Satisfaction with Antenatal Care Services and Its Associated Factors among Pregnant Women at Public Health Centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2022

Abstract

Pregnant women satisfied with the provided health care services will keep using the services at a particular health institution. This study aims to assess the level of satisfaction with antenatal services and its associated factors among pregnant women. A facility-based cross-sectional study design was conducted from November 1 to December 15, 2021. Systematic random sampling technique was used to select study participants. A total of 405 pregnant women were enrolled in the study. Structured questionnaire was used to collect the data. Data were entered into Epi-Data 4.1 and exported to SPSS for analysis. Bivariable and multivariable binary logistic regression with 95% confidence interval and P value of 0.05 were deployed. Pregnant women who had 5 and more family members were 6 times more likely to be satisfied than those who had a single family member (AOR: 6.3; 95% CI = (1.78–22.39)). Pregnant women who did not have chronic diseases were 2 times more satisfied with the antenatal care services (AOR: 2.18; 95% CI = 1–4.77). Having occupation such as housewife, distance of home from health facility, and mode of transportation were factors associated with satisfaction at P < 0.05.

1. Introduction

Antenatal care (ANC) is a branch of obstetrics that is dealing with presymptomatic diagnosis of general medical disorders, nutrition, immunological problems, health education, and social medicine, with the major focus on prevention and early detection of pregnancy disorders and other illness [1].

World Health Organization (WHO) in 2016 recommended at least eight ANC visits, and the first visit should take place before the first trimester of pregnancy [2]. However, Ethiopia has launched at least four visits as standard. The first visit takes place before or at 16 weeks; the second is planned between 24 and 28 weeks; the third at 32 weeks; and the fourth at 36–38 weeks. The initial visit takes 30–40 min, and the other visits take around 20 min each [3, 4].

Antenatal care (ANC) coverage is a success story in Africa, since over two-thirds of pregnant women have at least one ANC contact. However, to achieve the full life-saving potential that ANC promises for women and babies, four visits providing essential evidence-based interventions with a package often called focused antenatal care are required [5].

Essential interventions in ANC include identification and management of obstetric complications such as preeclampsia, tetanus toxoid immunization, and intermittent preventive treatment for malaria during pregnancy, and identification and management of infections including HIV, syphilis, and other sexually transmitted infections (STIs) [2].

ANC is also an opportunity to promote the use of skilled attendance at birth and healthy behaviors such as breastfeeding, early postnatal care, and planning for optimal pregnancy spacing [5]. ANC attendance during pregnancy also has a positive impact on the use of postnatal healthcare services [6].

Satisfaction is the extent of the client’s experience to the ideal care compared with expectations or the given care [7]. Patient satisfaction is accepted as one of the indicators of a health-care service, and it favors or limits the utilization of a health-care service in a certain health institution. The patients’ level of satisfaction highlights the breach between health-care service providers and the anticipation of the patients. Therefore, the client who is satisfied with the provided health-care service will keep using the service at a particular health institution, and this might eventually help pregnant women to complete their ANC services’ follow-up schedule correctly [8].

Assessing satisfaction is used to assess the quality of provided services with respect to health-care provider, institution, and provider–client interaction. It also indicates the effectiveness of the implemented policy. Studies have reported that satisfied service users are more likely to utilize health services, comply with services and follow-ups, and continue with the health care [6, 7, 9]. Thus, this shows that pregnant women who are satisfied with antenatal care services will have a capability to complete the recommended four visits and comply with interventions.

2. Literature review

2.1 Overview of antenatal care services

Antenatal care (ANC) continues to be one of the safest maternal care interventions aimed at significantly reducing maternal and perinatal morbidities. ANC utilization ensures effective management of prenatal morbidities, facility delivery, and postpartum care and to manage complications in order to improve the health outcomes of the mother and fetus. ANC offers pregnant women the chance to take and make appropriate lifestyle decisions and choices, respectively. Pregnant women are provided with the opportunity to have interactive engagements with nurses, midwives, doctors, and other caregivers among the broader health-care system during ANC visits. However, at which component of antenatal care pregnant mothers are satisfied or dissatisfied is not addressed well.

World Health Organization estimated that 25 percent of maternal deaths occur during pregnancy, with variability between countries depending on the prevalence of unsafe abortion, violence, and disease in the area. Between a third and a half of maternal deaths are due to causes such as hypertension (preeclampsia and eclampsia) and antepartum hemorrhage, which are directly related to inadequate care during pregnancy [5, 10].

In a study conducted in six West African countries, a third of all pregnant women experienced illness during pregnancy, of which three percent required hospitalization. Certain preexisting conditions become more severe during pregnancy. Malaria, HIV/AIDS, anemia, and malnutrition are associated with increased maternal and newborn complications as well as death where the prevalence of these conditions is high. New evidence suggests that women who have been subject to female genital mutilation are significantly more likely to have complications during childbirth, so these women need to be identified during ANC [2, 5, 10]. Maternal mortality is 412 deaths per 100,000 live births in Ethiopia, which is far higher than the global target of reducing maternal mortality to less than 70 per 100,000 live births by 2030 [10].

