Antenatal Care Satisfaction and Willingness to Come Back to the Hospital in Southwestern Nigeria: A Qualitative study

Patient satisfaction is a subjective and dynamic perception of the extent to which the patient’s expected healthcare needs are met. If the pregnant women are satisfied with the quality of service received, they will be willing to come back. The aim of this study is to explore the satisfaction of the pregnant women in Ekiti State University Teaching Hospital, Ado-Ekiti and their willingness to use the facility. The study was a qualitative design with 36 participants in 4 FGD in the antenatal clinic of a tertiary hospital to explore the factors enhancing their satisfaction and their willingness to come back to the hospital. During the discussions, note was taken and recorded with an android phone. Discussions were transcribed and analysed by themes manually. Many of the participants were satisfied with the services received in the hospital. The following were the reasons for their satisfaction; competency, confidentiality, health talk and respect by the health workers. Due to these factors, they were willing to come back to the hospital and to recommend to others. Some were dissatisfied because of the high cost, stress of moving from one pay point to another and lack of regular power supply and shortage of doctors at the radiology department. The factors associated with dissatisfaction are modifiable, and if they can be improved upon utilization rate will increase. We therefore recommend that cost should be reduced, harmonise the pay points, employ more doctors and ensure regular power supply in the radiology department. 

Introduction

Antenatal Care (ANC) is an important entry point to the health system and has been identified as a significant predictor of pregnancy outcome [1]. The aims of ANC model proposed by the World Health Organization (WHO) is to provide pregnant women with respectful, individualized, person-centred care at every visit [2]. ANCs provide preventive and therapeutic care, create awareness on danger signs of pregnancy, birth preparedness and improve health-seeking behaviour of women through the information given at each contact [3].

Nigeria is one of the 16 nations with high maternal mortality, 576 deaths per 100,000 live births [4]. Regular attendance of ANC with good quality service delivery has the potential of reducing maternal mortality by 20% [2]. Some reasons had been reported for the poor utilization of health facilities by the women for their ANC which include out of pocket payment, cultural preferences and lack of satisfaction with the quality of maternal care in the hospital [4].

Patient satisfaction gives the description of health-care service from the patient’s perspective [1]. A satisfied pregnant woman will promote the utilization of the service to four or five persons, while a dissatisfied pregnant woman on the other hand will complain to 20 or more persons. [5] The World Health Organization recommends that monitoring and evaluation of maternal satisfaction with public health-care services is sacrosanct to enhance the quality and efficiency of health care during pregnancy [6].

Reasons for dissatisfaction with ANC services include geographical location of the facility, high cost of services, cultural and social factors, unclean toilet facilities, lack of water in the toilet, and physical environment. Others include the information provided by the health care workers, their attitude and professionalism, inadequate staff and equipment, previous experience and long waiting time [3], [5], [7].

We investigated the quality of antenatal care services as perceived by pregnant women and their overall level of satisfaction with the services. Most of the previous works used quantitative design but this study was qualitatively designed to unravel the possible reasons for dissatisfaction.

Subjects and Methods

Study Area

The study was conducted in Atenatel Clinic of Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, a tertiary institution in South-Western Nigeria. In 2023, the clinic attendance was 5186 which averagely translates to 27 clients per clinic day. The ANC clinic runs four times a week, and health talk is delivered by trained Nurses and Dieticians. The education covers topics such as appropriate diet for pregnant women, personal hygiene, birth preparedness and complication readiness, labour and danger signs in pregnancy.

Study Design

The study used a qualitative design to explore the perception of the pregnant women on the quality of the antenatal care received in EKSUTH.

Study Population and Sampling Technique

The participants were selected through a purposive sampling. Pregnant women who have attended the ANC clinic at least once before the interview day and gave their consent were eligible. Those who needed emergency care were excluded. A total of 36 participants were selected in four focused group discussions (FGDs) with each group comprising of eight to ten persons. Each group was selected on different clinic days, taken to a quiet and conducive room for the FDG which lasted for about 45 minutes, after understanding the purpose of the study.

