Methods of Research

An Analysis on the Overcrowding Problem of Birthing Mothers in the Obstetrics Gynecology Ward of Vicente Sotto Memorial Medical Center

Submitted to:
Chona Sebastian
Adviser

Submitted by:
Bacasmas, Dianez Lora
Tudtud, Dennis
Courtney, Joe

TEAM LEGIONS

February 20, 2010
TABLE OF CONTENTS

I. Problem Statement ............................................................................. 3 II. Research Objective ............................................................................ 4 III. Background of the Study ................................................................... 5 IV. Hypothesis of the Study ...................................................................... 6 V. Scope and Limitations of the Study .................................................. 7 VI. Significance of the Study ................................................................... 8 VII. Methodological Framework .............................................................. 9 VIII. Methodology ...................................................................................... 10 IX. Data Presentation and Analysis ....................................................... 12 a. Interview with Integrated analysis on Survewy report ............. 12 b. Satisfaction Rating on Different Aspect on Hospital ................ 32 X. Conclusion .......................................................................................... 43 XI. Recommendation ............................................................................. 44 XII. Bibliography ........................................................................................ 47 XIII. Appendix ............................................................................................ 48

I. Problem statement

Main Problem:

What are the determinants of the overcrowding problem(s) at the Obstetrics Gynecology Ward of Vicente Sotto Memorial Medical Center Cebu (VSMMC)?

Subproblems: a. Does the respondent hospital comply with the hospital standard requirement (i.e. patient-bed ratio) set by the Department of Health (DOH) for government hospitals in Cebu City?

What is the current occupancy ratio of the respondent hospital? (i.e. Number of beds, number of patients on lean and peak months, spacing and lay-out of beds, facilities and nurse station, sharing scheme of patients)

b. What is the number of health care staff on duty? Is the number sufficient for the number of patients accommodated by the respondent hospital? Does the hospital comply with the standard set by DOH with regards to the (staff per patient ratio)?

c. Do the patients comply with the regulation mandated by the Cebu city Government with regards to the referral system?

d. What are the reasons for patient to choose VSMMC as their hospital care provider? Is it due to patient satisfaction?

II. Research objective

GENERAL OBJECTIVE
The study aims to determine if overcrowding persists in Vicente Sotto Memorial Medical Center Cebu as regulated by Administrative Order #70-A Series 2002 and Republic Act No. 4226 / Hospital Licensure Act of 1965. After having ascertained the problem, the proponents aim to determine the causes of overcrowding and the consequent strategies applied by the hospital to address the overcrowding problem. Furthermore, the researchers aim to formulate additional solutions to aide the hospital in the current overcrowding situation. SPECIFIC OBJECTIVE a. To observe the ward if there is a presence of overcrowding by counting the number of patients in the ward over the number of bed capacity. In particular, respondents aim to note the number of patients per bed. b. To analyze the seasonality of pregnancy and to monitor which months need more attention and solutions with regards to overcrowding.

c. To determine the number of healthcare professionals on duty in the ward through the records section of VSMMC.

d. To find out the residence of the patients if ever they are complying with the ordinance mandated by the city government.

e. To determine the level of satisfaction of patients with various aspects of the hospital, and note if it has a relationship with the preference of admission of the hospital

III. Background of the Study

Overcrowding is defined as a situation in which the identified need for services outstrips the available resources in the hospital. This situation is evident in hospital departments when there are more patients than staffed treatment beds and wait time exceeds a certain period. Crowding typically involves patients being monitored in nontreatment areas (such as hallways).
Vicente Sotto Memorial Medical Center Cebu is a general, Tertiary Medical Center, Teaching / Training Medical Facility owned by the Philippine Government. It aims to provide health care services that are available, affordable, accessible, and acceptable to all regardless of social status.
Its operation started as early as 1911 as Hospital Del Sur and was formally established on April 11, 1913. It was through Republic Act RA 2725 that granted its legal status on January 12, 1913. The name was then changed to Southern Islands Hospital. With only 30 beds at its inception, it then became 350 beds when it was upgraded to a Medical Center in 1984. This institution has continued to grow, develop, and improve its services responsive to the changing need of the community. After 84 years of operation, Republic Act 7528 was approved on May 21, 1992, legalizing the change of its name to Vicente Sotto Memorial Medical Center. Shortly after this, another law was approved increasing the bed capacity to 400 (R. A. 7588 dated June 1, 1992).
It’s been a dream of this institution to expand and improve its services offered to conform to the standards of these days to cope with the increasing number of people will seek for care. This dream is not far from reality when the copy of Republic Act 8658 was received authoring the operation of 800 beds spread across the different departments of the hospital last June 22, 1998.

Today, in the Obstetrics Gynecology Ward in VSMMC, there are 38 beds with beds (1-8) which serves the C/S patients while beds (9-38) are for normal pregnancies. However, beds (33-38) are for pathologic or critical case patients. This setup has been designed strategically so that beds (1-8) and (33-38) are the ones nearer to the Nurses’ Station because of the constant supervision needed by the patients due to their status.

As of present, the current political parties of Cebu City (namely Cebu City Mayor Tomas Osmena and Governor Gwen Garcia) have devised a plan to segregate patients admitted to the different government hospitals in Cebu City. It was decided that only patients from the province of Cebu (56,252 live births) will be admitted to Vicente Sotto Memorial Medical Center Cebu (VSMMC) and only patients residing in Cebu City (19, 834 live births) will be allowed entry to Cebu City Medical Center Cebu (CCMC). Despite this strategy however, both hospitals still face conspicuous overcrowding problems at the emergency department, ward and lobby. This perennial problem has prompted the proponents of this study to ascertain the overcrowding problem of one (1) major government hospital in Cebu (VSMMC) by focusing on their Obstetrics Gynecology Department and thereby point out possible determinants for such problem.
IV. Hypothesis of the Study

Based on the initial ocular inspection conducted by the proponents of this research, we hypothesize that there is indeed an overcrowding problem at the Obstetrics Gynecology Ward of Vicente Sotto Memorial Medical Center Cebu. One possible major determinant for this overcrowding problem is the flawed referral systems of government hospitals and the corresponding inefficiency of district hospitals and health centers. Respondents will look into the capacity of district hospitals to cater to patients and detrmine if supply meets demand. Careful scrutiny on the process flow will also determine possible loopholes in the referral process.

V Scope and Limitations of the Study

Due to constraints in manpower and time, the proponents have decided to limit the study to only one government hospital (VSMMC) with the aim of providing in-depth analyis on this particular hospital rather than spreading the research too thinly on many government hospitals.

After consulting with the ethics department of various government hospitals, respondents realized that each government hospital works with separate networks and the problem of one government hospital do not necessarily relate to the problems of the other government hopsitals. To determine the overcrowding problem of one, will necessitate the workers to study further the corresponding networks.

