Introduction

Quality is an essential requirement in the care provided by health personnel, demanding accessible, individualized, friendly, permanent and efficient delivery of care, the objective is to meet the needs of the user and of the providers who deliver the care. A topic of major interest in health management is patient satisfaction⁽¹⁾. This can be affected by various factors, one of those reported in the literature is pain, specifically pain management⁽²⁾. For this study, postoperative pain is a priority because it is one of the most common due to the high demand for surgical procedures^(3-5).

One of the greatest demands for care in Mexico is reproductive health, which emphasizes care during pregnancy, childbirth and postpartum. In Mexico, 49.7% of all women are at childbearing age, with a birth rate of 18.5 per thousand inhabitants⁽⁶⁾. It is expected that these pregnancies culminate in childbirth; however, 46.3% end in surgical delivery, which increases the demand for postoperative care in this population group within the health services⁽⁷⁾.

Some authors point out that postoperative pain is usually treated incorrectly and insufficiently. This is confirmed by studies which report that around 95% of women with surgical postpartum express moderate, intense or extreme postoperative pain^(8-10). The consequences of poor pain management in the surgical postpartum period can lead to an increase in respiratory and thromboembolic complications caused by the decrease in women's movement due to pain^(11,12).

This has a negative impact because the patients have difficulty wandering early and during their stay in the hospital, which increases their dissatisfaction and interferes with their mother-child relationship in the first days of the newborn's life, because the pain makes it difficult to hold and care for the newborn and breastfeed it, producing anxiety and postpartum depression^(13-16).

Satisfaction with postoperative pain management has been studied by different authors, who report that the greater the preoperative orientation, the greater the satisfaction with pain management ^(2,15). Likewise, another study shows that the more pain reported, the lower the satisfaction⁽²⁾; however, in the case of the postpartum period, the patients, in spite of the fact that pain is present, the level of satisfaction is high^(15-19). In another study carried out in Spain on women who underwent cesarean section, where postoperative pain was rated, the intensity reported a mean of 3.66, making it impossible for 58% of the women to carry out activities such as sitting up in bed or coughing. However, 41% of the participants who received preoperative information reported greater satisfaction with postoperative pain management⁽²⁰⁾.

Other authors conclude that the pain experienced postoperatively after cesarean section is the consequence of a unique experience caused by many factors, including anxiety, ethnic and cultural aspects, previous cesarean sections, age (particularly young women), type of cesarean incision and context, in addition to the health status of the newborn^(21-22).

In another study, they emphasize that the immediate attention or brevity of the health personnel to the need for pain after surgery is important for patient satisfaction, since a high percentage of patients (83.9%) who received the requested pain killer in less than 15 minutes, showed greater satisfaction with postoperative pain management⁽²³⁾.

From the foregoing, it can be seen that satisfaction has been associated with pain and its intensity, as well as with previous experience, orientation received, response time or perception of timely management in the presence of pain, and in the case of women during the surgical postpartum it has been associated with the type of surgical incision. However, the findings are not conclusive and in this particular group the results seem to differ, while for some, pain intensity decreases, in others satisfaction with care is high.

Taking into account this context, the objective of this research was to establish the relationship between maternal satisfaction with postoperative pain management, pain intensity, preoperative orientation, health personnel response time and obstetric factors.

Methodology

Descriptive and correlational study. The population corresponded to patients during the surgical postpartum period, hospitalized in the obstetrics department of a public social security institution, located in Monterrey, Nuevo Leon, Mexico. For the selection of patients, a systematic one-by-two sampling with a random start was used, the first participant was chosen at random and then every other patient. The study included women with one full day of postpartum surgery, without complications in their evolution or with the health of the newborn; those who, in addition to cesarean section, underwent another surgical procedure such as tubal ligation or hysterectomy, were excluded from the study.

To estimate the sample size, the statistical package nQueryadvisor 4.0 was used with a correlation of .20, a significance level of .05 and a power of 90%. A sample of 259 participants was obtained. Data collection was carried out from January to March 2016.

To measure the study variables: Maternal satisfaction with postoperative pain management, pain intensity, preoperative orientation, health personnel response time and obstetric factors, the Patient Pain Intensity Questionnaire (PPIQ) ⁽²⁴⁾ was used, which measures pain intensity and the level of satisfaction with pain management by nursing and medical personnel. The questionnaire has obtained a Cronbach's alpha of .85, which means that it is reliable. For the purposes of this study, only nine items were used, which measure the intensity and presence of pain, using a visual numerical scale, with evaluations ranging from a score of 0 to 10. Intensity was classified as no pain (zero values), mild pain ^(1-3), moderate pain ^(4-6) and severe pain ^(7-10).