Data Collection

FGD guide developed by the researchers was used for data collection. A researcher from another department moderated the sections, asking the women about their perception on the quality of care received in the facility. One of the researchers took note of the verbal and non-verbal responses while audio recording of all the sections was handled by another researcher.

Data Analysis

Data from the FGDs were transcribed verbatim and significant statements identified, and themes generated based on the FGD guide. The themes were clustered following the objectives of the study. Fundamental structure was created using descriptive analysis of the data content.

Ethical Approval

Approval for the study was obtained from the Ethical Committee of Ekiti State University Teaching Hospital, Ado-Ekiti (EKSUTH/A67/20022/12/014/2023/07/005), and consent obtained from each participant.

Theoretical Framework

This study employed Donabedian’s Theory to assess the women’s satisfaction with the quality of ANC services [8]. Based on Donabedian’s theory, three broad dimensions influence the quality of healthcare: structure, process, and outcome [8], [9]. The is the setting in which care occurs, including the physical environment, equipment and staffing. The process refers to the attitude and competency of the health workers, while the outcome refers to patient satisfaction [10].

Results

This study structured the themes in three phases based on the three dimensions of Donabedian’s theory:

• Phase I: Structure

This is the reflection of how patient perceived the setting in which the healthcare is being given, and it has three themes:

Theme 1: Cleanliness and availability of water in the toilet

Most of the women said the toilet is clean while some said it is dirty. For example, one said, “The toilet is always clean and there is water” (FGD 1, 34 yrs), while another said “Sometimes the toilets are clean and sometimes not. It is the patient that use and refuse to flush even when water is available” (FGD 3, 25 yrs).

Theme 2: General cleanliness and ventilation in the environment

Regarding ventilation in the clinic, most of the participants said there is need for more fans. These are some of the excerpts: “Clinic is comfortable, but the fans are not enough” (FGD 1, 29 yrs). “The environment is clean, but the fans are not enough. They should give us more standing fans” (FGD 2, 32 yrs).

Theme 3: Equipment

All the clients attested to the fact that the equipment in the facility and laboratory services is satisfactory, but most had issues with the radiology department due to erratic power supply and lack of manpower. Participants expressed their feeling as: “I am satisfied with the equipment, they are all working very fine” (FGD 4, 26 yrs). “There is no problem with the lab services” (FGD 3, 33 yrs). “I was told no diesel to put on the generator for me to do scan, so I had to come back another time” (FGD 4, 30 yrs).

• Phase II: Process

Six themes emerged here:

Theme 4: Respect for clients

All the discussants said they were well received by the staff and addressed with respect. Some staff even went to the extent of assisting them in paying and getting the receipt to reduce the stress. Below are some experiences from the discussants.

“I was well received. Initially I thought I’ve met the staff somewhere in the past the way she called my name and attended to me. Later I discovered we’ve never met before; she was just pleasant” (FGD 2, 33 yrs).

“I was well attended to during my first visit which was the booking day and subsequent visits. Though that first day was stressful moving round to pay but the staff assisted me at some point in payment and getting my receipt” (FGD 1, 26 yrs).

Theme 5: Information

The pregnant women were satisfied with the health education by the nurses and dieticians, though some were delivered in the vernacular which made it difficult for few ones to comprehend. Some women said doctors don’t give enough information after examination while some said they get all needed information upon enquiry.

“To me, I think we are given adequate information and good health talk” (FGD 3, 29 yrs).

“They give adequate information, though I struggle to understand the health talk because they give it mostly in “Yoruba” and I don’t understand the language very well. They don’t give us adequate information on the amount we will pay if it will be normal delivery or caesarean section. This will help us to prepare financially” (FGD 3, 30 yrs).

“The doctors don’t give adequate information on the well being of the baby e.g., the lie, sex of the baby and the adequacy of the liquor. We want them to tell us after examining us their findings because we want to know about our babies” (FGD 2, 23 yrs).