For instance, to study the referral system of VSMMC, respondents have to study all eleven (11) district hospitals across the different provinces of Cebu. To study the referral system of Cebu City Medical Center Cebu (CCMC), respondents have to delve into the possible problems of all health centers in Cebu.

With this predicament, researchers are limited to VSMMC. Limitations in manpower has prevented the researchers from exploring further the problems of the distict centers in Cebu. As it happens, researchers are limited to analyzing the figures of supply and demand for district centers and birthing mothers in the corresponding provinces as provided by the Department of Health in Cebu (Refer to Data Presentation and Analysis).

The study’s scope is further limited to the Ob Gyne Ward of Vicente Sotto Memorial Medical Center Cebu. Its primary thrust is overcrowding in this particular section of the hospital. The respondents have decided to narrow down the scope to this particular department in order to provide substantial analysis on the department’s problem rather than superficial analysis on all overcrowded departments.

As to population, the study is limited to 71 patients and the proponents will do convenience sampling due to limitations in the availability of the patients themselves.

Perceived constraints in the study is the availability of patients and the process of gaining entry to the said hospital through the Ethics Committee Department.

Lastly, respondents were unable to monitor the total amount of days the patient have stayed in the hospital because of the spacing of the dates of interview and the consequent limitations with which we can record data from the station due to the hectic schedules of the staff.

VI. Significance of the Study

This study was created with the ultimate goal of alleviating the overcrowding problems of VSMMC. By determining the causes of overcrowding at Ward 1, this study aims to benefit the largely young, uneducated and poor mothers of Cebu Province. It is the researchers’ long term goal to make giving birth a memorable event in the life of a mother. Furthermore, by alleviating overcrowding problems, hospital resources are maximized and government funds (although minimal) are utilized to the fulllest.

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VII. Methodological Framework

Definition of Problem

Interview Question Development

Selection of Participants (n = 21)

Pilot survey for feasibility

Indepth Interview N=21
Data collection from responses on OB Ward overcrowding and its determinants

Data Analysis for agreement
Consesus on Determinants

Survey-Interview Questions development

Survey interview (n=71)
Data from Hospital Records

Data Collection and Tabulation

Data from Observation Records
Data Analysis and Interpretation

VIII. Methodology

A. In-depth Interview The first methodology to be used will be an one on one interview with the Hospital staff management, respectively, Chief of Clinics / Chief Nurse / OB-Gyne Residents /Nurses and Consultants.
The proponents aim to obtain accurate information on their definition of overcrowding, status of bed-occupancy ratio in Ward I (OB charity Ward), exact bed capacity for labor and deliveries, birthrates and abscond rate. The proponents also aim to determine experts’ opinion regarding possible causes of the overcrowding as well as corresponding solutions to remedy the problem. Furthermore, data on healthcare team-to-patient ratio will be needed. These information will be compared to the hospital standards set by the Department of Health in the Philippines.
The interview will encompass one (1) government hospital in Cebu City (VSMMC) and is limited to the OB-Gyne Department specifically on the ward section. Sampling method would be a non-probability – judgement sampling method for the Hospital Staff Management. Sample size = 1 Chief of Hospital, 1 Head of Research Department, 1 Chief of Clinics, 1 Chief Nurse, 1 Nurse Supervisor, 1 Chief resident, 5 OB-Gyne resident/interns, 10 Ward Nurses. With the total of 21 as our participants for the interview section.
B.) Survey Interview
A Survey interview will be separately conducted for 71 patients at the OB-Gyne ward. A separate survey form for the patients will be used with emphasis on questions on the socio-economic profiles, obstetric history, perceptions of the satisfaction levels acquired from services rendered by the hospital which includes nursing care, medical care and miscellaneous factors.
Perceived difficulty will be accessibility of these repondents, considering that in light of recent scandals, government hospitals impose strict research restrictions, to avoid putting their hospitals in “bad light”.
C. Observation Research (Additional measures)

This type of methodology will be used as a way to verify the data gathered from the interview of hospital staff management. The same data will be gathered but this time, descriptive details will be used on patient-bed ratio and the other parameters established by the Department of Health as witnessed by the researchers themselves.

The ocular inspection will be conducted in one (1) selected government hospital in Cebu City (VSMMC) but limited to the Ob Gynecology Department.

The proponents will observe the OB- Gyne Ward. The proponents will do their own headcount evaluation concerning the patient-to-bed ratio and the healthcare team-to-patient ratio for the selected hospital.

The proponents will put into consideration the referral system as mandated by the City Government and observe a random provincial district hospital, a 2o level hospital in the city and a 1o level health care facility (health care centers) and see for ourselves the status of the facility, actual compliance to the Administrative Order #70-A Series 2002, and note if there are overcrowding issues at the different levels in the health care delivery system.

D.) Secondary Sources via Hospital records

The proponents have decided to tap into the secondary source of information to get the following information vital for our research such as:

1. Monthly Census Average from November 2008 to October 2009 2. Abscond rate from November 2008 to October 2009 3. General Nursing Staff Distribution 4. Ward I discharges and Status of discharges from November 2008 to October 2009

IX. Data Presentation and Analysis

A. INTERVIEW WITH EXPERTS 1. What is your definition of overcrowding? * Chief of Clinics and Chief of Hospital- Dr. Roque Paradela & Dr. Gerardo Aquino
“Overcrowding exists when there are more than one person in one bed.”

* Chief Nurse – Dr. Alma Ungab
“It is overcrowding when the environment already causes harm to the patient than it does good.” * Chief OB Resident – Dr. Netty Suarez
“Overcrowding exists when the patients are already forced to leave the hospital despite overstaying because of the lack of payments.”

* Head of the Research Department – Dr. Celia Mabalatan
“Overcrowding happens when other places other than the ward are used for treating patients such as the corridors or even under the beds.” * Nurses
“Overcrowding exists when the services and quality of care given to the patients becomes lesser due to the overflow of patients. It is not overcrowding when there are three people in one bed. It only becomes overcrowded if the quality of care for the patients is lessened. * Other OB residents
Overcrowding exists when there are already errors made on medications and treatment due to understaffing.

From the interview with the aforementioned experts and the Department of Health officials, the researchers have concluded that to date, there is no clear-cut definition for overcrowding. Overcrowding per se is subjective, different from one department to another. Deviations in perspecitive are varied. Some experts answered that more than “one mother in one bed” is not really overcrowding because the hospital is still able to attain its ultimate goal- to improve the health of the patients. According to these selected experts, unless the patients’ health is deteriorating or the medical staff is doing numerous lapses in skill and judgement, it is still not overcrowding.

