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 [5,6,7,8]. 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%) [5,6,7,8, 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%) . 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 . 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 ¾th (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%) . 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 . 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) [25,26,27], 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 . 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  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 .
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  and Riyadh  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 . 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  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 . 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 [33,34,35]. 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 . 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 . 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 .
Strengths of the study
Being facility based is an advantage for better representing of the study district on the outcome variable as compared to being community based house to house survey. This was because it included respondents in the most recent service use. So, recall bias was highly minimized. Being triangulated design was also the strength. Moreover, being professional data collectors (nurse) used was an advantage for effective collection of obstetrics related information from the respondent’s as it is difficult for non-health professionals.
Limitations of the study
Design related cause-effect relationship for all significant associations may not be established. Being facility based interviews could be disadvantageous in that it inhibits criticism of medical care by some of respondents even if it had weighted advantage over recall bias minimizations. The woman could depend on a single satisfying service for decisions of overall satisfaction, even though her self-report was the primary option for capturing customer satisfaction data. Social desirability bias could have affected the quality of data collected because study subjects might get difficulty to answer dissatisfaction in the presence of an interviewer. This bias was minimized via interviewing in a separate room by non-staff members’ enumerator without wearing gown. Being non-scale based satisfaction measurement data collection tool could be the disadvantage for better observation of concentrated area in a scale of satisfaction. Moreover, women who were on a first visit could not be able to judge quality of some components of services accurately. This bias was reduced by clarification of components of services and allowing her to observe some amenities back again during the interview. Selection of questions and indicators could also have lead to a skewed interpretation.