Theme 6: Confidentiality

All the participants agreed that there is confidentiality, their secrets are safe with the doctors and the nurses, and their files are well handled.

Theme 7: Consultation by Specialist

Some participants said “The specialist are attending to us very well. I was referred to this hospital during my last pregnancy that I will need a caesarean section to deliver. On getting here the specialist encourage me that I can deliver by myself and that was what happened. They are very good here” (FGD 1, 30 yrs).

“The specialist care was excellent” (FGD 2, 23 yrs).

The hospital is a tertiary specialist institution where patients are being seen by consultants and specialists in training. Many patients don’t understand this, hence the expression given below:

“I was being seen by a junior doctor. I think anybody with high gestational age should be seen by a specialist” (FGD 4, 30 yrs).

Theme 8: Cost of Services

The women in this study felt the services were too costly, being a government hospital “I think it’s expensive here, now I’ve spent more than N 30,000 and am yet to deliver” (FGD 1, 26 yrs).

“This is government hospital, so the amount for booking is much because you will still be asked to pay for other things. Though the doctors are trying. They collect money to screen for blood, if the blood is not used, they don’t return it and the money collected for screening will not be returned” (FGD2, 33 yrs).

Theme 9: Waiting Time

The discussants said the waiting time was satisfactory except in the radiology department. Below are some of their expressions.

“The time is okay” (FGD 3, 32 yrs).

“The time spent is okay except the time spent at the radiology department doing scan. A lot of time is wasted there” (FGD 1, 33 yrs).

• Phase III: Outcome

Theme 10: Level of Satisfaction

The level of satisfaction by participants ranges between 70% and 100%.

“I am satisfied with their service here, I was referred to this hospital during my last pregnancy and was properly monitored till I delivered safely, if not I would have lost the pregnancy. I will give them 100%” (FGD 2, 36 yrs).

“Am giving 70% because of the stress during scan” (FGD 4, 32 yrs).

“I will give 90%. Am satisfied because irrespective of the stress one goes through at the end of the day mother and child will be discharged home safe and sound” (FGD 4, 27 yrs).

Theme 11: Will you come back or recommend the hospital to someone else?

The discussants were willing to come back to the hospital if necessary and recommend it to others. In the second and fourth group, they all chorused that they would come back and recommend for others.

“I can come back to the hospital, and I can recommend the hospital to others because mother and child go home well and alive” (FGD 4, 34 yrs).

“This is the hospital we use in my church. My pastor recommends the hospital to members for different services because we believe that there are specialists that can take care of different issues” (FGD 1,33 yrs).

Theme 12: Recommendations

These are what some of the participants had to say: “More scanning machines should be provided” (FGD 2, 27 yrs). “The hospital management should look into the reasons why the doctors are leaving and proffer solution to them” (FGD 4, 25 yrs). “More standing fan in ANC” (FGD 3, 36 yrs). “The pay point should be synchronized” (FGD 2, 31 yrs). “The cost of ANC should be reduced” (FGD 3, 24 yrs).

Discussion

In this study, we investigated the quality of antenatal care services as perceived by pregnant women and their overall level of satisfaction with the services. We found that overall, the participants were highly satisfied with the quality of services received, want to reuse and recommend it to others. Areas of dissatisfaction include radiology and laboratory services, cost of services, language used for health education and inadequate ventilation in the clinic. For sustained and increased patronage, the areas of dissatisfaction should be addressed by the hospital management. Failure to do this may negatively affect the quality of ANC services, the image of the hospital and patronage by pregnant women. It has been documented that the willingness to come back to the hospital depend on the level of satisfaction of the users [5], [11], [12].

Most of the women in this study were satisfied with the quality of care received. This is similar to other reports within and outside the country [11]–[13]. Our participants were happy that both mother and child were discharged safe and sound after delivery. It has been documented that high level of satisfaction may reflect low expectation of interviewee, attempt to please the interviewer and most likely to hide the cultural belief of the community [13], [14]. Our finding is at variance with report from Hussen et al. and Dinagde et al. in Ethiopia where the level of satisfaction was low [15], [16]. The difference in outcome might be due to different setting in which the research was conducted and the type of questions asked. Poor infrastructure, out of stock for drugs and consumables, and incompetence on the part of the staff are associated with low quality of care [16], [17].

