Onyeajam et al. BMC Public Health (2018) 18:368 https://doi.org/10.1186/s12889-018-5285-0 RESEARCH ARTICLE Open Access Antenatal care satisfaction in a developing country: a cross-sectional study from Nigeria Dumbiri J. Onyeajam1*, Sudha Xirasagar1, Mahmud M. Khan1, James W. Hardin2 and Oluwole Odutolu3 Abstract Background: Utilization of Antenatal Care (ANC) is very low in Nigeria. Self-reported patient satisfaction may be useful to identify provider- and facility-specific factors that can be improved to increase ANC satisfaction and utilization. Methods: Exit interview data collected from ANC users and facility assessment survey data from 534 systematically selected facilities in four northern Nigerian states were used. Associations between patient satisfaction (satisfied, not-satisfied) and patient ratings of the provider’s interactions, care processes, out-of-pocket costs, and quality of facility infrastructure were studied. Results: Of 1336 mothers, 90% were satisfied with ANC. Patient satisfaction was positively associated with responsive service (prompt, unrushed service, convenient clinic hours and privacy during consultation, AOR 2.42, 95% CI 2.05–2.87), treatment-facilitation (medical care-related provider communication and ease of receiving medicines, AOR 2.03, 95% CI 1.46–2.80), equipment availability (AOR 1.10, 95% CI 1.01–1.21), staff empathy (AOR 1.82, 95% CI 1.03–3.23), non-discriminatory treatment regardless of patient’s socioeconomic status (AOR: 1.87, 95% CI 1.09–3.22), provider assurance (courtesy and patient’s confidence in provider’s competence, AOR 1.48, 95% CI 1.26–1.75), and number of clinical examinations received (AOR 1.28, 95% CI 1.10–1.50). ANC satisfaction was negatively impacted by out-of-pocket payment for care (vs. free care, AOR 0.44, 95% CI 0.23–0.82). Conclusions: ANC satisfaction in Nigeria may be enhanced by improving responsiveness to clients, clinical care quality, ensuring equipment availability, optimizing easy access to medicines, and expanding free ANC services. Keywords: Patient satisfaction, Antenatal care, Free care, Provider behavior, Provider communication skill, Availability of equipment, Ease of access to medications, Developing country Background and new-born health outcomes [3–5]. In Nigeria, 41% of Antenatal care (ANC) utilization rate in Nigeria (a women who utilized skilled ANC did not deliver in a lower-middle income country) is quite low, about 61% healthcare facility [1, 3]. Studies suggest that dissatisfac- of pregnant women visited a skilled provider at least tion with the ANC experience may partly explain this once during their pregnancy compared with the docu- low level of institutional delivery by ANC users [6, 7]. mented average of 79% for all lower-middle income Consistent with low antenatal care and institutional de- countries [1, 2]. ANC enables effective management of livery rates in Nigeria (36%), maternal outcomes are pre-natal morbidities, and may facilitate institutional de- poor [1, 2, 8]. Nigeria ranks among the top 16 nations in livery and postpartum care, thereby improving maternal maternal mortality, 576 deaths per 100,000 live-births [1, 2, 8]. With just 2.45% of the world’s population, Nigeria * Correspondence: onyeajam@email.sc.edu accounts for 19% of maternal deaths [2, 8]. Many devel- 1 Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Ste 360, oping countries have successfully reduced maternal Columbia, SC 29208, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Onyeajam et al. BMC Public Health (2018) 18:368 Page 2 of 9 mortality by expanding maternal service utilization survey data when the NSHIP project interventions were through policy innovations [9, 10]. not yet implemented. Our study used data from four Policies to maximize patient satisfaction at ANC visits northern states, namely, Adamawa, Nasarawa, Benue may translate into sustained ANC use throughout the and Taraba. These states had a documented skilled ANC pregnancy and increased rates of institutional delivery. utilization rate of 68%, (with 73% of utilizers having ≥ 4 The role of health facility and staff characteristics in visits) in a separate community survey, similar to the na- general outpatients’ satisfaction with care is well docu- tional average (61% skilled ANC use, and 81% of them mented and includes facility infrastructure and amenities having ≥ 4 visits). availability (equipment, drugs, comfortable waiting area), The NSHIP survey used multistage sampling to select interpersonal interactions of staff and providers (e.g. health facilities using state administrative divisions courtesy, empathy), provider technical performance, care (Local Government Areas [LGAs] and geographic wards) logistics and the absence of financial barriers to care as the strata. In Adamawa and Nasarawa (intended inter- [11–13]. The context of patient satisfaction with ANC vention states), all LGAs and wards were selected and in may be different compared to sick outpatient care the remaining two states, a random sample of LGAs, because of population perception of (1) low utility of and then all wards in the selected LGAs were sampled. ANC and (2) the opportunity cost of time and effort Within each ward, all state-owned hospitals (as spent on a preventive service such as ANC in the available), and a random sample of functioning context of others survival priorities of the poor in many government-owned primary care facilities (those with developing countries [14]. consistent maternal and child health service utilization Government facilities are the principal source of care in the prior year) were surveyed. Surveyors collected for the Nigerian population, particularly in rural areas. facility-level data on the availability and functionality of There is no study of the role of out-of-pocket expendi- infrastructure and manpower. A total of 84 surveyors tures and patient-experienced access to medications in (40-Adamawa, 20-Nasarawa, 16-Tarabae, 8-Benue, allo- ANC satisfaction at government health facilities [15–19]. cated according to workload) were trained in data collec- From patients’ perspective, the role of out-of-pocket tion and interviewing skills for the project. Facility-level expense in patient satisfaction is important as living variable values (objectively scored by surveyors after dir- expenditure competes with preventive maternal health- ect observation) are common to patients interviewed at care need for household income [14]. Further, despite of- the facility. At each facility, three ANC outpatients were ficially free services in some states, patients’ access to interviewed (the first three to exit the facility during sur- medicines, may be limited due to non-availability of veyors’ visit). Interviews were conducted at preselected medicines, apathetic pharmacy and facility staff, and designated exit areas within the facility that ensured procedural complexities in receiving the drugs [12, 20]. privacy and confidentiality. If a patient declined, the next This study identifies some policy-modifiable structural eligible exiting patient was interviewed up until 3 pa- factors (availability of equipment, qualified providers, tients were interviewed, the close of ANC clinic time or and out-of-pocket cost) and process of care factors (clin- end of survey time designated for a facility. Note, not all ical examination, staff responsiveness, care communica- facility had ANC patients visiting on day of survey. Sur- tion) driving ANC patients’ satisfaction with care (a veyors documented written informed consent. Survey measures of their judgement on quality of overall care questions covered patient socio-demographics, and their experience) at government facilities. These factors may perceptions of care access, provider-patient interactions, play a role in ANC utilization of specific demographic out-of-pocket expenditure for care and satisfaction with segments of the population [3, 21]. services. A Hausa-translated survey format was also of- fered (the major language in northern Nigeria). The Methods study was approved by the University of South Carolina We conducted a cross-sectional study, using the World Institutional Review Board. Bank-assisted, Nigeria State Health Investment Project Our unit of analysis is the ANC outpatient. All (NSHIP) baseline survey data. The NSHIP surveyed interviewed ANC patients were eligible for inclusion in functional government health facilities in six states (3 the study (2–3/facility). The primary outcome of interest project states selected for strengthening maternal and is the patient’s satisfaction with ANC (satisfied, not child health services infrastructure based on administra- satisfied). We adjusted for sociodemographic variables tive considerations and 3 control states [one state influencing use of maternal healthcare - age (years), edu- matching each project state on regional location and cation (less than or some secondary education, high demographic characteristics], out of 36 states and the school diploma or higher), marital status (married/liv- federal capital). The survey included exit interviews of ing-together, other), and household wealth quartile ANC outpatients in 2013–2014. We used baseline (poor, lower-middle, upper-middle, rich, computed by Onyeajam et al. BMC Public Health (2018) 18:368 Page 3 of 9 principal component analysis of patient-reported from