Antenatal care utilization is the only means that prevents morbidity and mortality related to pregnancy [11]. Utilization of antenatal care is determined by clients’ satisfaction. Unsatisfied pregnant women cannot comply and continue their antenatal care services. Poor satisfaction with antenatal care services has negative outcomes on the health status of both the mother and the baby [12].

Poor satisfaction with ANC services might predispose pregnant women to home delivery rather than the delivery in health-care facilities [13] and incomplete visits. In Ethiopia, only one third of pregnant women complete the recommended visits [14]. The Ethiopian Demographic Health Survey (EDHS) 2019 mini report showed that 74% of pregnant women attended at least one ANC visit, but among these, only 48% of clients gave birth at a health facility [4].

Furthermore, dissatisfaction of women with antenatal care (ANC) services has different consequences, such as poor adherence to treatment, poor participation in their own health care, breaking the continuum of care, and increasing maternal morbidity and mortality [15]. Breaking the continuity of care lowers the recommended number of visits [16].

Visiting health facility for antenatal care services decreases not only maternal mortality but also neonatal death [17]. Antenatal care visit decreases the likelihood of under-five mortality in Ethiopia by 45.2%, while the timing of the first antenatal care within the first trimester decreases the likelihood of under-five mortality by 10% [18].

Satisfaction with antenatal care services is affected by different dimensions such as structure (physical environment and availability of adequate human resources, medicines, and supplies), process (interpersonal behavior, privacy, promptness, cognitive care, perceived provider competency, and emotional support), and outcome (health status of the mother and fetus) [19]. It is also associated with sex of the health-care provider; the religion, educational status, residence, ethnicity, and age of the mother; history of antenatal care; waiting time; transportation; distance of health facility from home; type of pregnancy; and history of abortion [19, 20, 21, 22, 23, 24].

Satisfaction with antenatal care services among pregnant women at different parts of Ethiopia ranges from 33.4% to 83.9% [23]. This shows that the quality of antenatal care services is inconsistent and varied. There is no study that has assessed the satisfaction with antenatal care services at Lemi Kura Sub-City. Thus, this study is initiated to assess the satisfaction of pregnant mothers with antenatal care services at public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia.

2.2 Satisfaction with antenatal care services

Different studies were conducted across the world on the satisfaction of pregnant mothers with antenatal acre services. A study that was conducted in Sweden reported that 82% of the total study participants were satisfied with antenatal care services [12]. Another study that was conducted at Pakistan’s primary health-care facilities among pregnant women revealed that of the total study participants, 46% of them were satisfied with antenatal care services [25]. A study that was conducted in the Musandam region of Oman showed that 59% of pregnant women reported that the rendered antenatal care makes them satisfied [26]. Moreover, a study conducted in India showed that more than 90% of pregnant women who visited nurses were satisfied with antenatal care services. But in this study, only 31.8% of the mothers were satisfied with the health education on family planning [27].

A study conducted in Malaysia has reported that 75.4% of mothers reported satisfaction with the antenatal care services provided [28]. Another study conducted in Iraq reported that 85.7% of the study participants were satisfied with the care provided [29]. In Myanmar, 48% of the pregnant women were highly satisfied with ANC services [30].

A study that was conducted in Ibadan, Nigeria, on perception and satisfaction of pregnant women with antenatal care services reported that 81.1% of the respondents were satisfied [31]. Another study that was conducted at other parts of Nigeria revealed that the percentage of satisfaction with antenatal care services among pregnant women was 67% [32].

A recent cross-sectional study conducted in Ghana has revealed that 92.7% of pregnant women were satisfied with the provided antenatal care services [33]. Another study conducted on the quality of antenatal care among pregnant women in Uganda showed that 74.3% of them were satisfied [34].

A cross-sectional study that was conducted on the satisfaction of pregnant women with focused antenatal care services in Jimma Town showed that 60.4% of the study participants were satisfied with the provided antenatal services [35]. A study conducted at public health facilities in Guji Zone, South West Ethiopia, reported that 67% of pregnant women were satisfied with antenatal care services [22].

Another study that was conducted in Harari, Eastern Ethiopia, in 2017 at public health facilities reported that pregnant women’s satisfaction with antenatal care services was 70.3% [36]. A comparable finding is reported by a study conducted at public health centers in Hawassa in 2017. In this study, 79.2% the total study participants were satisfied with the ANC service. As per specific components, 74.2% of the respondents were satisfied with the information provided [8]. Moreover, a study conducted in Sidama Zone and Arba-Mich Zuria districts, South Ethiopia, reported that 33% and 68% of pregnant women were satisfied with antenatal care services, respectively [21, 24].

A cross-sectional study that was conducted in the Tigray region in 2019 reported that 83.9% of pregnant women were satisfied with antenatal care services [37]. Furthermore, a study conducted in Hossana, Ethiopia, in 2020 showed that 74% of mothers were satisfied with antenatal care services rendered in the public health institutions of Hossana town [38].