Likewise, it also contains a question that evaluates the interruption when there is pain in various activities such as sleep and mood, with scores from 0 to 10 (0=no interruption and 10=High interruption). To evaluate the guidance given to the woman for pain management, one item evaluates with a dichotomous response (Yes/No) whether she was given guidance. Finally, to evaluate satisfaction with pain management in the surgical postpartum period, as a result of the care provided by the nursing and medical personnel, two questions were asked with response options from 0 to 10 (0 points = total absence of satisfaction and 10 points = highest satisfaction). The response time to receive the requested analgesic was measured with options from less than 10 minutes to 60 minutes.

Regarding ethical aspects, this study considered the Regulations of the General Health Law on Research⁽²⁵⁾, and was approved by the Ethics and Research Committees of the School of Nursing of the Universidad Autónoma de Nuevo León and the participating health institution (FAEN-M-1506).

All participants were asked for their authorization and to sign the informed consent form. During data collection, attention was applied not to interfere with care. If the patient reported pain during the application of the instrument, she was referred to the nursing personnel for management and then returned to the patient to continue with the questionnaire.

Data capture and analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 20. Inferential analysis was performed using nonparametric tests because the data showed a non-normal distribution using the Kolmogorov-Smirnov test. To test the relationship of the proposed variables, Spearman's correlation and the Mann-Whitney U test were applied to identify differences between the groups.

Discussion

A quality indicator or criterion in all health systems is the timely and adequate management of pain; however, the findings of the present study show that all the patients reported moderate to severe pain during the postoperative period and that most of them present moderate to severe pain during the first 24 hours postoperatively. This finding matches what was reported by several authors ^{(2,8,9-12,19,20,22)}, who point out that the actions taken to treat pain are not sufficient. This result is relevant due to the limitations it generates and its effect on the morbidity of the patient.

In spite of the above, the opinion of pain management obtained a high satisfaction, this data coincides with that reported in other studies performed in women with characteristics similar to those of the present study^(2,9,15-18). This shows that in this particular group of participants, satisfaction is explained by other aspects, such as preoperative orientation. The women who reported greater satisfaction with pain management by the medical and nursing personnel were those who received preoperative orientation; this result was similar to that reported by Garcia^(2,19,20). The orientation that people receive about what is going to happen after surgery can have an effect on the patients' expectations; for the participants in the study, knowing that after a surgical event there is pain and that treatment is required, allows them to request the prescribed medication to relieve pain in a timely manner with the effect of reducing the intensity of the pain.

It is important to investigate other causes that explain this finding of increased pain and greater satisfaction, because in another study⁽²⁾, patients with postoperative pain were included, but not in the postoperative surgical period, and they reported less pain and greater satisfaction. This reflects that the findings are not conclusive and it is necessary to investigate the behavior of the variables in other surgical procedures.

Other relevant aspects that were related to satisfaction with pain management were the response time of the personnel for pain relief, as well as the number of cesarean sections. It was identified that women with less waiting time to receive analgesic indicated greater satisfaction, coinciding with other authors^(2,19,20). It is clear that if people are attended in a timely manner when they have pain, satisfaction will be greater.

It was seen that women who reported a greater number of previous cesarean sections reported greater satisfaction with pain management, this finding can be attributed to previous experience, women know that they will present pain, they already have an expectation for its management so interventions can be evaluated by comparing previous experience. These findings should be considered in interventions aimed at pain management.

The standardization of postoperative pain management that includes preoperative orientation and response time to attend to the presence of pain is a strategy that would be relevant and useful to improve women's satisfaction. It is important that these aspects are considered independently of the number of pregnancy of the woman, however, it is relevant to emphasize the orientation to primigravid women, because they do not have previous experience. Addressing these aspects will contribute on the one hand to reduce the level of pain in women by actively participating in its management, and on the other hand, it will contribute to increase satisfaction with pain management, both aspects considered quality indicators or criteria within health institutions.

Conclusions

All the patients reported pain in the postoperative period, a high proportion reported moderate to severe intensity in the first 24 hours. In spite of this, there was a high rate of maternal satisfaction with postoperative pain management. The patients who received preoperative orientation, who waited less time for the personnel to respond to pain and who had a greater number of cesarean sections were satisfied with postoperative pain management.

Since pain management is an indicator of quality and in view of the findings of the study, it is important for nursing care managers to consider strategies that contribute favorably to reducing the presence and intensity of pain in postpartum surgical women.

Conflict of interests

The authors stated that they do not have any conflict of interest in relation to the article.

Financing

The authors stated that they did not received any funding to perform this work.