home (< 3 km, ≥ 3 km). Exploratory factor analysis household assets) [3]. We also adjusted for parity (principal factor method, promax rotation, and simple (primi, multigravida), and prior ANC visit to the facil- structure) yielded two factors from 10 items on provider- ity (yes/no) [3]. patient interactions (Likert scale, agree, neutral, disagree). Facility-level independent variables of interest are The two factors are: assurance of providers and responsive- surveyor-assessed infrastructure (cleanliness and amen- ness of the facility to patients. The rotated factor pattern ities, general medical care equipment, and essential and loadings are presented in Table 1. The factor items are drugs), and staff availability (percent of employed clinical consistent with internationally documented, affective ele- staff present on the survey date). General medical care ments of outpatient experience [11]. Item scores were equipment included essential ANC items, such as adult added to compute factor scores. In addition, four composite weighing scale, height measure, thermometer, blood variables were constructed based on intuitive assessment of pressure meter, stethoscope, otoscope, fetoscope, etc. items cohesiveness: treatment-facilitation, clinical examina- Each item was scored 1 if available and functional, and tions, Maternal and Child Health (MCH) counselling, and added to produce the facility’s equipment score. Simi- preventive medication. Treatment-facilitation was the sum larly, the facility cleanliness and amenities score was the of item scores on the provider’s effectiveness of medical sum of scores on clean waiting area, protection from care-related communications and patient-perceived ease of weather elements, fan/AC, adequate seating (no patients access to medications. These items were combined because standing), clean restrooms, clean environment, consult- collectively they represent key patient goals in a medical en- ing room privacy, untorn beds, and adequate lighting. counter and may impact patients’ understanding of and ad- The drug availability score was the sum of essential herence to treatment, medical outcome, and patient drugs available on the day of survey (at least one dose, satisfaction [22, 23]. The clinical examination score was the no stock-out in the prior 30 days). Surveyed drugs sum of patient-reported examinations received (weight, included antibiotics, vitamins and minerals, antihista- height, blood pressure, uterine height, urine test, blood test mines, analgesics, antimalarials, antihypertensives, diag- and abdominal examination). The MCH counselling score nostic kits, and emergency obstetric drugs. was the sum of informational items received: dietary advice, The patient survey items used to capture patient-level in- danger signs during pregnancy, family planning, breast dependent variables below are presented in Additional file 1: feeding, HIV, and delivery care plan. The preventive medi- Table S1 “Pregnant Women’s Satisfaction with their Ante- cation score was the sum of preventive medications natal Care Visit - Survey Instrument”. Based on the total received: iron/folic acid supplement, antimalarial pills, and amount spent on registration, laboratory, ultrasound, medi- tetanus toxoid (pill possession was verified). Finally, stand- cines, and any informal fees, financial access (out-of-pocket alone items that did not load on a factor were used: em- expenditure) was measured as free vs. paid care towards pathic provider (patient-perceived caring attitude of staff, ANC visit. Geographic access measured travel distance yes/no), and non-discriminatory care behavior (perception Table 1 Factor loadings of items measuring perceived quality of patient-provider interactions (exploratory factor analysis, promax rotation) Items Standardized Coefficient Factor 1 Factor 2 The health staff are courteous and respectful 0.31 0.15 The health workers in this facility are extremely thorough and careful. 0.42 0.16 You trust in the skills and abilities of the health workers of this facility. 0.63 0.00 You completely trust the health worker’s decisions about medical treatments in this facility. 0.59 −0.04 The health workers in this facility are very friendly and approachable. 