediate postpartum women were represented through cone diagram and pie diagram respectively. Chi-square and Correlation coefficient test were computed to find the association between selected demographic variables and fulfilment of needs. Unpaired't' test was computed to find out the significant difference of mean score of primigravida and multigravida on needs fulfilment.  The data presented in the Table 1 depicts that most of women (95%) belongs to 18-28 years of age group, 58.33% women are Muslim & belong to nuclear family, maximum women were educated up to madhyamik (47.50%), most of (96.66%) women were housewife, Maximum family (40.83%) earned less than 2000 rupees and 67.5% women were primigravida.  , and majority of women wanted to know who will stand beside (75%) and whom to call in emergency (74.16%).  Informational needs about Newborn care   Data presented in the figure-8 shows that all women had need for assistance, pain reliving and nutritional needs. Most of the women wanted information about newborn care (91.35%) and self care (95.62%) after delivery.    (1) The data presented in the table 2 reveal that there is no significant association between education and informational (χ2=0.119), physiological (χ2=1.074), personal & psychological (χ2=0.019), safety (χ2= 0.336) and treatment need (χ2= 0.0) and social need as the obtained p value 1.0 through Fisher's Exact test at df 1 at 0.05 level of significance.

Summary of Intra-partum needs & expectations fulfillment
However there is significant association found between education and fulfillment of personal & psychological as evident from χ2 value 5.257 and no association found between education and fulfillment of informational (χ2=0.004), physiological (χ2=0.119), esteem (χ2=2.283), safety (χ2=0.119) and treatment need (χ2=0.875) at df 1 at 0.05 level of significance.  The data presented in the table 3 reveal that there is no significant association between education and informational need regarding newborn care (χ2= 0.090) and self care (χ2= 0.008) at df 1 at 0.05 level of significance.
However there is significant association between education and fulfillment of informational need regarding self care as evident from χ2 value 3.883 and no association found between education and fulfillment of informational need regarding newborn care (χ2= 0.317), assistance need (χ2= 1.544) and nutritional need (χ2= 0.503) at df 1 at 0.05 level of significance.  4 shows that there is moderate negative correlation between gravida and intra partum and immediate postpartum needs. It may be due to their experience. The relationship is statistically significant at 0.05 level of significance.  Data presented in table 5 depict that the t value is 5.399 at df 118. The obtained value (5.399) is higher than the table value (1.9803) at 0.05 level of significance. It means the mean difference is true difference between primigravida and multigravida not by chance. Therefore, interference can be drawn that there is significant difference of need fulfilment between multigravida and primigravida women.

Conclusion
Maximum of women's needs and expectations are partially fulfilled whereas needs and expectations are also not fulfilled and total fulfilment score is very low. So there is an urgent need to promote more focus on different types of needs and expectations of women during intra-partum and immediate postpartum period. Health care provider has the responsibility to provide quality care to pregnant women, which can be ensured by fulfilling the all needs and expectations of the woman during intra partum and immediate postpartum period. Findings from the study can be utilized to improve the quality care of women during hospitalization. Awareness of nursing personnel is needed regarding needs and expectations of women during intra-partum and immediate postpartum period. Findings of this study can be utilized to sensitize the nursing personnel from very beginning of their preparation period.

Recommendations
 A similar study can be conducted on large sample in different setting.  A qualitative study can be conducted on fulfillment of needs and expectations.  A comparative study can be conducted between primigravida and multigravida o this area.  A study on effect of interventional package regarding needs, expectations and fulfillment on satisfaction level of clients can be conducted.

Acknowledgement
The research is the product of many person's contribution, extensive help, intensive knowledge and skills, who supported and encouraged the investigator throughout the study. These contributors helped the investigator as friends, philosophers and guides. It is her privilege to offer heartfelt thanks to all of them for their timely help to complete the task on time.
The investigator sincerely thanks the lord for his abundant grace, mental strength, blessings and unconditional love bestowed on investigator throughout the study. The investigator gratefully mentions the efforts of Mr. Naresh Chandra Roy and Madhusudan Adhikary for language validation of data collection tool in English version and also in Bengali version.
The investigator's special thanks to the intra-partum and immediate postpartum women who have willingly participated and made the study possible.
An expression of gratitude goes to the librarians and other staff of the library of College of Nursing, Medical College & Hospital, Kolkata.
Profound gratitude is expressed to Dr. Sandip Mondal, Associate Professor of Calcutta University, for his patient endeavour in editing dissertation.
The investigator acknowledges the perseverance, understanding, and extension of encouragement and constant moral support of her family members during the entire period of the study. Word of acknowledgement would be incomplete if investigator does not express her sincere thanks to all friends and classmates.
The investigator extends her gratitude to all other members who directly and indirectly contributed their co-operation for the successful completion of research project. The topic selected for research study is "Does the health care provider fulfill the needs and expectations of women during intra-partum and immediate post-partum period in a selected Govt. Hospital of West Bengal"?