A recent study published in 2021 in Hawassa, South Ethiopia, has revealed that 79.2% of the total respondents were satisfied with antenatal care services provided by health-care professionals [8]. Another recent cross-sectional study that was conducted at public health facilities of Debre Tabor showed that 53.8% of pregnant women were satisfied with antenatal care services [39]. A study that was conducted in the northwest part of Ethiopia showed that 68.3% of pregnant women were satisfied with antenatal care services [40].

2.3 Factors associated with satisfaction with antenatal care services

Satisfaction with antenatal care service is associated with different factors that are categorized as client related, health-care provider related, and health facility related. Studies show that age has a significant association with the satisfaction with antenatal care services. For example, a study conducted in Debre Tabor indicated that study participants whose ages were 25–29 years were 6 times more likely to be satisfied compared with those whose ages were 35 years and above [39]. In another study that was conducted in Hosanna, younger mothers were more likely to be satisfied than their counterparts [38].

A study conducted in Guji Zone, Ethiopia, reported that pregnant women who were students were 6 times more likely to be satisfied compared with those who were government employees [22]. Besides this, pregnant women who lived in urban areas were 2 times more likely to be satisfied compared with women who lived in rural areas [22]. Furthermore, studies conducted in Ghana revealed that the satisfaction of pregnant women with antenatal care services is increased when the charges of services are increased [33]. This is also reported by a study conducted in Nigeria [41].

Different studies showed that educational status is also associated with the satisfaction with antenatal services [28, 32, 40]. Women who had no formal education and attended primary education had 2.53 and 2.17 higher odds of satisfaction with ANC services compared with those who had secondary education and above, respectively [36]. Similarly, in a study conducted in Hosanna, study participants who are illiterate were four times more likely to be satisfied than those who were in primary school and above [38].

Family monthly income is also associated with the level of satisfaction [32]. A study conducted in Jimma town revealed that pregnant women whose family monthly income is below Ethiopian Birr (ETB) 500 were 8 times more likely to be satisfied compared with pregnant women whose monthly income is above ETB 1000 [35].

The level of satisfaction is increased while pregnant women visit health facilities repeatedly [22, 40]. This is supported by a study conducted in Debre Tabor. In this study, pregnant women who had 4 and above visits were 3.3 times more likely to be satisfied [39]. Moreover, pregnant women who had more than one ANC visit had 4.62 times the odds of being satisfied with ANC services than those who had the first visit [36]. Furthermore, the odds of pregnant women’s satisfaction were 1.74 times higher among women who initiated their ANC in the first trimester of pregnancy compared with those who had initiated the same after the first trimester of their pregnancy [36].

Another factor that has an association with satisfaction is the type of pregnancy. Women became more satisfied with antenatal care services when their pregnancy was planned and wanted [39]. This finding is supported by a study conducted in Jimma Town. In this study, pregnant women whose pregnancy was planned were 5 times more likely to be satisfied compared with their counterparts [35]. Pregnant women who had no history of stillbirth had 2.52 times the odds of being satisfied with ANC services compared with their counterparts [36].

In a study conducted in Hawassa, South Ethiopia, pregnant women waiting for their health-care providers for 30 minutes and less than 30 minutes were 2.6 times more likely to be satisfied than their counterparts [8]. Besides, pregnant women who waited for less than 30 minutes in the health facility to get the services had 2.31 times higher odds of satisfaction with ANC than those who waited for more than 30 minutes [36].

The commitment and interaction of the health-care provider is the other factor [40]. Timely and complete adherence by the provider to the protocol during the first ANC visit has been shown to increase the women’s level of satisfaction, enhance their motivation to attend subsequent follow-up visits, increase the likelihood of institutional delivery, and improve perinatal outcomes [40, 42]. Despite this, in a study conducted in Guji Zone, Ethiopia, major attributes for the overall satisfaction with focused antenatal care services were in relation to the service providers [22]. Pregnant women who got services from female health-care providers were more likely to be satisfied compared with those who got the same from male health-care providers [22]. Satisfaction increases when pregnant women access health facility easily [33].

In study conducted in West Guji Zone, Ethiopia, most attributes of the overall dissatisfaction of mothers during antenatal care services were received from health facilities and transportation, that is, toilet-related structural dimensions, electric power availability, laboratory services, water availability, transportation, waiting area, service room cleanness, and others [22]. Distance of the health facility from home is significantly associated with satisfaction [40]. Pregnant women who travel less than 30 minutes to reach facilities were two times more likely to be satisfied than those who travel more than 30 minutes [38].

In study conducted in Hareri, pregnant women who had no history of stillbirth had 2.52 times the odds of being satisfied with ANC services compared with their counterparts. In another study that was conducted in Jimma Town, pregnant women who had no history of stillbirth were 5.47 times more likely to be satisfied compared with those who had it [35]. Presence of chronic disease is explored as a factor for satisfaction with antenatal care services [29].