0.61 − 0.09 The health workers in this facility are easy to make contact with. 0.35 0.19 The amount of time you spent waiting to be seen by a health provider was reasonable. −0.02 0.40 You had enough privacy during your visit. −0.04 0.46 The health worker spent a sufficient amount of time with you 0.01 0.60 The hours the facility is open are adequate to meet your needs −0.02 0.58 Minimum factor loading coefficient set at 0.30 Factor 1: Assurance (Cronbach alpha, reliability coefficient: 0.70) Factor 2: Responsiveness (Cronbach alpha, reliability coefficient: 0.57) Inter-factor correlation: 0.55 Onyeajam et al. BMC Public Health (2018) 18:368 Page 4 of 9 of care provided without socioeconomic status-based dis- verified the final model fit using the Hosmer- crimination, yes/no). Lemeshow goodness-of-fit test (9.40, p value of 0.31). For 77 facilities with missing drug availability data, we A p-value of 0.05 was used for statistical significance. imputed data by multivariate normal regression analysis Stata version 14 was used for analysis. using the facility scores on cleanliness and amenities, general medical equipment, and availability of employed Results clinical staff as predictor variables. Multiple imputations Of 826 selected health facilities, 717 were surveyed, out predict missing data values based on available data to of which 554 facilities had ANC patient survey data produce stable estimates [24]. We used 50 imputations available on 1438 patients. Of 1438 interviewed ANC (exceeding the percentage of facilities with missing data, patients, we excluded 102 patients with missing data (6 14.4%), and assumed that data were missing at random on age, 51 on the response about non-discriminatory (MAR). Because the observed and imputed data distri- treatment, and interviewees from 45 facilities with miss- butions did not differ based on visual comparison of the ing data on staff availability (imputation was deemed un- plots, the imputation model was considered acceptable reliable). The final analytical sample consisted of 1336 for these variables. This was a pragmatic decision rule ANC patients (93% of interviewee) attending 534 health used to determine the reliability of the imputations. The facilities (range 2–3 ANC patients/facility). same approach was applied to impute missing data on Table 2 presents the distributions of the health facility staff availability. Imputed values were deemed unreliable variables, showing generally poor infrastructure - general and rejected because the observed and imputed data dis- medical care equipment (on average, 6.40 items available tributions were different. Therefore, facilities with miss- out of 23), drugs (13 out of 48), and general cleanliness ing staff availability were excluded from data analysis. and amenities (6.35 out of maximum possible score of We conducted univariate analysis to describe the 11). Table 3 presents the sample distribution of the1336 patient and facility samples, and bivariate analysis ANC outpatients with a mean age of 25 years, and the (chi-square/t-tests) to study unadjusted associations majority married or living together (96%), generally less of the independent variables with patient satisfaction. educated (85% with primary or no formal education), Testing for multicollinearity using variance inflation had a previous pregnancy experience (63%), paid for care factors indicated that correlations among the ex- (71%), and satisfied with the ANC visit (90%). The num- planatory variables were not a concern. We used ber of essential ANC services received by surveyed pa- multilevel logistic regression modeling, accounting tients, on average, was inadequate: clinical examinations for clustering of patients within facilities, to study (4.64 examinations out of 7 expected), MCH counselling factors associated with ANC satisfaction. All inde- (3.16 out of 6), and preventive medications (1.93 out pendent variables capturing the structure and of 3). A significant proportion of patients reported process of care discussed above and consistent with unfavorable staff attitudes; discriminatory behaviors, the Donabedian framework of healthcare quality 36%, and non-empathic providers, 30%. Regarding which could be measured as patients’ judgment on other perceptions, the scores were generally high (re- care received (patient satisfaction) were included in sponsive service, 7.20 out of a maximum possible the initial model, adjusting for potential maternal score of 8; provider assurance, 11.40 out of 14; socio-demographics as covariates [21]. We used man- treatment-facilitation, 3.70 out of 4). ual, backward selection process to progressively ex- Table 4 presents the factors associated with patient clude non-significant variables (p > 0.10), and tested satisfaction, adjusted for demographic variables. Paid for goodness of fit with Wald test statistics. We care was associated with lower odds of satisfaction Table 2 Healthcare facility variables summary scores, and bivariate associations with ANC patient satisfaction at the facility, northern Nigeria. N = 534 Facility structural characteristicsa Mean (std.dev) Maximum