The researchers have realized that overcrowding (i.e. seeing more than one patient in one bed) has become a way of life for the medical staff at VSMMC. While it is a perennial problem across all government hospitals, the medical staff has come to accept that funding for their hopsitals will never be enough and they can only do so much when it comes to controlling the influx of patients. It is with this notion that the researchers were not able to obtain “complaints” on overcrowding and lack of funding. The medical staff have decided to stop complaining, accept reality as it is, and despite the odds – maintain its crucial goal which is to improve (and not worsen) the health of its patients. Figure 1 Ward 1 Discharges

Figure 1 shows the nature of discharges for patients at the OB Gynecology Ward at VSMMC and verify the opinion of experts during the interview. Nature of discharges are categorized as improved, expired, HAMA (Home Against Medical Advice), absconded and transferred.

Improved refers to patients who were discharged in better health condition compared to their actual state during admission. Expired refers to the mortality of mothers. HAMA refers to the mothers who preferred to leave the hospital (against medical advice) in order to prevent the piling up of hospital bills. Absconded refers to patients who left the hospital premises without the permission of the hopsital authorities in order to avoid their financial liabilities. Transferred refers patients who were adviced to obtain the services of other hopsitals because VSMMC could not deal with the complications of their pregnancies. Figure 1 also shows that despite overcrowding, majority of the patients (87%) went through the normal process of giving birth and were adjudged as improved. Incidences of mortality (expired) remain to be minimal and negligible at 0.16%. VSMMC is to be commended for this feat. It has proven that the medical staff and the authorities involved have utilized the hospital resources to the fullest despite minimal funding. Furthermore, out of 6401 patients in VSMMC, 576 of them went home against medical advice. Despite the affordable services of the hospital, there are still mothers who cannot afford to pay for the rate of hopital payments. Authorities should look into this marginalized sector and determine possible involvement of NGOs to help these patients. Aditionally, abscond and transferred rates are minimal. Reserachers agree with hospital experts that despite overcrowding, patients’ health are improved and prevalence of mortality is low. Thus, the ultimate goal of maintaining good health and preserving life is maintained by the respondent hospital.

2. What areas in the hospital would you consider as overcrowded?
Most of the respondents to the interview considered 3 areas in the hospital as very overcrowded.

i. OB Charity Ward (WARD I) ii. Emergency Room iii. Orthopedic Ward (WARD VIII)

It is with this notion that the respondents have chosen the OB-Gynecology Ward of VSMMC. As to severity of the patients’ cases, the OB-Gynecology ward presents the easiest access.

3. What do you think caused the overcrowding situation in the OB WARD?

The following are the reasons for overcrowding as enumerated by the experts interviewed. With each enumerated determinants are the corrresponding analysis and verification of the researchers. * Hospital Bed Shortage and Seasonality of Pregnancies * Nursing staff shortage * Noncompliance to the referral system as mandated by the City government * Increase in unplanned pregnancy / incidence of teenage pregnancy and interference of the Church on contraceptive use.

* Hospital bed shortage and seasonality of pregnancies

As per ocular inspection done by the researchers, there are 38 beds in the OB-Gynecology ward of VSMMC. The beds are arranged in such a manner that the most critical cases are situated nearest to the nurses’ station. Hence, beds (1-8) are are c/s patients, beds (9-38) are for normal pregnancies. However, beds (33-38) are for pathologic or critical case patients.

As per ocular inspection, an average of two (2) to three (3) mothers occupies one (1) bed, with four (4) mothers as the maximum. Thus, one single bed’s full capacity would total to four (4) mothers and four (4) infants, all of them lying horizontally to maximize the space.

Figure 2 shows the average daily census of Ward 1 at VSMMC. This data was obtained from the records section of VSMMC. These data proves that with 38 beds, there is no month that Ward 1 complies with the standard one mother (1) for one (1) bed ratio. The closest that the hospital hits this standard is on the month of March- which is 44 mothers for 38 beds. Moreover, Figure 2 shows that peak seasons for giving birth are June, September, November and December. Lean season for Ward 1 is summertime / March. This data will help the medical staff at Ward 1 in anticipating peak / non-peak seasons by corresponding the number of medical staff deployed. It is expected that during peak seasons of giving birth, overcrowding at Ward 1 is deemed to be worst. VSMMC expects around 150 mothers to a 38 bed vicinity. On lean seasons, VSMMC expects 77 mothers to a 38 bed vicinity. Either way, whether peak or lean, the hospital never had a ratio of 1 mother is to 1 bed.

Figure 2 Daily Census at Ward1 of VSMMC 2009

By crossmatching interview results with ocular inspection and records from the hospital, the researchers affirm that indeed, there is hopsital bed shortage at the Ward 1 of VSMMC. Lack of adequate beds is a major determinant for the overcrowding problem.

* Nursing staff shortage Table 1 shows the Staffing Distribution of Nursing Personnel in the Wards of VSMMC 2009. | 6am - 2pm | 2pm - 10pm | 10pm-6 am | Total | Nursing Personnel | | | | | Nurse IV | 2 | | | 2 | Nurse III | 18 | 2 | 2 | 22 | Nurse II | 35 | 10 | 7 | 52 | Nurse I | 50 | 40 | 30 | 120 | Total / Shift Nurses | 105 | 52 | 39 | 196 | Nursing Attendant | 45 | 25 | 15 | 85 | Nurses Assigned to Ward 1 | 5 | 3 | 2 | 10 | Table 1 shows the number of nurses assigned to the different wards at VSMMC. The nurses assigned at Ward 1 are five (5) in the morning, three (3) in the afternoon to evening and two (2) in the late evening. This totals to 10 nurses deployed for the whole day.

The effective nurse to bed ratio is one (1) nurse for four (4) beds. From the table we can deduce that nurses are critically understaffed. In the morning the ratio is one (1) nurse to eight (8) beds; in the afternoon – one (1) nurse to thirteen (13) beds and one (1) nurse to nineteen (19) beds in the evening. As per ocular inspection however, the researchers note that the shortages on nurses is not apparent. This is due to the presence of student nurses who come in groups of ten (10) in two shifts- one in the morning (peak houtrs) and another in the afternoon. During the night shift, there were no student nurses in sight. While nurses per se are understaffed at VSMMC, the current strategy of accepting student nurses (without salaries) is beneficial to the hospital. It has addressed the understaffing problem of Ward 1 without involving additional expenses for the hospital. As per observation, student nurses appear to be relaxed and accommodating because the workload has been evenly distributed.
With the existence of student nurses and nurses on duty, the ratios have changed considerably. In the morning, the ratio is one (1) nurse to 3 beds- within the standard (effective nurse to bed ratio). The same ratio applies in the afternoon. In the evening however, there are no student nurses. These are however no longer needed because patients just sleep all throughout the night. However, student nurses are deployed three times a week only.

Reserachers thereby agree that without nurses, the nurses on duty are severely understaffed. But the current strategy of accepting student nurses has greatly alleviated, if not remedied the problem of Ward 1 at VSMMC.