3. Obejectives

3.1 General objective

To assess the level of satisfaction with antenatal care services and its associated factors among pregnant mothers at public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2021.

3.2 Specific objectives

• To determine the level of satisfaction with antenatal care services at public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2021

• To identify the factors associated with the satisfaction with antenatal care services at public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2021

4. Methods and materials

4.1 Study area and study period

The study was conducted at public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia. Lemi Kura Sub-City is one of the 10 sub-cities of Addis Ababa. The sub-city covers 118.08km² with total population of 451,631. Among the total population, one-third of them are women under the reproductive age. There are one public hospital, nine public health centers, and three private hospitals. Public health centers in the sub-city are Summit Health Center, Amoraw Health Center, Merry Health Center, Goro Health Center, Arabsa Health Center, Raey Health Center, Hidasa Health Center, Abado Health Center, and Woreda 13 Health Center. The total number of health-care providers who are working in these public health centers is near to 750 [43]. The study was conducted from November 1 to December 152,021.

4.2 Study design

Institution-based cross-sectional study design was employed.

4.3 Source population

All women who were utilizing antenatal care services in public health centers of Lemi Kura Sub-City were the source population.

4.4 Study population

All women who were utilizing antenatal care services in selected public health centers of Lemi Kura Sub-City during the data collection period were the study population.

4.5 Eligibility criteria

4.5.1 Inclusion criteria

All women whose ages were 18 years and above and who were utilizing antenatal care services at public health centers of Lemi Kura Sub-City were included.

4.5.2 Exclusion criteria

• Women who were unable to communicate,

• Women who were seriously ill, and

• Women referred to other public health centers and hospitals were excluded from the study.

4.6 Sample size calculation

Sample size for the first objective is calculated by using single population proportion formula with 95% confidence level, 5% margin of error, and proportion of pregnant mothers’ satisfaction toward antenatal care services at a similar setting. Proportion, which was 60.4%, is taken from a study conducted on the satisfaction of pregnant women with focused antenatal care services at public health centers of Jimma town [35].

$$\text{N}=\frac{{\left(Z_{\frac{\propto }{2}}\right)}^2\left(P\right)\left(1-P\right)}{d^2}$$E1

N: Sample size.

Z _a/2 = 1.96 (standardized normal distribution curve value for the 95% confidence Interval).

P = 0.604 (proportion of satisfaction with antenatal care services).

D = 0.05 (degree of margin of error)

$$=\frac{{\left(1.96\right)}^2\left(0.604\right)\left(0.396\right)}{{0.05}^2}$$

= 368 by adding 10% nonresponse rate, the final sample was 405.

4.7 Sampling procedure

First, from the nine public health centers, 5 of them were selected by lottery method. Selected health centers were Summit Health Center, Goro Health Center, Merry Health Center, Amoraw Health Center, and Arabsa Health Center. Then, the total sample was allocated to each public health center proportionally based on the previous 2 months’ report. The previous 2 months’ antenatal care visit reports for Summit Health Center, Goro Health Center, Amoraw Health Center, Merry Health Center, and Arabsa Health Center were 152, 202, 171, 186, and 160, respectively. Study participants were selected by using systematic random sampling in every K value. K value was calculated by dividing the reported number of pregnant mothers to sample size, which is 2. The first client was selected by lottery method from the first visitors.

4.8 Study variables

4.8.1 Dependent variables

Satisfaction with antenatal care.

4.8.2 Independent variables

• Socio demographic and economic characteristics: age, marital status, educational status, occupation, ethnicity, religion, address, monthly family income, family size, presence of chronic disease

• Obstetric history: gravid, parity, type of pregnancy, history of ANC follow-ups, number of visit, gestational age at first visit, history of abortion, history of still birth

• Health-care provider-related factors: sex of health-care provider

• Others: cost of service, waiting time, distance of health facility from home, mode of transportation, payment for transportation, reason for visit

4.9 Data collection tool

Data were collected using a structured questionnaire, and a face to face interview was used for data collection. The tool had three parts. The first part was focused on the sociodemographic status. The second part assessed the services related to health-care providers and health institutions. The third part assessed pregnant women’s satisfaction toward antenatal care services. Satisfaction tool was adapted from previous researches [22, 36, 38] and was presented using a 5-point Likert scale (1 – very dissatisfied, 2 – dissatisfied, 3 – neutral, 4 – satisfied, and 5 – very satisfied). It has a total of 29 items that assessed the process, structure, and outcome. In this study, the internal reliability of the tool was 0.924. For the purpose of description, the 5-point Likert scale was categorized into two: strongly dissatisfied, dissatisfied, and neutral were categorized as dissatisfied, while satisfied and strongly satisfied were categorized into satisfied. After calculating the total score, the cut point for satisfaction and dissatisfaction was calculated by using demarcation formula: [(highest score – lowest score) divided by 2 + lowest score] [8]. All parts of the questionnaire were prepared in English version initially and translated into Amharic and then back to English to check their consistency.