expected score Number Availability of general-care equipmentb 6.38 (4.34) 23 534 Availability of drugsb 12.98 (9.57) 48 457 Proportion of employed clinical staff available on day of survey (%)c 75.40 (25.1) 100 534 Facility cleanliness and amenities 6.35 (2.77) 11 534 ANC Antenatal Care a Indicators are objectively measured by surveyors b Significantly associated with satisfaction in bivariate analysis at p < 0.05 c Clinical staff: Doctors, nurses, midwives, auxiliary nurse, pharmacists, laboratory technologists, technicians, community health officers, community health extension workers Onyeajam et al. BMC Public Health (2018) 18:368 Page 5 of 9 Table 3 ANC patients’ sociodemographic distribution and reported care experience by satisfaction with care, Northern Nigeria. N = 1,336a Total Satisfied Not satisfied n(%) p-value n(%) n(%) Total Respondents 1336 (100) 1204 (90) 132 (10) Sociodemographic and Maternal Factors Age (years) 24.7 (6) 24.6 (6) 25.6 (6) 0.97 Marital status Married/living-together 1286 (96) 1161 (90) 125 (10) 0.32 Others 50 (4) 43 (86) 7 (14) Education Less than secondary 1135 (85) 1024 (90) 111 (10) 0.77 Secondary or higher 201 (15) 180 (90) 21 (10) Wealth quartile Poor 333 (25) 300 (90) 33 (10) 0.24 Lower-middle 335 (25) 306 (91) 29 (9) Upper-middle 333 (25) 291 (87) 42 (13) Rich 335 (25) 307 (92) 28 (8) Gravida statusb Primigravida 494 (37) 447 (91) 47 (9) 0.73 Multigravida 842 (63) 757 (90) 85 (10) Previous ANC in visited facility Yes 975 (73) 884 (91) 91 (9) 0.27 No 361 (27) 320 (89) 41 (11) Healthcare Access Factors Distance travelled (km) <3 1223 (92) 1099 (90) 124 (10) 0.30 ≥3 113 (9) 105 (93) 8 (7) Out-of-pocket expenditure (Naira) Free (no payment) 392 (29) 354 (90) 38 (10) 0.88 100–1000 832 (62) 747 (90) 85 (10) > 1000 112 (8) 103 (92) 9 (8) Patient Care Experience Assurance (mean, SD)c 11.4 (1.20) 11.5 (1.06) 10.0 (1.80) 0.00 d Responsiveness (mean, SD) 7.2 (1.30) 7.5 (1.00) 5.2 (1.60) 0.00 Treatment-facilitation (mean, SD)e 3.7 (0.70) 3.8 (0.60) 3.12 (1.10) 0.00 Clinical examinations received (mean, SD)f 4.64 (1.71) 4.72 (1.70) 3.94 (1.59) 0.00 Maternal and child health counselling items (mean, SD)g 3.16 (1.90) 3.25 (1.89) 2.37 (1.73) 0.00 h Preventive medications received (mean, SD) 1.93 (0.91) 1.92 (0.91) 2.05 (0.92) 0.95 Non-discriminatory treatment regardless of socioeconomic status Yes 853 (64) 792 (93) 61 (7) 0.00 No 483 (36) 412 (85) 71 (15) Empathic providers Yes 933 (70) 883 (95) 50 (5) 0.00 No 403 (30) 321 (80) 82 (20) ANC Antenatal Care a Differences in the distributions of satisfactory and non-satisfactory ANC are significant at p < 0.05 b Gravida status: Primigravida-first pregnancy, Multigravida-second or higher c Assurance: Provider courtesy and accessibility, and trust in provider’s skill and treatment decisions d Responsiveness: Wait time, unrushed consultation, privacy during care, and clinic service hours e Treatment-facilitation: Effective provider communication regarding maternal and neonatal health condition and treatment, and ease of access to prescribed drugs f Clinical examination score: Measurement of weight, height, blood pressure, uterine height, urine test, blood test, and abdominal examination g Maternal and child health counselling score: Counselling on diet, danger signs during pregnancy, family planning, breast feeding, HIV and delivery care plan h Preventive medications score: Receipt of iron/folic acid supplement, antimalarial, and tetanus toxoid Onyeajam et al. BMC Public Health (2018) 18:368 Page 6 of 9 Table 4 Logistic regression analysis (final model) showing objective and subjective health system related factors evaluated for association with satisfaction with ANC, adjusted for sociodemographic factors, northern Nigeria, N = 1336 Independent variables Adjusted Odds Ratioa p value Patient Socio-demography Age (years) 0.98 (0.94–1.03) 0.49 First Pregnancy Yes 1.11 (0.64–1.94) 0.71 No (ref) 1.00 First ANC visit in facility for the pregnancy Yes 0.78 (0.45–1.36) 0.39 No (ref) 1.00 Marital status Married/living-together 2.34 (.078–7.03) 0.13 Others (ref) 1.00 Education Secondary or higher 0.96 (0.48–1.91) 0.91 Less than secondary (ref) 1.00 Wealth quartile Poor 1.35 (0.68–2.66) 0.39 Lower-middle 1.67 (0.85–3.26) 0.13 Upper-middle (ref) 1.00 Rich 1.29 (0.66–2.54) 0.45 Access to Care Out-of-pocket expenditure (Patient reported) Free care (ref) 1.00 0.01 Paid care 0.44 (0.23–0.82) Distance travelled in km (Patient reported) <3 1.84 (0.42–8.16) 0.42 ≥ 3 (ref) 1.00 Patient Care Experience (Subjective perception) Non-discriminatory treatment regardless of socioeconomic status Yes 1.87 (1.09–3.22) 0.02 No (ref) 1.00 Empathic providers Yes 1.82 (1.03–3.23) 0.01 No (ref) 1.00 Assuranceb 1.48 (1.26–1.75) 0.00 Responsivenessc 2.42 (2.05–2.87) 0.00 Treatment-facilitationd 2.03 (1.46–2.80) 0.00 Clinical examinations receivede 1.28 (1.10–1.50) 0.00 Preventive medications receivedf 0.67 (0.48–0.95) 0.02 Facility Level Variable (Objectively measured by surveyors) Availability of general-care equipmentg 1.10 (1.01–1.21) 0.00 Facility cleanliness and amenities 0.96 (0.87–1.07) 0.50 Availability of employed clinical staff on day of surveyh 0.99 (0.98–1.01) 0.31 ANC Antenatal Care a Adjusted for socio-demographic factors. None of the socio-demographic factors were significant. Significant at 0.05 level b Assurance: Provider courtesy and accessibility, and trust in provider’s skill and treatment decisions c Responsiveness: Less wait time, adequate consultation time, respect for privacy, and clinic hours d Treatment-facilitation: Effective provider communication regarding maternal and fetal health condition and treatment, and ease of access to prescribed drugs e Clinical examinations received: count of weight, height, blood pressure, uterine height, urine test, blood test, and abdominal examination received f Prophylactic treatment: count of items received - iron/folic acid supplement, antimalarials, and tetanus toxoid g Availability of general-care equipment: count of essential equipment available h Clinical staff: Doctors, nurses, midwives, auxiliary nurse, pharmacists, laboratory technologists, technicians, community health officers, community health extension workers Onyeajam et al. BMC Public Health (2018) 18:368 Page 7 of 9 (AOR 0.44 relative to free care, 95% CI 0.23–0.82). Per improvements to these aspects to render them truly patients’ perspective on quality, each unit increase in functional, which may improve ANC utilization rate provider assurance score was associated with signifi- in Nigeria and may translate into a higher rate of in- cantly higher odds of satisfaction (AOR: 1.48, 95% CI: stitutional delivery. 1.26–1.75), as also responsive service (AOR: 2.42, 95% We also identified a number of important factors rele- CI: 2.05–2.87), and so was treatment-facilitating climate vant to ANC patient satisfaction that are not docu- (AOR 2.03, 95% CI: 1.46–2.80). Provider concern for mented thus far. This study shows that out-of-pocket patients’ wellbeing was associated with higher odds of expenditure for ANC is of significant concern to patients satisfaction (patients’ perception of empathic provider - in Nigeria, and this may be the case in similar low- AOR: 1.82, 95% CI: 1.03–3.23), as also a perception of income countries [14]. The ease of access to medicines being treated without discrimination based on socioeco- at the facility may increase the likelihood of ANC users’ nomic status (AOR: 1.87, 95% CI: 1.09–3.22). Each add- satisfaction with services. Poor medication access may itional clinical examination received (reported by reflect poor supervisory oversight resulting in unavail- patients) was associated with 28% higher odds of satis- ability of drugs and/or procedural bottlenecks to access faction (AOR: 1.28, 95% CI: 1.10–1.50). By contrast, each available drugs [20]. additional preventive medication received was nega- Compared to earlier studies, our study tested a com- tively associated with patient satisfaction (AOR: 0.67, prehensive range of patient-, provider- and facility-level 95% CI: 0.48–0.95). Among facility-level variables, factors associated with ANC patients’ satisfaction, and equipment availability was significant, with each was therefore, well-positioned to robustly evaluate the equipment item associated with 10% increased odds role of these factors [15–19, 21]. Another strength of the of satisfaction (AOR: 1.10, 95% CI 1.01–1.21). No study is the population based, large sample of both pri- other facility variable, nor demographic variable, in- mary care and secondary level hospitals in rural and cluding parity, was statistically significant. urban areas with an economically diverse patient clien- tele [15–19]. In addition, the proportion of patients ex- cluded due to missing data (7%) was also quite low. Discussion Excluded patients were similar to the analytic sample The study purpose was to identify the modifiable factors on sociodemographic characteristics and satisfaction associated with pregnant women’s satisfaction with ANC (table not shown). This study accounted for many at government health facilities in Nigeria. First, removal of structure and process variables impacting patients’ financial barriers (out-of-pocket payments) is important to judgement of services (facility infrastructure, pro- pregnant women [14]. Secondly, we find an association viders’ technical performance and interpersonal roles, between patient satisfaction and both the perceived qual- and access to treatment) [21]. ity of clinical aspects of care and interpersonal interactions The observed negative association of out-of-pocket ex- of providers. Important clinical care quality factors were: penditure with satisfaction is consistent with other stud- patients trust in their providers’ medical decisions, and ies of family planning, and sexual health services [25, the number of clinical examinations patients received. 