* Noncompliance to the referral system as mandated by the City government

To date, government hospitals in Cebu operate by referral systems. For instance, VSMMC hospital caters only to patients residing in the province of Cebu. While CCMC hospital caters to patients residing in Cebu City only. This current segregation of patients has led to a lot of controversies and has been blamed by experts as the cause of overcrowding in government hospitals. According to the experts, VSMMC is accepting non-qualified patients, thus the influx of patients admitted to VSMMC are beyond the hospital’s capacity.

In addition, experts claim that 2o and 1o level of Health care providers are inefficient and ineffective in handling birth cases. In most instances, experts claim that they easily refer to the tertiary hospitals even though they could have accepted these cases in their respective hospitals.

Upon the survey conducted on 71 patients, researchers inquired about the reasons of the mothers for choosing VSMMC, sources of these referrals and the residency of these patients in order to determine if they are qualified patients or not. These data will further ascertain the claims of experts that the referral system is flawed. Figure 3 shows the various reasons of mothers for choosing VSMMC. Included in the reasons are referral systems, preference (i.e. cleanliness, safety, familiarity, affordability) Figure 3 Reasons for Choosing VSMMC

Figure 3 shows that majority of the patients regard referral as the number one reason for choosing VSMMC. This is followed by preference of patients to be admitted to VSMMC. The succeeding chart will show the sources of referrals for these patients. The sources of referrals will determine if the referrals are valid or not. Figure 4 shows the sources of referrals for VSMMC

Figure 4 shows that majority of the referrals for VSMMC are either from trained hilots / district hospitals, this is followed by barangay health centers and lastly lying-in clinics. This chart shows potential deviations from agreed partitioning of patients, which is consequently a determinant for overcrowding. Trained hilots / midwives are not supposed to refer patients to VSMMC, rather they should refer patients to CCMC. Patients in particular are also responsible for this mix up. From the interview, patients confess to declaring false addresses in order to be accommodated at VSMMC. Figure 5A presents a map of Cebu and the corresponding residences of the patients at VSMMC. These data will help justify which patients are qualified or not. (Please refer to next page) CITIES | No. | | Cebu City | 17 | | Mandaue City | 10 | | Lapulapu City | 5 | | Talisay city | 8 | | CEBU PROVINCES | | | Carcar | 3 | | Aloguinsan | 1 | | Balamban | 2 | | Bogo | 1 | | Catmon | 3 | | Compostela | 2 | | Consolacion | 2 | | DaanBantayan | 2 | | Dalaguete | 2 | | Danao | 3 | | Dumanjug | 2 | | Liloan | 3 | | Naga | 1 | | Oslob | 1 | | Ronda | 1 | | San tander | 1 | | Tabuelan | 1 | | Tuburan | 1 | | | | |

This figure shows that 56% of the patients at VSMMC, majority of them are not qualified for VSMMC admission. Patients residing in Cebu City, Lapu-lapu City and Talisay City should be admitted at CCMC instead. It has to be verified if the loopholes exist in the leniency of the respondent hospital in admitting patients, given that the patients themselves fabricate false addresses.
Given the aforementioned data, the researchers conclude that the referral system is indeed flawed. While VSMCC is catering to referrals, as mandated by the policy, sources of these referrals are invalid. Trained hilots for instance should not refer patients to VSMMC. Only district health center referrals are valid for VSMMC case. Investigation on the addresses of the patients reveal that majority of the patients are not qualified for VSMMC but CCMC instead. The researchers affirm that overcrowding exists because VSMMC is catering to patients that should be catered by other hopsitals.
With regards to experts’ claim that district hospitals are ineffecient and ineffective, researchers do not have substantial data to gauge their inefficiency or effectiveness. In order to arrive at a justified answer, the researchers will have to study eleven (11) district hospitals from the different provinces of Cebu, which is beyond the researchers’ manpower and time constraints. The researchers however were able to gather from the Department of Health, data on eight (8) district hospitals only. Other disctrict hopsitals did not submit their data to the Department of Health.

Table 2 District Hospitals in Cebu and Corresponding Birth Rates Hospital | Total Bed | OB Ward | Normal | C/S | Others | TOTAL | Births / Day | Balamban District Hospital | 20 | 6 | 352 | 0 | 0 | 352 | 3 | Bantayan District Hospital | 40 | 6 | 338 | 2 | 0 | 340 | 3 | Barili District Hospital | 10 | 6 | 565 | 0 | 0 | 565 | 5 | Bogo Medellin District | 25 | 7 | 259 | 21 | 0 | 280 | 2 | Brigadier Airbase Hospital | 31 | 2 | 13 | 0 | 0 | 13 | 0 | Danao District Hospital | 55 | 10 | 58 | 0 | 0 | 58 | 0 | Daan bantayan District Hospital | 14 | 4 | 202 | 0 | 0 | 202 | 2 | Dr. Jose Borromeo Memorial hospital | 20 | 4 | 190 | 0 | 0 | 190 | 2 |

Table 2 shows the total number of beds per district hospital. These hospitals are further subdivided into the different departments and for purposes of this research, the OB Ward. Births in these provinces are categorized as normal or C/S. Births/day was calculated by multiplying total number of births / year by 3 (average number of stay at the hospital) and divided by 365 days.
Further analysis on these data reveal that when you contrast bed capacity vs. Births / day, district hospitals are not overcrowded. In fact, there exists an excess of supply. Which leads the researchers to conclude that possible flaws in the referral system exist on why district centers are referring majority of their patients when they have excess beds to accommodate them.

* Increase in unplanned pregnancy / incidence of teenage pregnancy and interference of the Church on contraceptive use.

According to Philippines UPIA Study (Unintended Pregnancy and Induced Abortion Guttmacher Institute), nearly half of pregnancies in the Philippines are unintended. Researchers found out that there are occurrences with the age bracket that pose risks to pregnancies such as those aged 15 years old and below or those above 35 years old. About Six in 10 Filipino women say they have experienced an unintended pregnancy at some point in their lives. About 1.43 million pregnancies each year—nearly half of all pregnancies in the Philippines—are unintended. Prevalence of teenage pregnancy has been increasing in the Philippines, emphasizing on the level of unpreparedness for young mothers.

The following charts will show the demographic profile of the patients surveyed at VSMMC.

