Determinants of client satisfaction to skilled antenatal care services at Southwest of Ethiopia: a cross-sectional facility based survey

Pregnancy is a very important event from both social and medical point of view. ANC is an opportunity to advice the women on how to prepare for complications and promote the benefit of skilled attendance at birth [1].

W.H.O recommends that pregnant women should feel welcome at clinics for ANC in that it should be user-friendly. Examinations and tests should be carried at times that suit the woman. The teamwork between professionals and the pregnant woman is decisive for the safety of the woman and her fetus [2]. Every woman has the right to obtain recommended services of ANC from a skilled attendant at her pregnancy. A skilled attendant is not only trained to attend to normal pregnancies but also to recognize and manage complications and make referrals to hospital if more advanced care is needed. Women in rural areas were most at risk of giving birth and ANC services in the absence of skilled attendant [3, 4].

Ratings of women satisfaction for ANC indicated higher across developing countries and vary from country to country [5–9]. Studies found that overall satisfaction was highest in Cameroon and Egypt. In Cameroon, it was about 96.9% satisfied [10]. In Egypt, more than 90% reported satisfied for waiting time in lab results, Staff help, trust the doctor followed by cleanness of the center, privacy, most of accessibility items, and most of physician performance items. Least satisfied (below 30%) for location of the center, health education program, and explanation of the problems by physicians [11].

In Riyadh, about 87.7% pregnant women attending ANC felt unhappy because they had to wait up to 1 hour before being seen by the physician. About 63.1% were satisfied with information regarding their treatment. Around 18.9% thought that information was not enough and 17.25% reported they did not receive any information about their treatment [12].

In Kenya, about 96% of women who attended FI ANC clinics and 97% who attended NI ANC clinics were either “satisfied” or “very satisfied” with their clinic visit. A ‘very poor’ grade of satisfaction was considered to be a weak area of antenatal services. The dissatisfaction expressed mainly related to the process of imparting health education (such as: commitment, availability of time and language barrier) and not to the availability of health education material [13].

In Nigeria, most respondents were satisfied by the services given at the clinic (81.1%). Sitting arrangement was most satisfied (97.9%). Toilet and bathroom facilities were least satisfied (39.3 and 38.1% respectively). About 91.6% respondents reported “diet and nutrition” more satisfied during the interactive session than others. Prevention of cervical cancer was least discussed topic (65.7%) [14]. Obafemi Awolowo University study findings added that about 55% of women attending ANC clinic were satisfied with the quality of health talk. Around 72.6% were satisfied by the opinion that the services of the hospital were good and met their needs. About 53.7% agreed with the competency of the hospital staff. About 39.1% agreed with timely response of the staff and 20.5% on the opinion that the staffs were friendly and polite [15].

In various African country, Continued utilization of ANC services in the future pregnancy was directly linked to the satisfaction of the clients (p < 0.05) [14]. Significant satisfaction was also observed for being attending in public centers over private in Cameroon and those who served in Mendera Kochi and Higher Two Centers over others at Jimma town of Ethiopia [10, 16]. Those who have no formal education, attended primary education, monthly income < 500 birr and between 750 and 1000 birr, planned pregnancy and no history of stillbirth had significant associations for satisfied ANC services over their counter parts at p < 0.05 [16].

In Cameroon, significant association was observed for good satisfaction at their first pregnancy, the sitting area comfort, and competence of staff as compared to its counterparts [10]. Pakistan qualitative discussants reported, distant location of facilities, lack of functional equipment, medicines and supplies as perceived poor satisfaction [17]. Previous Ethiopian studies focused on the relationship between women’s satisfaction and the provision and utilization of health care services [18]. No data could have been found on specific component of services satisfaction in Ethiopia in general and the study area in particular. This study, therefore, attempted to place its contribution through its findings.

Conceptual frame work

As indicated by Fig. 1, this conceptual frame work was adopted from one systematic review on women satisfaction to maternity care services in developing world, since it matches with this local system [9]. ANC services satisfaction was one component with background characteristics, provider factors, obstetrics factors and amenities were independent predictors. The frame work was adjusted to local system for to make it more convenient (Fig. 1).

This health institution based cross-sectional study was attempted to assess the satisfaction status of women to Skilled Antenatal Care services in the district of Arba Minch Zuria, Southwest of Ethiopia. Findings of this study showed Skilled Antenatal Care services satisfaction were associated with demographic, economic, obstetric and accessibility factors of the respondents.

Accordingly, high number of respondents had reported they had good-satisfaction to the services. Many studies suggested that satisfaction of clients to ANC services varied from country to country [5–8]. This was inconsistent and higher finding as compared to Oman and previous Ethiopian (68% Vs 59% & 60%) [13, 16] and lower than Nigerian, Kenyan and Cameroons (68% Vs 81.1, 95, 96.4%) [10, 14, 23]. The highest finding could be an indication in Ethiopia for the ever-growing health sector development program for quality services so that it could be contributed to this comparative greater satisfaction. Conversely, the lower finding could be related to still the existence of comparative quality shortages in the study area of Ethiopia.