4.10 Data collection procedure

After preparing the questionnaire, 5 BSc nurses for data collection and 1 BSc nurse for supervision were recruited. Two days’ training was given to each of them on the meaning of every item in the questionnaire and the techniques of data collection such as ways of greeting, ways of taking consent, ways of data-quality monitoring, and ways of addressing ambiguous items. After this, data were collected by face-to-face exit interview. To prevent repeated interview, the data collectors verified with the clients whether they were interviewed before or not. Supervisor and principal investigator monitored closely the data collection process.

4.11 Operational definition

Satisfied: pregnant women who responded to the items at or above the cut point (demarcation point) were categorized as satisfied.

Dissatisfied: pregnant women who responded to the items below the cut point (demarcation point) were categorized as dissatisfied.

4.12 Data quality control

The quality of data was assured by training data collectors and supervisors, designing questionnaire carefully, monitoring the data collection process, and checking completeness of data during the data collection time. In addition to these, before reaching the respondents, all questionnaires were pretested on 5% of sample size at Hidasa Health Center to address confusing items and to increase the quality of data. Necessary amendment was made on the questionnaire based on the result of the pretest. Supervisors closely supervised the completeness and consistency of gathered information, and timely corrections were made.

4.13 Data processing and analysis

After data collection, data was entered into EpiData version 4.1 and exported to Statistical Package and Service Product (SPSS) version 26 for analysis. The results of the study were presented by using text, tables, and figures, and binary logistic regression model was enrolled by considering 95% confidence level and P value of 0.05. Multivariable binary logistic regression was done by taking variables that had P value of ≤0.2 from bivariable logistic regression by using backward stepwise likelihood ratio method to identify the factors associated with the satisfaction with antenatal care services. Hosmer and Lemeshow test was utilized to check whether the data fit with model or not before data analysis, and its result was 0.924.

4.14 Ethical consideration

Prior to data collection, ethical clearance was obtained from Unity University, Addis Ababa Campus and proceeded to Addis Ababa Health Bureau and Public Health Research directorate. Then, a supportive letter was obtained from Lemi-Kura Sub-City Health Department and attached to the managers of each health centers. The purpose and importance of the study were explained to each of study participants. Informed consent was obtained from each participant. Confidentiality was maintained at all levels of the study. To keep confidentiality, names of respondents were not registered. Participation in the study was on voluntary basis. If participants were unwilling, they can quite their participation at any stage of the data collection.

5. Result

5.1 Sociodemographic characteristics

From a total of 405 study participants, 399 participated in this study with a 98.5% response rate. The mean of age of study participants was 29.15 (SD ±5.22). Among the total study participants, 265 (66.4%) were in the age group of 25–34 years. Educational status of 192 (48.1%), or nearly half, of the total study participants was above grade 12. But 82 (20.6%), or one-fifth, of them were single in their marital status. One hundred and twenty-five (31.3) of the study participants had a family size of five and above. Thirty-eight (9.5%) of the study participants had a history of chronic diseases, and among these, 22 (5.5%) had a history of hypertension (Table 1).

Variables	Category	Frequency (n)	Percentage (%)
Age	18–24	63	15.8
	25–34	265	66.4
	> = 35	71	17.8
Educational level	Unable to read and write	35	8.8
	Informal school	33	8.3
	Primary school (Grade 1–8)	61	15.3
	Secondary school (Grade 9–12)	78	19.5
	Above grade 12	192	48.1
Marital status	Single	82	20.6
	Married	271	67.9
	Widowed	20	5
	Divorced	26	6.5
Residence	Urban	316	79.2
	Rural	83	20.8
Occupation	Farmer	63	15.8
	Merchant	93	23.3
	Student	44	11
	Employee	174	43.6
	Others (housewife, no permanent job)	25	6.3
Monthly income (ETB)	≤2500	103	25.8
	2501–5200	98	24.6
	5201–8000	99	24.8
	>8001	99	24.8
Family size	1	18	4.5
	2	63	15.8
	3–4	193	48.4
	≥ 5	125	31.3
Presence of chronic disease	Yes	38	9.5
	No	361	90.5
Type of chronic disease	DM	12	3
	Hypertension	22	5.5
	Others	4	1

Table 1.

Sociodemographic and economic status of study participants in public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2022 (N = 399).

Note: Monthly income was categorized based on quartile range; separated couples are added to divorced.

5.2 Obstetrics history

Among the total study participants (399), 79 (19.8%), or nearly one fifth, were null Para. One hundred and seventy-nine (44.9%) of the total study participants had no history of antenatal care (ANC) follow-up. Three hundred and fifty-four (88.5%) of them had started their visit at first trimester, and 329 (82.5%) of them had a history of more than one visit. However, 45.4% of the total study participants had started their ANC visit because of reasons such as getting sick and pressure from others. The current pregnancy was unplanned for 110 (27.6%) of the total respondents (Table 2).