Figure 5B Age Brackets of Birthing Mothers at VSMMC

Figure 5B shows the age brackets of birthing mothers at VSMMC. The bar chart shows that mothers at VSMMC Ward 1 are relatively young. Majority of the mothers conceive children from the age of 20 years old to 34 years old, the ideal adult reproductive age. This is closely folllowed by the 16-19 age bracket (11 respondents), which comprises the adolescent stage and >35 years old age bracket which comprises the aging stage. It was also a sad reality that some mothers are as young as 14 years old. Prevalence of teenage pregnancy has been increasing in the Philippines, emphasizing on the level of unpreparedness for young mothers. Correspondingly, as the age increases, we see lower incidences of giving birth.
“Additionally, it has been a known fact that girls aged 15 and younger is at increased risk of preeclampsia (a type of high blood pressure that develops during pregnancy). Young girls are also at increased risk of preterm labor and anemia. They are more likely to have babies who have anemia or who are underweight (small for gestational age). Women aged 35 and older are at increased risk of problems such as high blood pressure, gestational diabetes (diabetes that develops during pregnancy), chromosomal abnormalities in the fetus, and stillbirth. Also, they are more likely to have complications during labor such as preeclampsia, a placenta that detaches too soon (placental abruption) or is mislocated (placenta previa), and difficult labor.” Figure 5C Religion of Birthing Mothers at VSMMC

Figure 5C shows the espoused religion of the mothers at the OB Ward 1 of VSMMC. As depicted by the pie chart, the vast majority of the mothers (97%) are Roman Catholics. Out of 71 respondents interviewed, only 1 belonged to the Seventh Day Adventist Group and Iglesia ni Cristo respectively. This data shows that depsite being Roman Catholics, prevalence of pre-marital sex is high. Furthermore, prevalence of teenage pregnancy is increasing. Possible intervention of the Church with regards to their opposition to contraceptive use and prohibition of sex education is blamed by many medical experts. With the ban on contraceptives, there was a noted increase in unplanned pregnancies and improper spacing of children.

Figure 6 Civil Status of Birthing Mothers at VSMMC Figure 6 shows the Civil Status of Birthing Mothers at VSMMC. Majority of the mothers are married, comprising 45% of the total population of the respondents. This is followed by the live-in group which comprises 39% and lastly the single group, which comprises 16% of the total population. Included in the singles group are those who are separated / divorced and those who are not in good terms with their current partners. Figure 7 Occupation of Birthing Mothers at VSMMC Figure 7 shows the primary occupation of the birthing mothers of VSMMC. Their occupations are basically diverse, ranging from vocational to service-oriented jobs. Out of 71 respondents majority of the respondents are housewives / jobless. Majority of the women in Ward 1 are dependent on their husbands / parents for financial support. Figure 8 Occupation of Spouses Figure 8 shows that correspondingly, the occupation of the respondents’ husbands are also diverse. Their jobs range from vocational to service-oriented jobs, with none employed in white-collar jobs. Figure 1.6 shows that common fields of interest are welding, farming, driving and construction work. Out of 71 respondents, 6 of them had unemployed husbands. Aside from raising a family in the poverty line, they also have to contend with raising the family on their own because their husbands are jobless. Figure 9 Educational Attainment of the Birthing Mothers’ Spouses at VSMMC Figure 9 shows that the spouses of the respondents are also largely uneducated. Majority of the husbands belong to the high school level. Likewise, out of 71 respondents, only 4 of them had husbands who finished college. Figure 10 Combined Monthly Household Income of Birthing Mothers at VSMMC

Figure 10 shows that more than half of the respondents interviewed (63%) had an income ranging from 1000 php to 5000 php. This is followed by those who belong to the 5001 php -10,000 php group. On closer scrutiny, if the income is pegged to the maximum amount of 5000 php, it can be deduced that majority of the mothers are living on a budget of 166.66 ph / day with a husband and child (or children) in tow, making them belong to the poverty line group. According to the National Statistics Coordination Board (NSCB) the poverty threshold for Filipino family per day is 206.29 php, or roughly 6200 php per month. Majority of the mothers interviewed not only belong to the poverty line group they also live way below the poverty threshold. The researchers thereby conclude that the typical demographic profile of the mothers at VSMMC is that they are relative young (20 to 34 years old) and with increasing prevalence on teenage pregnancy, practicing Catholics, either married or live-in, basically jobless or employed at service-oriented jobs, uneducated and with incomes ranging from 1000 php to 5000 php. The demographic profile for majority of the patients show that mothers are basically unprepared for their pregnancies, especially in financial terms, which results to them overflowing at VSMMC and other govenrment hospitals since they could not afford the services of private hospitals given that they are uneducated with no stable jobs. Additionally, since they are young, there are increased instances of severity of patients’ condition (complicated pregnancies) because they are also biologically unprepared for conceiving children. 4. What are the strategies adopted to address the overcrowding situation?

* By stressing on the training of medical and nursing staff in the district hospitals and health centers to improve efficiency and effectiveness and thereby relieve the burden of the massive amounts of deliveries in VSMMC. Based on the aforementioned data, there are no spill-overs for district hospitals.

* By improving the CCMC hospital so Cebu City residents will comply with the city ordinance and allow themselves to be delivered there.

* By creating more programs on reproductive health to educate the teens and even mothers who frequently give birth and do not practice proper spacing and remind them on their responsibilities of being a mother (especially since unplanned pregnancies could cause complication to the mother and the baby). * By opening another Charity Ward to cater to the increasing amount of mothers giving birth.

B. Satisfaction Rating of Patients on Different Aspects of the Hospital

The researchers surveyed 71 mothers admitted at VSMMC with the aim of measuring perceptions of satisfaction at various hospital services as a source of improvement for the respondent hospital and consequently as a way to determine if admissions are due to patient satisfaction and how this will relate to overcowding.

Figure 11 Satisfaction Rating on Frequency of Nurses’ Visits

Figure 11 shows that majority of the patients at Ward 1 VSMMC are satisfied with the frequency of nurses’ visits. Although understaffed, the presence of student nurses alleviated the problem. Furthermore, the overcrowding situation at the hospital has trained the nurses on the art of multi-tasking. In fact, during our interview, they commented that things were manageable status quo. For them, there was no need for additional staffing or additional funding.

Figure 12 Satisfaction Rating on Perception of Nurses’ Friendliness

Figure 12 shows that majority of the patients are satisfied with the nurses’ friendliness. Despite the overcrowding situation, the patients still perceive the nurses as gentle and accommodating. Common feedback of the mothers was that given the price that they are paying for hospital bills, they are not in the situation to demand for exemplary service from the nurses.

Figure 13 Satisfaction Rating on Frequency of Doctors’ Visits

Figure 13 shows that majority of the patients are satisfied with the frequency of doctors’ visits. The overcrowding situation at VSMMC has not prevented the patients from receiving regular and timely visits from the doctors.

Figure 14 Doctors Explained the Procedures of Delivery Figure 14 shows that majority of the patients agree that the doctors explained the procedures of their delivery. Accroding to the patients, when the pregnancy is normal, minimal explanations are needed. With complicated pregnancies however, thorough explanations are needed. Figure 15 Doctors Answered all the Mothers’ Questions Figure 15 shows that the respondents agree that the doctors answered all their questions regarding giving birth. While there are dissatisfied groups, their numbers are minimal only. Figure 16 Satisfaction Rating on Visitor’s Policy at VSMMC

Figure 16 shows that majority of the patients (41%) are satisfied with the visitor policy, while 25% are Dissatisfied and another 22% are undecided. This is due to the stringent policies adopted by the hospital to control overcrowding. Visitation is from 9:00 am-11:00 nn, 3:00 pm-5:00pm, 7:00pm-9:00pm. Common complaints of the mothers was that they wanted consideration for complicated cases like caesarian cases, others wanted prolonged visitations especially since they had to contend with sleeping with “strangers” at night (sharing scheme of hospital beds). Those who reported satisfaction however, explained that the visitor policy was appropriate to control overcrowding. According to them, there are those who abuse visitation and bring as many as 5 visitors / patient. If all 4 patients in 1 bed will have 5 visitors each, one can imagine how congested and unsanitary the hospital would be.

