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Client satisfaction with antenatal care and associated factors among pregnant women attending three teaching hospitals in Addis Ababa, Ethiopia: a cross-sectional study

A cross-sectional study of 325 pregnant women at three teaching hospitals in Addis Ababa revealed that only 54.6% were satisfied with antenatal care, a rate significantly below WHO benchmarks, with dissatisfaction primarily driven by long waiting times and inadequate sanitation, while satisfaction was independently associated with higher income, first-time visits, and lack of abortion history.

Original authors: Bush Kumbi, Seid Arage, Namus Muhajir

Published 2026-08-06

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CC BY 4.0

Original authors: Bush Kumbi, Seid Arage, Namus Muhajir

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine the healthcare system as a giant, bustling theme park. You've bought your ticket (the pregnancy), and you're ready for the ride. But a theme park isn't just about the rollercoaster itself; it's about the whole experience. Is the line too long? Are the restrooms clean? Is the staff friendly? Do you feel safe and heard? In the world of medicine, this "whole experience" is called client satisfaction. It's not just about whether a doctor fixes a problem; it's about how a patient feels while getting help. When people are happy with their visit, they are more likely to come back, listen to advice, and tell their friends to visit too. If they are unhappy, they might skip future visits, which can be dangerous for both mom and baby. This paper dives into the "theme park" of pregnancy care in Ethiopia to see if the visitors are having a good time or if they're stuck in a long, dirty line.

The researchers decided to check the reviews at three major teaching hospitals in Addis Ababa, Ethiopia: Tikur Anbessa, Zewditu Memorial, and Gandhi Memorial. Think of these as the "flagship" parks of the city, where the most complex cases go. Between December 2024 and February 2025, the team interviewed 325 pregnant women who were there for their check-ups. They didn't just ask, "Did you like it?" They used a detailed checklist with 12 questions, ranging from "Was the waiting time fair?" to "Was the water supply adequate?" and "Did the doctor explain things clearly?" They then crunched the numbers to see what made women happy and what made them grumpy.

The results? It's a bit of a mixed bag, like a theme park with amazing rides but terrible bathrooms. Overall, 54.6% of the women (177 out of 325) said they were satisfied with their care. That's a passing grade, but it's far below the World Health Organization's "gold standard" benchmark of 80–90%. The women were thrilled with the human side of things: 96.6% felt the cost was fair, 93.5% felt their privacy was respected, and 89.8% found the doctors easy to understand. It seems the staff were doing a great job being kind and clear.

However, the "infrastructure" part of the park was where things fell apart. Satisfaction plummeted when it came to the basics. Only 51.1% of women were happy with the waiting time, and just 56.3% were satisfied with the cleanliness of the latrines and the water supply. It's like having a world-class chef but serving the meal on a dirty plate while you wait in a hot, crowded line.

The study also uncovered some interesting patterns about who was happy and who wasn't. Women on their very first visit were much happier (3.55 times more likely) than those on their second or third visit. It's as if the first visit is a grand tour with lots of new information, but the follow-up visits feel a bit routine and shorter. On the flip side, women who had a history of abortion were significantly less satisfied (72% less likely to be happy). The authors suggest that women who have lost a pregnancy before might have higher hopes for reassurance and attention, so they judge the care more critically. Finally, money played a role: women with higher monthly household incomes (over 10,000 Ethiopian birr) were more satisfied than those with lower incomes. This suggests that wealthier women might have an easier time navigating the system or have different expectations.

So, what's the takeaway? The paper suggests that the doctors and nurses are doing a fantastic job with their words and attitudes, but the hospitals are struggling with the physical environment and the flow of people. The authors propose that to fix the "unhappy" majority, these hospitals need to expand their capacity to shorten lines, fix the plumbing and water systems, and make sure that every visit—not just the first one—feels just as important and thorough as the grand opening tour. Until then, the "theme park" of pregnancy care in these hospitals has a great staff but needs some serious renovation work.

Technical Summary: Client Satisfaction with Antenatal Care in Addis Ababa Teaching Hospitals

Problem Statement
Antenatal care (ANC) serves as a critical entry point into the health system, where client satisfaction acts as a primary indicator of service quality and a predictor of future health-seeking behaviors, including facility delivery and adherence to medical advice. While Ethiopia has expanded ANC coverage to reduce maternal mortality, quality indicators often lag behind coverage statistics. Existing data on satisfaction in Ethiopia is predominantly derived from primary-level health centers and general hospitals. There is a notable gap in evidence regarding teaching hospitals, which manage higher caseloads, more complex case mixes, and referred high-risk pregnancies. This study addresses the lack of localized data on client satisfaction within the specific context of three major teaching hospitals in Addis Ababa to identify specific areas for service improvement.