Variables	Category	Frequency(N)	Percentage
Parity	Zero	79	19.8
	One	78	19.5
	Two	133	33.3
	Three or more	109	27.3
Gravida	One	82	20.6
	Two	82	20.6
	Three or more	235	58.9
Having history of ANC follow-up	Yes	220	55.1
	No	179	44.9
Number of visit for current pregnancy	First visit	63	15.8
	Repeated visit	329	82.5
Gestational age during first visit	<16 weeks	354	88.7
	16-24 weeks	32	8
	25–32	7	1.8
	> 32 weeks	6	1.5
Type of pregnancy	Wanted	289	72.4
	Unwanted	110	27.6
History of abortion	Yes	55	13.8
	No	344	86.2
History of stillbirth	Yes	24	6
	No	375	94

Table 2.

Obstetric history of study participants in public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2022 (N = 399).

5.3 Health service-related factors

From the total study participant, 139 (34.8%), or slightly higher than one third, participants had contact with a male health-care provider. Two hundred and nine (52.4%) of the study participants had spent more than 30 minutes at the health center to be seen by the health-care provider. Two hundred and sixty-four (66.2%) respondents took more than 30 minutes to arrive at the health center. One-tenth of the total study participants (10.8%) had paid a charge for the services (Table 3).

Variables	Category	Frequency (n)	Percentage (%)
Sex of health-care provider	Male	139	34.8
	Female	260	65.2
Waiting time before being seen by health-care provider	≤30 minutes	190	47.6
	>30 minutes	209	52.4
Distance of home from health institutions	Takes up to 30 minutes	135	33.8
	Takes more than 30 minutes	264	66.2
Way of transportation	Ambulance	6	1.5
	Public transport	177	44.4
	Private	116	29.1
	On foot	100	25.1
Payment for transportation (ETB)	Free	138	34.6
	Paid	261	65.4
Charge for service (drug, laboratory request…)	Free	43	10.8
	Paid	356	89.2
Reason for ANC visit	Pressure from family and friends	54	13.5
	Heard from media	24	6
	Got sick and needed health care	100	25.1
	I feel it is necessary	218	54.6
	Other reasons	3	0.8

Table 3.

Health service-related factors in public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2022 (N-399).

5.4 Satisfaction of pregnant women with antenatal care services

High proportions of pregnant women were satisfied in some areas of antenatal care services. From the total study participants, 311 (77.9%), 288 (72.2%), 276 (69.2%), 272 (68.2), and 272 (68.2) were satisfied with the welcoming environment of the health center starting from the gate, performance of procedures with clean and safe manner, effort of health-care providers to involve them in decision-making and asking concerns and interests, respectively. On the contrary, only 157 (39.3%), 160 (40.1%), 164 (41.1%), and 183 (45.9%) were satisfied with the availability of functional toilet, availability of hand-washing facility, the way of the health-care provider to introduce himself/herself, and waiting time to be seen by health-care provider, respectively (Table 4).

Variables	Women satisfaction
	Satisfied N (%)	Dissatisfied N (%)
Welcoming environment of health center starting from the gate	311(77.9)	88(22.1)
Politeness of health-care providers	211(52.9)	188(47.1)
The way a health-care provider introduces himself/herself	164(41.1)	235(58.9)
Adequate explanation of procedures	186(46.6)	213(53.4)
Keeping privacy during examinations	255(63.9)	144(36.1)
Cleanness of examination room	288(72.2)	111(27.8)
Light and space of examination room	247(61.9)	152(38.1)
Effort of health-care provider to give comfort	228(57.1)	171(42.9)
Easiness of understanding their explanation	236(59.1)	163(40.9)
Talking in clear and straightforward manner.	231(57.9)	168(42.1)
Ease of accessibility of antenatal care room	252(63.2)	147(36.8)
Effort to involve you in decision-making	272(68.2)	127(31.8)
Asking interests and concerns	272(68.2)	127(31.8)
Cleanness of waiting room	264(66.2)	135(33.8)
Light and space of waiting room	214(53.6)	185(46.4)
Waiting time to be seen by health-care provider	183(45.9)	216(54.1)
Cooperativeness of health-care providers	228(57.1)	171(42.9)
Listening carefully during conversation	256(64.2)	143(35.8)
Antenatal care advices given	269(67.4)	130(32.6)
Duration of advice	261(65.4)	138(34.6)
Laboratory and other diagnostic services	254(63.7)	145(36.3)
Explain adequately about the result or finding of examination	256(64.2)	143(35.8)
Availability of drug and medical supplies	202(50.6)	197(49.4)
Explain about the drug adequately.	244(61.2)	155(38.8)
Availability of functional toilet	157(39.3)	242(60.7)
Availability of hand-washing facility	160(40.1)	239(59.9)
Performing procedures with clean and safe manner	276(69.2)	123(30.8)
The overall cleanness of health facility	268(67.2)	131(32.8)
Administrative process of the institution	235(58.9)	164(41.1)

Table 4.

Level of women’s satisfaction with antenatal care services in public health centers of Lemi Kura Sub-City Addis Ababa, Ethiopia, 2022 (N = 399).