Figure 17 Satisfaction Rating on Number of Patients Admitted / Sharing scheme for Hospital Beds

Figure 17 shows that majority of the patients are dissatisfied with the number of patients admitted at Ward 1. Out of 71 respondents, 31% are very dissatisfied and 21% are dissatisfied. This totals to 52% of respondents reporting dissatisfaction, of varying degrees. At the extreme end however, 39% are satisfied. Those who reported satisfaction explained that they would rather be placed at temporary inconvenience than be heavily indebted. Sharing their bed with another mother is not a problem for them since the sacrifice came with a lesser hospital bill. As they said, “Beggars cannot be choosers”. Those who were dissatisfied however belonged to higher income groups who vowed never to be subjected to such conditions again. According to them the pain endured during giving birth was heightened because of the poor post-natal conditions.

Figure 18 Satisfaction Rating on the Cost of Bills in the Hospital

Figure 18 shows that respondents are partly dissatisfied (23% very dissatisfied and 17% dissatisfied = 40% total) and partly satisfied (39% satisfied). An undecided group also comprises 21% of the total population. This shows that when it comes to the hospital billing, respondents have varying opinions. Those who were satisfied explained that while VSMMC is more expensive than health centers, it is less expensive compared to district hospitals. Furthermore, according to them, the additional price they pay for guaranteed safety and well-equipped facilities, is well worth it. Those who answered dissatisfied explained that the government should have shouldered the bulk of the hospital expenses. Given the conditions of the hospital, hospital billing should be minimal if not free.

Figure 19 Satisfaction Rating on Overall Cleanliness of the Ward

Figure 19 shows that majority of the respondents are satisfied with the overall cleanliness of VSMMC Ward1. According to the patients, VSMMC is better off compared to the conditions of other neighboring government hospitals. Regular cleaning was observed at timely intervals. Those who reported dissatisfaction expressed dismay over the smell and stains of other patients and the ventilation of the hospital.

Figure 20 History of Giving Birth at VSMMC Figure 1.20 shows that 52%, half of the respondents, are first-timers at giving birth at VSMMC. However, they have histories of giving birth at their respective houses or at health centers. Next in line are the first time mothers, whose first child is born at VSMMC. Lastly, only 17% of the respondents are repeaters for VSMMC. Thus, VSMMC is currently catering to first time patients, majority of which are mothers who have tried giving birth outside hospitals. This chart shows the growing prevalence of mothers choosing hospitals as the location for giving birth. Those who answered no (52%) depict a paradigm shift in the location of giving birth. More and more mothers are disregarding trained hilots for actual doctors. Despite the low educational attainment of these mothers, more and more of them are becoming educated on the hazards of giving birth without sound medical advice and proper facilities.

Figure 21 Patients Who Decided to Give Birth at VSMMC Again Figure 21 shows that majority of the patients will not give birth at VSMMC again. Table 1 below shows the various reasons not coming back tabulated from the answers of patients during the survey. Ligated | 21 | Hot and crowded | 16 | Expensive | 5 | Prefer Home | 5 | Distance | 3 | Unaccommodating staff | 1 |

Figure 22 Recommend VSMCC to Friends Figure 22 shows that a little over half of the respondents (51%) will recommend VSMMC to their friends while 49% will not recommend the hospital. Common reason for the mothers is that giving birth is a personal decision, one that involves a lot of sacrifice, and they are not in the proper place to influence such decision. Researchers have concluded that when it comes to patient satisfaction, patients are basically satisfied at the frequency of nurses’ visits and friendliness of the nurses, frequency of doctors’ visits. Majority of the patients agreed that doctors explained the nature of their deliveries and answered all their pertinent questions. Deviations in the satisfaction rating were in the areas of visitation, sharing scheme of hospital beds and hospital beds. These are the areas that the authorities could improve on in order to improve patient satisfaction. Researchers have concluded that admissions are not directly related to patient satisfaction since majority of the patients are first-timers and only a few are repeaters. Researchers find negligible relationship between patient satisfaction and overcrowding since VSMMC operates by referrals and not preference of patients. Thus, patients have little say on where to admit themselves, they are only followers of the segregation policy of the government hospitals.

X. CONCLUSIONS
The researchers have concluded that there is not one standard definition of overcrowding. The Department of Health and the various experts interviewed have various opinions with regards to overcrowding but common ground is that having more than one patient in one bed is a signal of overcrowding. The researchers then have decided to choose 1 mother is to 1 bed as the standard occupany ratio for government hospitals.
With this standard, researchers thereby conclude that overcrowding exists (as validated by ocular inspection and daily census report of the hospital) and is a perennial problem for Vicente Sotto Memorial Medical Center Cebu (VSMMC).
Verfied determinants for overcrowding are hospital bed shortage, nurse shortage, non-compliance with the referral system and increase in unplanned pregnancies and increased incidence of teenage pregnancies with possible interference of the Church on the use of contraceptives.
Current occupany ratio of the VSMMC is 77 mothers to 38 beds. During lean months, there are 42 mothers to 38 beds and during peak seasons there are 150 mothers to 38 beds. Either way, there has been no incidence of a 1:1 ratio for VSMMC. Researchers conclude that nurses are actually understaffed but the presence of student nurses have greatly alleviated the problem. The referral system of VSMMC however is flawed because of numerous referrals from the trained hilots. The referral system for VSMMC is not strictly followed. Furthermore, patients choose VSMMC as their hospital care provider because of the referrals from district hospitals and trained hilots and a few from their own preference.
Admissions at VSMMC cannot be directly correlated with patient satisfaction. Patients however appear to be satisfied in terms of frequency of nurses’ visits, friendliness of nurses, frequency of doctors’ visits. Majority of the patients agree that doctors explained the nature of their deliveries and answered all their questions. Deviations in the satisfaction rating were in the areas of visitation, sharing scheme of hospital beds and hospital beds. These are the areas that the authorities could improve on in order to improve patient satisfaction.

XI. RECOMMENDATIONS
We would like to give out our recommendation to the respondent hospital: 1. The Researchers would like to recommend to the hospital to provide an additional ward and alongside it an increase in number of beds to OB Gynecology Ward. This is in consideration with availability of funds.

Moreover, if funding is available we would like to recommend a separate crib or small bed for the babies because it is very dangerous for the babies to be in close proximity with so many people which could cause infection.