26]. In low-income countries like Nigeria, among the Providers’ interpersonal interactions of significance were poor population, the perceived benefits of ANC may be providers’ non-discriminatory behavior regardless of pa- quite low compared to the opportunity cost in lost tient’s socioeconomic status, their concern for patients’ wages [14, 27]. Simulation studies have projected a sig- wellbeing (empathy), responsive provision of services (re- nificant increase in maternal healthcare utilization spect for patients’ time and privacy) and effective commu- among the poor if user fees are abolished [28]. Our nication at consultation (a component of treatment study provides empirical confirmation that, in order to facilitation). The facility’s status of essential equipment achieve universal ANC coverage, it is important to availability was also associated with patient satisfaction. Fi- offer it free of charge in poor communities. Our nally, medication logistics promoting ease of access to pre- study evaluated the effect of any out-of-pocket ex- scribed drugs at the facility was associated with patients’ penses vs. none, supporting that all charges for ANC satisfaction. The study identified a number of health sys- should be eliminated, along with effective facility tem indicators needed improvement. There were wide- oversight and supervisory measures to prevent infor- spread and major deficiencies in the availability of mal fee demands by providers. essential medical equipment and drugs, and the perform- Notably, while the ease of medication access was posi- ance of essential clinical examination. A significant pro- tively associated with satisfaction (even when excluded portion of patients reported discriminatory behaviors from effective communication during consultation, and based on patients’ socioeconomic status and un-empathic separately studied), the number of preventive medications staff attitudes. Public health facilities require significant received showed a negative association. More research is Onyeajam et al. BMC Public Health (2018) 18:368 Page 8 of 9 needed to explore the reasons for this contradictory find- provider adherence to national antenatal care guidelines, ing, because of its potential consequence for medication link provider compensation to the number of low- compliance. Other studies corroborate the positive associ- income patients served (to dis-incentivize discriminatory ation of effective provider communication with satisfac- behavior toward disadvantaged patients), train and tion with ANC [16–18, 22, 23].Equipment availability at incentivize providers to engage in positive interactions health facilities as verified by independent surveyors was with patients, establish a supervisory emphasis on a independently associated with ANC patient satisfaction. patient-centered care culture, optimize patient flow The odds of patient satisfaction associated with this vari- and medication logistics, expand free ANC clinics in able appears modest (a 10% increase in odds with each es- poor communities, and lastly, monitor care quality sential equipment item available), yet, when viewed through regular, anonymous patient satisfaction sur- against the prevailing equipment gap (17 out of 23 essen- veys. This strategic approach should potentially trans- tial equipment unavailable, on average), the incremental late to increased ANC utilization, and in turn, high odds translate into a significant role of equipment avail- rates of institutional delivery and lower maternal mor- ability in patient satisfaction. Patients sense the lack of tality in Nigeria [9, 10]. functional equipment and connect it with care quality [29]. Other studies are consistent with our findings: pa- Additional file tients’ intent to return for care is associated with the ad- equacy of clinical examinations provided, and with Additional file 1: Table S1. Patient Satisfaction Survey. Pregnant Women’s providers’ ability to inspire confidence in their clinical care Satisfaction with their Antenatal Care Visit - Survey Instrument. Details the survey items on the questionnaire used to interview the ANC outpatients and [7, 19, 