Methodology
The study employed a facility-based cross-sectional design conducted between December 2024 and February 2025 at three Addis Ababa University-affiliated teaching hospitals: Tikur Anbessa Specialized Hospital, Zewditu Memorial Hospital, and Gandhi Memorial Hospital.

Population and Sampling: The study included 325 pregnant women aged 18 and older attending ANC. Participants were selected using systematic random sampling, with sample allocation proportional to each hospital's estimated caseload (917 at Gandhi, 721 at Zewditu, and 512 at Tikur Anbessa).
Data Collection: Data were gathered via face-to-face, interviewer-administered questionnaires in Amharic. The instrument was adapted from the WHO Maternal Satisfaction on Health Care (Part IV) tool and included 12 Likert-scale items (ranging from 1 to 5) assessing provider communication, waiting times, facility conditions, and costs.
Variables: The dependent variable was overall satisfaction, dichotomized using a demarcation threshold formula based on the summed Likert scores. Independent variables included sociodemographic factors (age, income, education), obstetric history (parity, abortion history, pregnancy wantedness), and service-related factors.
Analysis: Data were analyzed using SPSS version 26. Bivariate logistic regression screened variables at $p < 0.2$ , which were then entered into a multivariable logistic regression model to determine independent associations. Results were reported as Adjusted Odds Ratios (AOR) with 95% Confidence Intervals (CI), with statistical significance set at $p < 0.05$ .

Key Results

Overall Satisfaction: Only 177 of 325 participants (54.6%) were classified as satisfied with ANC services, falling significantly below the World Health Organization (WHO) benchmark of 80–90%.
Item-Level Performance: Satisfaction varied widely across specific service dimensions.
- High Satisfaction: Perceived fairness of cost (96.6%), maintenance of privacy (93.5%), and ease of understanding provider communication (89.8%).
- Low Satisfaction: Waiting time (51.1%) and the adequacy of latrine cleanliness and water supply (56.3%).
Associated Factors: Multivariable analysis identified three independent predictors of satisfaction:
1. Number of Visits: Women attending their first ANC visit were significantly more likely to be satisfied than those on subsequent visits (AOR = 3.55; 95% CI: 1.49–8.42).
2. History of Abortion: Women with a history of abortion were less likely to be satisfied (AOR = 0.28; 95% CI: 0.16–0.51).
3. Household Income: Women in the highest income bracket (>10,000 ETB) were more likely to be satisfied compared to those in the lowest bracket (AOR = 2.57; 95% CI: 1.35–4.88).
- Non-Significant Factors: Age, religion, education, occupation, and parity showed no independent association with satisfaction after adjustment.

Significance and Claims
The authors claim that the study provides essential baseline data for teaching hospitals, which differ operationally from primary facilities. The findings highlight a dichotomy in service delivery: while interpersonal aspects of care (communication, privacy, cost) are performing well, structural and environmental factors (waiting times, sanitation) are driving dissatisfaction.

The study posits that the decline in satisfaction among women on repeat visits suggests a need to maintain substantive counseling throughout the entire ANC course, rather than focusing intensity only on the first visit. Furthermore, the strong association between abortion history and dissatisfaction indicates a need for tailored, more attentive counseling for women with prior pregnancy losses. Finally, the income-satisfaction link suggests that service improvements may not benefit all socioeconomic groups equally unless specific barriers for lower-income women, such as opportunity costs associated with long waits, are addressed.

The authors conclude that to bridge the gap between current satisfaction levels and WHO benchmarks, these teaching hospitals should prioritize expanding outpatient capacity and staffing to reduce waiting times, upgrade sanitation infrastructure, and ensure consistent, high-quality counseling at every visit. They note that due to the cross-sectional nature of the study and the specific setting of teaching hospitals, findings should be interpreted with caution regarding causality and generalizability to private or lower-level facilities.

Technical Summary: Client Satisfaction with Antenatal Care in Addis Ababa Teaching Hospitals

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