2. The researchers would like to recommend hiring more nurses to prevent possible medical errors brought about by understaffed nurses who are overburdened by multi-tasking.

3. The researchers would like to recommend allowing linkages to more schools to have a pool of student nurses which could help distribute the services needed by the patients. Consequently, VSMMC is partnering with universities like University of San Carlos to provide a steady stream of student nurses.

4. We would like to recommend the hospital to take notice of the level of dissatisfaction with some of the clients with regards to the visitors policy of the OB ward, overall costing or billing and the status of overcrowding.
These recommendations are addressed to the Government and to the public: 5. We would like to recommend on the training of medical and nursing staff in the district hospitals and health centers to improve efficiency and effectiveness thereby relieve the burden of the massive amounts of deliveries in VSMMC.

6. We would like to recommend the improvement of CCMC hospital so Cebu City residents will comply with the city ordinance and allow themselves to be delivered there.

7. We would like to recommend the upgrading of the district hospitals into provincial hospitals to provide more bed capacity and better medical services to the public.

8. We would like to recommend stressing to the public the importance of proper reproductive health and information dessimination to every community to aware people so they will be able to have a responsible, satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicating in this are the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice; and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.

9. We would like to recommend to the government to invest in contraceptive dessimination and increase in funding to reproductive health. Increasing publicly funded contraceptive services is especially important to improve the sexual and reproductive health of poor women, who experience disproportionately high levels of unmet needs, unintended pregnancy and pregnancy-related health risks. Meeting the needs of these women and their families will require developing services and outreach efforts, and directing resources to areas of the country where poverty is greatest.
Investing in contraceptive services not only protects women and families, it also saves money. By taking on the cost of providing contraception, the Philippines government could avoid much greater expenses down the road, including those for maternal and newborn services, treatment for pregnancy-related complications and life-long services for millions of additional people. The savings could be invested toward improving public services and encouraging economic development.

We would like to recommend to future researchers interested with our topic: 10. We would like to recommend that further studies should include mode of contraceptives used in the past and study effectiveness of such forms of contraception. 11. We would like to recommend a further study on the respondents to ascertain if current pregnancy is planned or not. 12. For future researches we would recommend to include the two other areas of the hospital which are also overcrowded which are the Ortho Ward and the Emergency Department. 13. We would like to recommend to include in the next research the spacing of pregnancies of the patient in order to analyze if it could be another determinant to overcrowding. 14. We would like to recommend to include the incidence of possible infection or contamination which can be brought about by overcrowding such as Methicillin resistant staphylococcal Aureus infection (MRS) which is a common nosocomial infection in hospitals. 15. We would like to recommend to put into consideration the side of the hospital staff with the effect of overcrowding to the state of depression it brings to the staff.

XII. BIBLIOGRAPHY http://home.doh.gov.ph/ao/ao70A-02.pdf, pp 36-38
2 http://www.chanrobles.com/republicactno4226.htm#REPUBLIC%20ACT%20NO.%204226
3 JCR (Joint Commission Resources) Inc. 2004. Managing patient flow: strategies and solutions for addressing hospital, page 6 4http://www.doh.gov.ph/vsmmc/index9498.html?option=com_content&view=article&id=19&Itemid=27
5 http://67.225.139.201/network/transport-patients-governors-office
6 http://home.doh.gov.ph/ao/ao70A-02.pdf. pp 24-35
7 Guttmacher Institute- NON-PROFIT org based in New York that works to advance reproductive health as defined by WHO.
8 www.Merck.com/mmpe/sec18/ch262/ch262b.html
9 http://www.guttmacher.org/pubs/2009/04/15/IB_MWCNP.pdf
10 http://www.uq.edu.au/news/index.html?article=15093
11 http://ajp.psychiatryonline.org/cgi/content/full/165/11/1482

XIII. APPENDIX APPENDIX A Republic Act No. 4226 AN ACT REQUIRING THE LICENSURE OF ALL HOSPITALS IN THE PHILIPPINES AND AUTHORING THE BUREAU OF MEDICAL SERVICES TO SERVE AS THE LICENCING AGENCY Section 1. This Act shall also be known as the "Hospital Licensure Act." Sec. 2. Definitions. -
(a) "Hospital" means a place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other medical and nursing care. The term "hospital" shall also be construed as any institution, building or place where there are installed beds or cribs or bassinets for twenty-four hour use of longer by patients in the treatment of diseases, diseased-condition, injuries, deformities or abnormal physical and dispensaries, and such other means by which they may be designated.
(b) "Government Hospital" is a hospital operated and maintained either partially or wholly by the national, provincial, municipal, or city government or other political subdivision, or by any department, division, board or other agency thereof.
(c) "Private Hospital" is one which is privately owned, established and operated with funds raised or contributed through donations, or by private capital or other means, by private individuals, association, corporation, religious organizations, forms, company or joint stock association.
(d) "Clinic" means a place in which patients avail of medical consultations or treatments on an out-patient basis. However, any clinic or dispensary where there is at least six (6) beds or cribs or bassinets installed for twenty-four hour use by patients shall be construed to fall within the definition of a hospital as described in this Act.
(e) "Licensee" is a person, or persons granted a license to operate and maintain a hospital according to an approved minimum standard.

Sec. 8. Minimum Standards of Construction. - In order that a permit to construct a hospital can be issued, the hospital plan shall provide sufficient bed space for the hospital bed capacity proposed, a laboratory room and operating room, including work rooms for sterilization, anesthesia, etc. an e-ray or radiology room, pharmacy dispensary or out-patient department, delivery room, isolation rooms, autopsy room or morgue, sufficient quarters for residents, nurses, attendants and helpers and sufficient number of toilet facilities. Wards shall be constructed such that segregation of the sexes is observed and as far as practicable as to the cases to be confined. revocation of the license: Provided, That the licensee may resort to the courts, as in other cases provided by law. Sec. 16. Classification of Hospitals. - The licensing agency shall study and adopt a system of classifying in the Philippines as to (1) general or special; (2) hospital service capabilities; (3) size or bed capacity; and (4) class of hospital whether training or not. Sec. 20. Effectivity. - This Act takes effect upon its approval.