5.5 Overall level of satisfaction of women with antenatal care services

The overall satisfaction of pregnant women is calculated by using demarcation formula. According to the finding, from the total study participants, 230 (57.6%) were categorized as satisfied toward antenatal care services (Figure 1).

Figure 1.

Level of overall satisfaction with antenatal care services in public health centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2022.

5.6 Factors associated with women satisfaction with antenatal care services

Variables that have an association with satisfaction with antenatal care services at P value ≤0.2 in bivariable logistic regression were age, educational status, marital status, residence, occupation, family monthly income, having chronic disease, family size, history of abortion, history of stillbirth, distance of home from health facility, mode of transportation, type of pregnancy, and charge for services. All these variables were entered in multivariable logistic regression to identify the factors associated with satisfaction. However, in multivariable logistic regression, only occupation, family size, having chronic disease, mode of transportation, and distance of home from health facility were associated with the satisfaction with antenatal care services at P value of 0.05. According to the finding of the study, pregnant women whose occupation is other than farmer, merchant, student, and employee were 5 times likely to be satisfied with the given antenatal care services compared with pregnant women who are merchants (AOR: 5.08; 95% CI = (1.63–15.87). On the other hand, pregnant women who had 5 and more family members were 6 times more likely to be satisfied compared with those who had a single family member (AOR: 6.3; 95% CI = (1.78–22.39)). Pregnant women who were coming to the health center by public transport were 2 times more likely to be satisfied with the given antenatal care services compared with those who used private transport (AOR: 2.33; 95% CI = (1.38–3.91)). Pregnant women whose house is far from the health center were 2 times more likely to be satisfied with the given antenatal care services compared with those whose house is near to the health center (AOR: 1.72; 95% CI = 1.08–2.74)). In addition, pregnant women who did not have chronic diseases such as hypertension, diabetes, and others were 2 times more likely to be satisfied with the antenatal care services compared with their counterparts (AOR: 2.18; 95% CI = 1–4.77) (Table 5).

Variables	Category	Satisfaction		COR at 95% CI	AOR at 95% CI
		Satisfied	Dissatisfied
Age	18–24	28	35	0.40(0.20–0.82)
	25–34	110	155	0.72(0.41–1.24)
	> = 35	47	24	1
Monthly income (ETB)	<2500	60	43	1.81(1.04–3.17)
	2501–5200	63	35	2.34(1.31–4.15)
	5201–8000	64	35	2.38(1.34–4.22)
	>8001	43	56	1
Type of pregnancy	Wanted	180	109	1.98(1.27–3.09)
	Unwanted	50	60	1
Educational status	Unable to read and write	13	22	0.31(0.15–0.67)
	Informal school	19	14	0.72(0.34–1.54)
	Grade 1–8	27	34	0.42(0.23–0.76)
	Grade 9–12	46	32	0.77(0.45–1.32)
	Above grade 12	125	67	1
Occupation	farmer	27	36	0.87(0.45–1.66)	0.87(0.43–1.76)
	Merchant	43	50	1	1
	Student	23	21	1.27(0.62–2.61)	1.7(0.75–3.86)
	Employee	117	57	2.38(1.42–3.99)	2.3(1.31–4.03)
	Others(house wife, no job)	20	5	4.65(1.60–13.44)	5.08(1.63–15.87)
Marital status	Single	38	44	0.38(0.15–0.98)
	Married	167	104	0.71(0.30–1.7)
	Widowed	7	13	0.23(0.06–0.82)
	Divorced	18	8	1
Family size	1	4	14	1	1
	2	38	25	5.32(1.57–18.02)	4.58(1.23–17.17)
	3–4	108	85	4.44(1.41–14.00)	3.49(0.99–12.27)
	≥5	80	45	6.22(1.93–20.04)	6.3(1.78–22.39)
Residence	Urban	190	136	1.61(0.99–2.63)
	Rural	40	43	1
Mode of Transport	Ambulance	1	5	0.23(0.02–2.09)	0.49(0.51–4.79)
	Public transport	120	57	2.50(1.54–4.05)	2.33(1.38–3.91)
	Private	53	63	1	1
	On Foot	56	44	1.51(0.88–2.59)	1.55(0.85–2.83)
Abortion	Yes	22	33	0.43(0.24–0.78)
	No	208	136	1
Stillbirth	Yes	8	16	0.34(0.14–0.82)
	No	222	153	1
Distance of home	Takes less than 30’	66	69	1	1
	Takes more than 30’	164	100	1.71(1.17–2.60)	1.72(1.08–2.74)
Charge for services	Yes	20	23	1	1
	No	210	146	1.65(0.87–3.12)
Chronic disease	Yes	14	24	1	1
	No	216	145	2.55(1.27–5.10)	2.18(0.99–4.77)

Table 5.

Bivariable and multivariable logistic regression output on the association between satisfaction with antenatal care services and factors, 2022 (N = 399).