Satisfaction regarding location of the center, health education program and provider explanation of the problems on women ranges from about one-third to two-third, such as 39.5 to 66.9%. This was higher than Peruvian, Pakistan, European, and two African findings (39.5 to 66.9% Vs < 30%) [5–8, 17]. This higher finding of Ethiopia could be related to minimum surface area of the center due to few departments and buildings. This could give the center location closer to the roadside. Ethiopian provider usually had few minutes session for health education and explanation of the problem to the client. Greater satisfaction in this regard could be due to this short duration in the absence of intervention or treatment process that satisfies most of busy Ethiopian women to go to their home for home based work.

This study showed more than half women had satisfaction by ‘hours of work’ (61%). It was lower finding as compared to African Egyptian study finding (61% Vs 77.9%) [11]. This difference could be due to minimal working hours passed on work by providers in the facility of Ethiopia as per 24 h a day and 7 days a week. Shortage of skilled provider was also another issue to be considered in Ethiopia. Existence of these two facts alone were reported by Ethiopian HSDP-IV of 2012 report [24]. This comparative lower finding was also strengthened by majority of discussants that “………every health professionals within the department on which they were in-charge had not found at government work hours that as we know, we mean at early 2:30 to 3:00hrs morning and 8:00 hrs to 8:30 hrs afternoon. Some exist in the facility compound, but not availed in the department on time. Some others totally not availed, but come late. Others, but not all, exit the facility early, before exit time (exit time: 6:30 morning or 11:30 after noon). It is most disappointing to all of us………….thanks to opportunity to talk”.

In this study, good satisfaction to sitting arrangements, ventilation and cleanness of the toilet reported were nearly ¾^th (71.4%), below half (48.4%), and more than half (55.8%) of the respondents, respectively. These were still lower from the highest findings of Nigeria (71.4, 48.4, 59.5% Vs 97.5, 84.1, 60.7%) [14]. This could show still insufficient arrangements for the three variables here in Ethiopia in the extent of its proper functioning to until it brings highest good satisfaction as compared to Nigeria’s center with-in the continent of Africa.

Regarding performance of the provider and staff, all the findings of ‘good satisfaction’ in the current study were more than average as reported, such as: answering questions (71.6%), taking history (63%), trusting the provider (71.4%), examination time (76.3%), explanation of rational for investigation (68.4%), explanation of results of Investigations (59.5%) delivering information (66.4%) and maintaining privacy (81.7%). All of the mentioned components of services were comparatively lower from the Shawa Village Egyptian finding [11]. The probable explanation in this regard could be shortage of professional ethics, availability of non-women friendly services, and performance negligence’s by professionals were dominating here in Ethiopian as compared to outside higher satisfaction countries. As it is mentioned in various studies (such as: Bangladesh and India) [25–27], high satisfaction was also related to Maintenance of privacy via a separate room or screen for examination.

This study assessed ‘poor- satisfaction’ health education and communication sessions as components of services. These included: Prevention of Cervical cancer, STI’s prevention, Malaria prevention, Physical exercise, and Breast Self examination. On the other hand, more than average women reported for each of major HE sessions as ‘good-satisfaction’ included: Personal hygiene, Teeth care, Diet and nutrition, Clothing, Fetal movement monitoring, Allowable medications, Breast feeding, Basics of newborn care, Follow-up appointment, Signs of labor, Danger signs of pregnancy, and Family planning and child spacing. The poor satisfaction was contrary to Nigerian finding [14]. This could be due to not addressing these specific tasks on HE session here in Ethiopia by majorities of providers as contrasted by Nigeria. The good satisfaction components was in-line with Nigerian and Cameroon findings [10, 14]. The positive relationship could be due to increasing health sector development program for education session development here and there.

More than average women reported for each of major HE sessions as ‘good-satisfaction’ included: Personal hygiene, Teeth care, Diet and nutrition, Clothing, Fetal movement monitoring, Allowable medications, Breast feeding, Basics of newborn care, Follow-up appointment, Signs of labor, Danger signs of pregnancy, and family planning and child spacing. This was in-line with Nigerian and Cameroon findings [10, 14]. This positive relation could be due to increasing health sector development program for education session development here and there. Focus group discussants also supported positive finding in that “…….ohhh, it was good and interesting. Health education session focusing on personal hygiene, diet and nutrition, and communicable disease prevention were clear to all of us. After education we have got special things to ourselves and our life. Our child can be protected from future infections, especially diarrhea and vomiting problems. One 38yrs old woman said: Now I will breast feed only for six months exclusively. Vaccinating baby is beneficial to me and to him”.