APPENDIX B
For 2007, Filipino families consisting of five members should be earning a combined monthly income of PhP 6,195 in order to meet their most basin food nd non-food needs for this year. Individual/ year NSCB | P15,057.57 | Individual/ Month | P1254.80 | Individual/ Day | P41.26 | Family/ month | P6195 | Family/ day | P206.29 |

APPENDIX C THEORETICAL FRAMEWORK OF HEALTH CARE DELIVERY SYSTEM

DEPARTMENT OF HEALTH
ARMM

NCR

CAR

XII

XI

X

VIII

IX

VII

VI

IV

III

II

V

I
Provincial Health Office
Provincial Health Office
City Health Office
Health Services
Hospital
District Hospital
District Head Office
Regional Health Unit
Regional Health Unit
Regional Health Unit
Baranggay Health Station
Baranggay Health Station
Baranggay Health Station

PUBLIC

APPENDIX D CIVIL STATUS BY AGE GROUP with Risk Factors Indicators | | | | CIVIL STATUS | Age | Label | Risk Factors | Total | Single | Live-in | Married | <16 | Very Young | *** | 2 | 1 | 1 | 0 | 16-19 | Adolescent | ** | 11 | 2 | 7 | 2 | 20-34 | Ideal Adult Reproductive Age | * | 46 | 7 | 17 | 22 | >35years | Aging | *** | 12 | 1 | 3 | 8 |
APPENDIX E HOUSEHOLD INCOME BY AGE GROUP | HOUSEHOLD INCOME | Age | none | <1000 | 1000-5000 | 5001-10000 | 10001-15000 | >15000 | <16 | 1 | 1 | 0 | 0 | 0 | 0 | 16-19 | 0 | 0 | 8 | 3 | 0 | 0 | 20-34 | 0 | 3 | 25 | 13 | 3 | 2 | >35years | 0 | 1 | 7 | 3 | 1 | 0 |
APPENDIX F HIGHEST EDUCATIONAL ATTAINMENT BY AGE GROUP | HIGHEST EDUCATIONAL ATTAINMENT ON MOTHERS | | | Age | No Education | Elem Student | Elem Grad | HS Student | HS Grad | College Student | College Grad | | | <16 | 0 | 2 | 0 | 0 | 0 | 0 | 0 | 2 | 2 | 16-19 | 0 | 2 | 0 | 2 | 6 | 1 | 0 | 11 | 11 | 20-34 | 3 | 6 | 5 | 10 | 13 | 6 | 3 | 46 | 46 | >35years | 1 | 3 | 2 | 5 | 1 | 0 | 0 | 12 | 12 | | | | | | | SUPPLEMENTAL DATA Status of Pregnancy by Age group | | | | | | | | | | | | | Age | Normal | % | CS | % | Stillbirth | % | Total | <16 | 1 | 50.0% | 1 | 50.0% | 0 | 0.0% | 2 | 16-19 | 6 | 54.5% | 5 | 45.5% | 0 | 0.0% | 11 | 20-35 | 28 | 60.9% | 17 | 37.0% | 1 | 2.2% | 46 | >35 | 2 | 16.7% | 10 | 83.3% | 0 | 0.0% | 12 | Status of Pregnancy by Location | Normal | | CS | | Stillbirth | % | Total | City | 23 | 57.5% | 17 | 42.5% | 0 | 0.0% | 40 | Province | 14 | 45.2% | 16 | 51.6% | 1 | 3.2% | 31 | | | | | | | | | | | | | |

APPENDIX G SURVEY INTERVIEW QUESTIONNAIRE
DATE:_________________________________
I. SOCIO-ECONOMIC PROFILE 1. Patient CODE ____________________ 2. Bed Number _____________________ 3. Patient Name _____________________ 4. Age ____________________________ 5. Religion:________________________ 6. Marital Status:____________________ 7. Household Monthly income:_________ 8. What is your primary occupation?
________________________________
9. What is your spouse’s occupation?
________________________________
10. What is your highest educational attainment?______________________ 11. What is your spouses highest educ. attainment?______________________ 12. Resident Home Address
____________________________________ ____________________________________________________________

____________
II. CLINICAL/ OB HISTORY 13. Date of Admission: ________________ 14. Is this your first Pregnancy? _________ a. If No please note years, status, hospital born
_______________________________________ ____________________________________________________________

____________________________________________________________

____________________________________________________________

_______________ 15. Length of Pregnancy: b. 38weeks &up –full term c. 37weeks & below –preterm 16. Duration of labor?_________________ 17. Status of Pregnancy : Encircle d. NP with NC e. NP with C : _______________ f. C/s indication:_____________ 18. Causes for delay in discharge:________
________________________________

III. Client Satisfaction on Process of Hospital Admission IV. NURSING STAFF 19. How satisfied were you with the frequency with which the nurses checked on you? VS S U DS VDS 20. How satisfied were you with the friendliness of the staff?
VS S U DS VDS

V. DOCTOR CARE 21. How satisfied were you with the frequency with which the doctors checked on you? VS S U DS VDS 22. My doctor fully explained the procedures of my delivery? SA A U D SD 23. My doctor fully answered all my questions regarding medication and treatment? SA A U D SD

VI. OTHERS 24. How satisfied were you with the visitors policy at the hospital?
VS S U DS VDS 25. How satisfied are you with the number of patient admitted in the ward?
VS S U DS VDS 26. How satisfied are you with the cost of the bills in the hospital?
VS S U DS VDS 27. How Satisfied are you with the overall cleanliness of the ward?
VS S U DS VDS 28. Why have you chosen this hospital apart from a hospital located nearer your location of residence?
____________________________________________________________

____________________________________ 29. Why have you chosen this hospital with respect with the degree of care needed could be looked at in primary or secondary level hospitals or health centers?
____________________________________________________________

____________________________________ 30. Have you ever delivered in this hospital before? Y or N 31. If Yes, What are the reasons for coming back to the services of this hospital ?
____________________________________________________________

____________________________________ 32. If No, what are the reasons for choosing this hospital to deliver your baby?
____________________________________________________________

____________________________________ 33. If you get pregnant again, would you consider on delivering in this hospital again? Why or Why Not?
____________________________________________________________

____________________________________ 34. Would you recommend this hospital to people you know? Why or why not?
____________________________________________________________

____________________________________

* Number of Mothers in Beds ___________
* Number of Mothers Admitted __________

APPEN

--------------------------------------------
[ 2 ]. http://home.doh.gov.ph/ao/ao70A-02.pdf, pp 36-38
[ 3 ]. http://www.chanrobles.com/republicactno4226.htm#REPUBLIC%20ACT%20NO.%204226
[ 4 ]. JCR (Joint Commission Resources) Inc. 2004. Managing patient flow: strategies and solutions for addressing hospital, page 6
[ 5 ]. http://www.doh.gov.ph/vsmmc/index9498.html?option=com_content&view=article&id=19&Itemid=27
[ 6 ]. http://67.225.139.201/network/transport-patients-governors-office
[ 7 ]. http://home.doh.gov.ph/ao/ao70A-02.pdf. pp 24-35
[ 8 ]. Guttmacher Institute- NON-PROFIT org based in New York that works to advance reproductive health as defined by WHO.
[ 9 ]. www.Merck.com/mmpe/sec18/ch262/ch262b.html
[ 10 ]. http://www.guttmacher.org/pubs/2009/04/15/IB_MWCNP.pdf
[ 11 ]. http://www.uq.edu.au/news/index.html?article=15093
[ 12 ]. http://ajp.psychiatryonline.org/cgi/content/full/165/11/1482