22]. Courteous behavior is documented to increase capture patient-level independent variables. (DOCX 15 kb) ANC patient satisfaction [15–17]. Other studies also sup- port our findings on the importance of responsive service Acknowledgements (wait time and clinic hours), privacy during medical con- We acknowledge the Minister of Health and the senior management of the sultations (respecting patient dignity and confidentiality of Federal Ministry of Health, the Executive Director and the senior management medical information), adequate medical consultation time of the National Primary Health Care Development Agency (NPHCDA) and the World Bank for providing the data from the baseline survey of the Nigeria State (unrushed service and alleviating patient concerns), em- Health Investment Project (NSHIP) for the study. pathic staff attitude, and non-discriminatory treatment re- gardless of socioeconomic status [15–17, 30]. Funding The work was supported by the World Bank (Contract number: 7163343). World Bank was involved in the identification of project states and their Limitations controls. The study questionnaire was designed by researchers at the One study limitation is the small number of patients University of South Carolina and World Bank consultants suggested few interviewed per facility (2–3). No data were collected on changes, which were adopted. World Bank played no role in data collection, cleaning and analysis, interpretation of results, and drafting of the the officially levied charges by the facility. Another limi- manuscript. tation is the lack of data on provider-patient language concordance. Inability to communicate effectively with Availability of data and materials the patient due to language barrier may be miss- The data that support the findings of this study are available from the World Bank Nigeria Office and not publicly available. Data are however available classified as an issue of interpersonal communication. from the corresponding author upon reasonable request and with Given the states for the NSHIP project were selected permission of the World Bank Nigeria Office. purposively from the Nigerian government’s perspective, the study findings may not be representative across Authors’ contributions Nigeria. We have no data on actual number of eligible DJO conceptualized and designed the study, conducted statistical analysis, interpreted results, drafted manuscript and finalized the paper. SX guided ANC patients at the facilities visited and interview re- the study and analysis plan, and was involved in the preparation of the sponse rate. manuscript draft and finalization of the paper. MK oversaw the NSHIP data collection, guided study conceptualization and design, and provided key input to finalize the paper. JWH directed the statistical analysis. OO was Conclusions involved with the NSHIP data collection, and provided valuable policy The study identified four modifiable factors associated directions. All co-authors provided consultative guidance at various stages, with antenatal patients’ satisfaction with care; the avail- revised draft, approved the manuscript in its final form, and have agreed to be accountable for all aspects of the study ability of equipment and drugs, adequacy of clinical care, empathic and nondiscriminatory environment, and ease Ethics approval and consent to participate of access to treatment in healthcare facilities. These The study was approved by the University of South Carolina Institutional attributes fared poorly reflecting the poor state of the Review Board. A written informed consent was obtained from patients at the facility before they were interviewed. functioning health facilities in Nigeria. The policy implications of the study are to: equip health facilities Consent for publication with essential equipment and consumables, ensure Not applicable. Onyeajam et al. BMC Public Health (2018) 18:368 Page 9 of 9 Competing interests income women: development of a new measure. Womens Health Issues. The authors declare that they have no competing interests. 2004;14(4):118–29. 17. Korenbrot CC, Wong ST, Stewart AL. Health promotion and psychosocial services and women's assessments of interpersonal prenatal care in Publisher’s Note Medicaid managed care. Matern Child Health J. 2005;9(2):135–49. Springer Nature remains neutral with regard to jurisdictional claims in published 18. Ohnishi M, Nakamura K, Takano T. Training of healthcare personnel to maps and institutional affiliations. improve performance of community-based antenatal care program. Adv Health Sci Educ Theory Pract. 2007;12(2):147–56. Author details 19. Smith LF. 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