Najnina Khatun Investigator
I will bear all the expenses of the research project on my own and will have informed consent and permission of the participants and concerned authorities before starting the study. Privacy, safety and confidentiality of all the study participants will be maintained strictly.
I shall be highly obliged if you kindly grant permission to conduct the proposed study. I will bear all the expenses of the research project on my own and will have informed consent and permission of the participants and concerned authorities before starting the study. Privacy, safety and confidentiality of all the study participants will be maintained strictly.
I shall be highly obliged if you kindly grant permission to conduct the proposed study. Topic: "Does the health care provider fulfill the needs and expectations of women during intrapartum and immediate post-partum period in a selected Govt. Hospital of West Bengal"?

1)
To assess the needs of the women during intra-partum and immediate postpartum period.

2)
To assess the expectations of the women during intra-partum and immediate postpartum period.

3)
To assess the care provided by the health care provider to fulfill the needs and expectations of women during intra-partum and immediate postpartum period For above purpose I have prepared  A structured questionnaire for demographic variables.  Semi structured questionnaire to identify needs and expectations.  3 point rating scale to assess fulfillment of needs and expectations.
I am requesting you to kindly go through the content of the tool and give your expert opinion and suggestion about the appropriateness of the item which needs to be modified and deleted by using evaluation checklist. I would like to go take your permission for keeping your name in the expert list of my dissertation.
This is also my request that, kindly sign the certificate of validation that is enclosed with tool. I will remain grateful if you kindly provide me your expert judgment by checking my tool.  Appendix E

E1: Informed Consent Form in English
I have been properly explained by the researcher the purpose and method of this research (Does the health care provider fulfill the needs and expectations of women during intra-partum and immediate postpartum period in a selected Govt. hospital of West Bengal?). My participation in this study is purely voluntary and I can withdraw from the study whenever I wish. I have also understood that the researcher can take any decision regarding my participation in the study. I will not be given any incentive for participating in this study. After agreeing to participate in this study I give my full consent for participation and shall fully cooperate with the researcher for achievement of the objectives provided confidentiality is maintained.

F 2 Semi structured interview schedule
Purpose -To assess the needs of the women during intra-partum and immediate postpartum period. Instruction -The investigator will ask the questions and write the answers given by the women in intra-partum & immediate post-partum period.

Code no: Part II (A) Intra-partum period
Informational needs Q.1. What information do you need regarding the ward environment (like location of basin, toilet and bathroom, Doctors and nurses station etc)?
Q.2 What information do you need regarding your labour and delivery process? (Foetal condition, Time of delivery, Plan of delivery, Who will stand besides you, Who will conduct delivery, Whom to call in emergency, What to do & not to do).

Physiological needs
Q.3. What do you want to get services regarding your physiological needs? (information about whom to call in nausea, vomiting or headache occur, information whom to call if foetal movement is less, to check blood pressure, pulse, to check foetal heart rate, Information about type of diet to be taken during, before, after delivery, help to take light diet, help to take drinking water).
Personal and Psychological needs Q.4. What services do you want to get to maintain your personal hygiene? (Help to clean the body or to take bath, help to change the clothing) Q.5. What do you want to maintain your physical comfort in this ward? (comfortable environment in terms of light, temperature and cleanliness, Clean bed linen). Q.6. What kind of behaviour do you want to get from health care provider? (Behave kindly with you, verbal encouragement, Response in calling).
Social needs Q.7.What are your needs to maintain communication regarding delivery from health care provider? (Allowing support person like one family member to stay with you, Communication of the health care provider with you, Communication of the health care provider with family member).
Esteems needs Q.8. What are your needs regarding respectful maternity care like maintain privacy during check up or delivery like use of curtain, screen, no physical harm, consent before doing any procedure, equal treatment indiscriminating caste, creed, rich or poor, respect like calling by "name" or by "you", freedom in care like involvement in decision making, allowing comfortable position for delivery, to get timely care. What information do you need regarding breast feeding (when to initiate breast feeding, either colostrums is given or not, breastfeeding technique)? 2.
What information do you need to know from health care provider to maintain warmth of newborn (type of baby's clothing, time of bathing)? 3.
What information do you need to know from health care provider regarding baby's immunizations like when or where to give immunization? 4.
What information do you need to know from health care provider to prevent infection? 5.
What information do you need to know from health care provider to know the signs of baby is getting enough milk? 6.
What information do you need to know from health care provider about the danger signs of baby?
Regarding self care 7.
What information do you want to know regarding postnatal diet? 8.
What information do you want to know to take perineal care like dressing, pad changing ? 9.
What information do you want to know about the danger signs of postnatal mother?
Assistance needs 10. What services do you want from health care provider to take care of self (assistance to change clothing, sanitary napkin, cleaning extremities, in ambulation) and newborn care (supporting to hold baby during breastfeeding)?
What do you need to relieve pain at perineal area?
What do you want to get services regarding nutrition like providing food and water?
Other need 13. What other information or services do you want from health care provider during intrapartum or immediate postpartum period?