6. Discussion

This study was aimed to assess the level of satisfaction with antenatal care services among pregnant women at Lemi Kura Sub-City public health centers. The finding of this study will be helpful to different bodies by showing areas that dissatisfy pregnant women.

Based on the study finding, the level of satisfaction with antenatal care services among pregnant women was 57.6% (95% CI: 53% -63%). This finding is in line with study conducted in Jimma, Ethiopia (60.4%) [35], Oman (59%) [26], and Debre Tabor (53.8%) [39]. However, this finding is higher than the study conducted in Sidama, South Ethiopia (33%) [24], Pakistan (46%) [25], and Myanmar (48%) [30].

In contrast, there are studies that have reported higher findings. For example, a study conducted in Arba Minch, Ethiopia (68%) [21]; Hawassa, Ethiopia (79.3%) [8], Gujji, Ethiopia (67%) [22]; Harare, Ethiopia (70.3%) [36]; Uganda (74.3%) [34]; and Nigeria (67%) [9]. The possible reason for this discrepancy might be the difference in sample size, study design, and sociodemographic status. Additionally, the difference in the study area might be another reason for the discrepancy.

In this study, satisfaction among pregnant women was assessed in only public health centers. But in other studies, satisfaction was assessed in both public hospitals and health centers.

Unlike the previous studies, this study revealed that pregnant women who were housewives or did not have permanent job were 5 times more likely to be satisfied with the given antenatal care services compared with pregnant women who were merchants (AOR: 5.08; 95% CI = (1.63–15.87)). The possible justification for this might be the decreased workload and stress. Women who do not have any permanent job will take the responsibility of childbearing. Thus, when they are coming to health facility, they become relaxed and cooperative with the care given.

Family size has shown an association with the level of satisfaction. Pregnant women who had 5 and more family members were 6 times more likely to be satisfied compared with those who had a single family member (AOR: 6.3; 95% CI = (1.78–22.39)). Women who have many children might have repeated exposure to antenatal care services and understand their meaning and use the given services. These women come to health centers for the same purpose by themselves. In spite of this, the previous studies did not show the association between family size and satisfaction.

Pregnant women who were coming to the health center by public transport were 2 times more likely to be satisfied with the given antenatal care services compared with those who used private transport (AOR: 2.33; 95% CI = (1.38–3.91)). This might be due to the fact that public transport is cost-effective, easily accessible, and quick. This finding is supported by a study conducted at West Gujji zone, Ethiopia [22].

In this study, pregnant women whose house is far from the health center were 2 times more likely to be satisfied with the given antenatal care services compared with those whose house is near the health center (AOR: 1.72; 95% CI = 1.08–2.74). Unlike to this study, a study that was conducted in Hossana, Ethiopia, reported that pregnant women who traveled less than thirty minutes were more likely to be satisfied. This discrepancy might be related with women’s preparedness and plan for their antenatal care. On the other hand, women who are near the health center might plan to return home quickly [38].

In addition, pregnant women who did not have chronic diseases such as hypertension, diabetes, and others were 2 times more likely to be satisfied with the antenatal care services compared with their counterparts (AOR: 2.18; 95% CI = 1–4.77). This might be related with anxiety and fear from the adverse effects of chronic diseases. Women who do not have chronic diseases will not have any anxiety and fear for the outcome of their pregnancy when compared with those who do have chronic diseases. This finding is supported by a study conducted in Iraq [29].

In this study, the level of satisfaction with antenatal care services ranged from 39.3% to 77.9%. Availability of hand-washing facility and toilet and health-care providers introducing themselves to their clients were areas of poor satisfaction among pregnant women. This finding is in line with the study conducted in Harare, Ethiopia [36].

7. Conclusions

In this study, the level of satisfaction with antenatal care services among pregnant women was low. Occupation, family size, mode of transportation, distance of home from health center, and having chronic diseases were factors associated with the level of satisfaction. Welcoming environment of health center starting from the gate, performance of procedures in a clean and safe manner, and the effort of health-care providers to involve clients in decision-making and asking concerns and interests were areas that pregnant women were highly satisfied with.

Based on the findings, the following recommendations are given to different bodies.

Health-care workers: Pregnant women whose family size is single need extensive and detail discussion. Thus, health-care workers have to discuss with them in detail. Additionally, pregnant women who are merchants need to receive care immediately.

Health centers: Adequate advice and counseling is needed for pregnant women who have a history of chronic diseases to decrease their stress due to the concomitant diseases. To make this feasible, health centers better prepare additional antenatal care rooms and deploy health-care workers who are experts in chronic diseases.

Governmental and non-governmental organizations: The most dissatisfying area of antennal care services is the unavailability of functional toilet and hand-washing facility. Thus, organizations should give attention to these facilities in every health-care center.

Researchers: The finding of the study will be strong if researchers use a mixed research method. Factors that are found in quantitative study will be explored in qualitative research methods.

Conflict of interest

This is the original work, and there is no form of competing interests of authors. And authors have agreed to the publication of this article.