Causes of dissatisfaction as client reported in the facility were: absence of sonar test, no doctor and long waiting time in the clinic. Other studies (Ghana, Nigeria and Ethiopia) also supported this as causes of dissatisfaction with services [16, 28, 29]. But, in this study, sonar test was the pioneer that reported by the majority of respondents as compared to other findings.

This study observed that having satisfied to Skilled Antenatal Care services was statistically significantly associated (AOR = 2.27; 95% CI, 1.27, 4.06) with distance > 1 km that women traveled to arrive to the nearest Health Center. This was inconsistent with Pakistan qualitative finding [17] as far distance was one of the factors for dissatisfaction. This difference could be due to reduced expectations of women from outside village that she could get adequate services of her need. As suggested by developing countries study, women with low expectations with more services could result in good satisfaction of services and the vice versa [9].

Women Satisfied to SANC services was significantly associated (AOR = 2.93; 95% CI, 1.21, 7.12) with frequent (> 1times) previous ANC visits that women had. This was directly linked to Ibadan, Nigerian finding [14] and Riyadh [12] in which patient satisfaction was significantly higher among women in the highest visit groups. The positive association in this regard could be due to developing awareness on its importance by repeated visiting, increasing client need and effective response to this need by the health care workers here and there. Moreover, satisfied woman are more likely to increase the compliance with ANC visits [30]. Therefore, majority of subsequently visiting women could probably be satisfied groups in the current study and others.

In this study, having satisfied to Skilled Antenatal Care services was significantly associated (AOR = 0.4, 95% CI; 0.2, 0.8) with respondents who had monthly family income of $U.S 25–50/month. This was in line with previous home study [16] in that better satisfaction observed in lower income groups. Outside home, Malaysia, it was also positively linked as having no cost or low spending money for the ANC services had better services satisfaction [30]. The synonymous finding could probably indicate that low costly services are more satisfying to the poor ANC clients here and there.

Women in married marital status were significantly associated (AOR = 8.17, 95% CI; 1.43, 46.5) for having satisfied to Skilled Antenatal Care services. No other studies before could have observed this association directly. In this study, we could explain that this significant association could probably be related to existence of high number of married women among the study participants. This was because, married marital status and ANC service utilization had significant association in Ethiopia [31, 32].

This study revealed that having satisfied to Skilled Antenatal Care services were statistically significantly associated with being from Welayta (AOR = 0.26, 95% CI; 0.13, 0.54) and other (other includes: Amhara and Zayse) ethnic group (AOR = 0.2, 95% CI; 0.07, 0.61) respondents. This ethnic association with maternal Skilled Antenatal Care services satisfaction was also linked by Kenyan, Sri Lanka and Nigerian studies [33–35]. This particular ethnic discrimination could probably be related with non-native ethnic group’s perception as being discriminated for services quality. This was because there was no one from minor ethnic group reported for ethnic related discrimination in FGDs. Concerned bodies needed to make specific interventions to poorly satisfied ethnic groups and further study is required.

This study shows that respondents who were in the fourth ANC visit were significantly associated (AOR = 9.02, 95% CI; 1.76, 46.1) for good-satisfaction to Skilled Antenatal Care services. This was supported by finding of Riyadh [12]. High good-satisfaction with highest visit gives the women opportunity to ask her concerns and this could increase her good feeling towards the services. Besides this, high number visit could possibly enhance positive relationship between providers and client, making maximum good feelings or satisfaction towards the women. This probable explanations were also supported by Tanzanian finding [36]. As satisfaction can be one of the effect for quality, perceived good quality services was also associated to that of subsequent ANC visit by a woman, as one home study suggested [37].

Women who reported having good-satisfaction to overall Skilled Antenatal Care services were highest. The most common specific component of ANC that had good-satisfaction by the respondents was maintaining “Privacy” during examination (81.7%). The most common health education topic during ANC services which was satisfied by the respondents was “Diet and nutrition” (82.2%). Absence of sonar test, no doctor, and long waiting time in the center were commonest causes of dissatisfaction by client report. Woman birth order, distance to the nearest health center, previous ANC visit, family monthly income, marital status, ethnicity, and current ANC visit type were independent predictors of satisfaction to Skilled Antenatal Care services. Providers must re-plan and improve their performances in the district for another highest satisfaction in the future. Especial attention must be given to those ethnics other than Gamo in the district regarding overall ANC services, since dissatisfaction was highest among them. Policy makers and other stake holders should give attention to increase ANC visit coverage in the country by developing strategies with the aim of maximum satisfaction to Skilled Antenatal Care services. Government officials should be engaged in development of middle income economy for women through women economy development strategy and intervention throughout the country. Early ANC visitors should also be given attention by providers to increase chance for return visit through maximizing client satisfaction in every component of services.