Participants in this study were addressed with respect and treated with dignity. Politeness, and kindness make them feel accepted and on their own, are therapeutic form of communication [1]. Respect is a major determinant of satisfaction as expressed by one of the pregnant women “I was well received. Initially I thought I’ve met the staff somewhere in the past the way she called my name and attended to me. Later I discovered we’ve never met before, she was just pleasant.” This is similar to the findings from other researchers [4], [5], [7]. On the contrary Okonofua et al. reported that the pregnant women were not spoken to with respect and dignity [1].

Our participants were satisfied with the competence of the health professionals. This is similar to the finding by Bergh and Hibusu in Tanzania and Zambia [8], [9]. According to one of the participants, “The specialist are attending to us very well. I was referred to this hospital during my last pregnancy that I will need a caesarean section to deliver. On getting here the specialist encouraged me that I can deliver by myself and that was what happened. They are very good here.” On the other hand, Creaga et al. in Namibia reported that most of the health workers were not competent [18]. Another outstanding area of satisfaction of the participants is confidentiality. Privacy was ensured during consultation and their files were professionally handled. This is comparable with another study in Nigeria by Onyeajam et al. and Ethiopia by Kebede et al. [2], [7].

The pregnant women in this study were satisfied with the content of the health education received and the skill with which it was delivered. This is similar to the findings of Ademuyiwa and Belachew [5], [6]. Though sometimes some information was given in the native dialect to make it clearer to the majority who understand the langue but at such times those who do not understand the language missed out of the information. The doctors in this study also gave information especially while teaching the medical student or when asked.

The pregnant women were satisfied with the equipment in the ANC and the laboratory department. This is similar to the report in Onyeajam [4] but contrary to what was reported by Okonofua et al. in the three geopolitical regions of the country [1]. Different settings of the hospitals where the research was conducted might be responsible for these variations. Participants were dissatisfied with radiology services due to long waiting time. The appointments were rescheduled either because there was no light to power the machine or the only one doctor on duty is tired. Shortage of doctor in the radiology department may be as a result of massive emigration of Nigeria doctors to European countries [19]. This is in contrast with the finding from Hsai et al. in South Okkalapa in Myanmar [20].

High cost of service is a major determining factor in patient satisfaction. In this study, majority of the participants were not satisfied with the cost of the services and stress encountered during payment. It is a well documented fact that the benefits of antenatal perceived by the low-income earners is very low [1], [4]. Out of pocket expenditure has been associated with low satisfaction of services by the patient [4].

Nearly all the participants were not satisfied with the ventilation in the waiting area. This is what one of them said “The environment is clean, but the fans are not enough.” One of the recommendations made by the pregnant women is that the hospital should provide more standing fans for the waiting area. Chemir et al. in Ethiopia and Hsai in Myanmar also reported poor ventilation in the waiting area [12], [20].

Overall, the pregnant women were satisfied with the quality of care received and are willing to reuse and recommend the hospital to their friends and relatives. One of the pregnant women even said, “I can come back to the hospital, and I can recommend the hospital to others because mother and child go home well and alive.” Though their level of satisfaction might be affected by low level of expectation or low knowledge of what is obtained else where.

Conclusion and Recommendation

In conclusion, this study reveals that majority of the pregnant women have high level of satisfaction with the attitude, competency and confidentiality with which the health workers attend to them, but are dissatisfied with ventilation in the clinic, cost, and radiological services. We recommend that the management address the areas of dissatisfaction to improve utilization.

Limitation

The study was conducted in a tertiary institution, the picture here might be different from what is obtained in the primary and secondary facilities, with fewer or no specialists, and services are likely to be cheaper.