Proportion and factors influencing client satisfaction with delivery services in health facilities in the Sissala East Municipality, Ghana: A cross‐sectional study

Abstract Background and Aims Client satisfaction is the difference between the healthcare services delivered and the needs of the client. Anecdotal evidence suggests the quality of maternal health and delivery services in Ghana especially in the Upper West Region is appalling. Moreover, there is a paucity of data on clients' satisfaction with maternal and delivery services rendered by healthcare. This study, therefore, assessed clients' satisfaction with delivery services and their associated factors. Methods This analytical cross‐sectional study included 431 women who had delivered in the last 7 days from four health facilities within Sissala East Municipality using a multistage and simple random sampling technique. A well‐structured questionnaire was used to collect sociodemographic and client satisfaction data. All statistical analyses were done using Statistical Package for Social Sciences Version 26.0 and GraphPad Prism Version 8.0. A p < 0.05 was considered statistically significant. Results Clients’ satisfaction with general delivery services was rated as 80.3% and was significantly associated with process‐related factors (p < 0.0001) and structural‐related factors (p < 0.0001) of the health facilities. This study found that health facilities' delivery services differed significantly and were associated with clients’ satisfaction (p < 0.0001). Moreover, age group (p = 0.0200), occupation (p = 0.0090), kind of delivery (p = 0.0050), and delivery outcome (p < 0.0001) were significantly associated with client satisfaction with delivery services. Conclusion More than two‐thirds of women are satisfied with delivery services within selected health facilities in the Sissala East municipality, although satisfaction within health facilities differs. Furthermore, age group, occupation, kind of delivery, delivery outcome, process, and structural‐related factors significantly contribute to client satisfaction with delivery services. To provide more comprehensive coverage of customers' satisfaction with delivery services in the municipality, strategies such as free maternal health initiatives and health education on the significance of facility delivery should be reinforced.


| INTRODUCTION
Globally, maternal deaths have witnessed a significant reduction compared to maternal deaths in the year 2000. An estimated number of 495,000 maternal deaths were recorded globally, and the 2017 global maternal deaths were estimated to be 279,000 (35%). 1 Moreover, in 2017, an estimated 515,000 pregnancy-related deaths were recorded globally, and 30 million women suffered from maternal-related complications in developing countries yearly. 2 Over 98% of these maternal deaths were recorded in resource-poor countries. 3 Currently, the African Region accounts for 65% (two-thirds) of maternal deaths in low-and middle-income countries. 1 In Ghana, maternal mortality is reported to have decreased sharply from 760/100,000 live births in 1990 to 319 per every 100,000 live births in 2015. 4 Previous studies showed that preterm birth and stillbirths are associated with maternal problems, such as hypertensive disorders of pregnancy, nonobstetric complications, obstetric hemorrhage, and pregnancy-related infections. 5,6 Reduction in maternal mortality can be achieved by making health services available, accessible, and of quality to women in cases of complications related to pregnancy and childbirth. [7][8][9] The most common evidence-based practice for improving quality care includes active referral and actionable information systems, adequate flow of communication, respect, dignity preservation, supporting women emotionally, engagement of talented and motivated human resources, and making available essential physical infrastructure or resources. 10 Client satisfaction could be viewed as the difference between the healthcare services delivered and the needs of the client. This measurement gives an opportunity to reduce maternal mortality due to the fact that the mothers will obey the instructions of the healthcare provider once they are satisfied with the delivery of care which meets their needs, and health authorities use the feedback from clients to improve upon service delivery which will ultimately help in reducing mortalities. 11 Furthermore, client satisfaction is the evaluation of healthcare received. It is usually based on their perception of the health service rendered to them and the physical structures and relationships which exist between health providers, the performance of their roles, while others see clients' satisfaction as a comparison between their expectations and what they experienced. 12,13 Ghana has made some gains toward addressing maternal and under-five (5) mortality during the Millenium Development Goals (MDGs) era. Currently, maternal mortality stands at 310 in every 100,000 live births and 52/1000 live births for children under-five (5) years. 5 Antenatal coverage nationally in 2018 was 89%, while pregnant women who received skilled birth delivery accounted for 79%. 5 Attitudes portrayed by healthcare providers, facility characteristics, and sociodemographic characteristics of pregnant women seeking care have been linked to facility delivery services. [14][15][16] However, evidence suggests that the quality of maternal health services and delivery services especially in the Upper West Region of Ghana is appalling although the region recorded 87% in antenatal care (ANC) and 68.7% in supervised deliveries in 2018. 17  were also recounted to be 2272 and 2456, respectively. 18 Stillbirths for 2019 and 2018 were also recorded as 20 and 22, respectively. 18 In addition, there is a paucity of data on clients' satisfaction with maternal and child health services rendered by healthcare workers in health facilities in the Upper West Region, including the Sissala East Municipality. Anecdotal evidence suggests that some pregnant women are not happy with some of the maternal and child health services received. The consequences of pregnant women not being attended to or served by skilled healthcare providers could result in complications for the mother and babies. In the unfortunate event, maternal and neonatal deaths may occur and hence the need to explore the factors accounting for clients' satisfaction with delivery services in the municipality.

| Study design
In achieving the main objective of the study, an analytical crosssectional design was adopted using the quantitative approach. The design was used to determine the factors that influence client satisfaction with care in a specific population at a single moment in time. 19

| Study site
The study was conducted in four health facilities such as Tumu  20 Tumu which is the capital and has a municipal hospital which is the only referral facility for the municipality and receives referrals from the Sissala West district.

| Study population
This study included all women who had delivered in the last 7 days and between the age brackets of 18-49 years at the time of conducting the study in the four selected health facilities. Exclusion criteria include pregnant women in labor. Postnatal mothers who had exceeded the seventh day following delivery and had reported to the facility were also excluded from the study.

| Sample size calculation
The women of fertility age population in the district is estimated as  Hence, a minimum of 390 participants were required for the study. Accounting for 10% nonresponse of the respondents and to increase statistical power, 431 women were recruited for the study. Hospital and other selected health centers. Respondents in these facilities were selected consecutively provided they accepted to participate in the study and sign the consent form.

| Instruments and procedures for data collection and measurement of client satisfaction
Instruments for data collection comprised a structured questionnaire developed based on studies done earlier among delivery clients. 14,22 The primary data included raw data collected using questionnaires which were done by the researcher and four research assistants.
The questionnaire consists of questions related to the rating of hygiene of the facility, the attitude of healthcare providers toward clients, the competence of care providers, general health information on labor and 7 days postnatal, and client-healthcare provider interaction on the sociodemographic characteristics information of respondents was also obtained. All clients who came to the selected facilities were questioned once they accepted to partake in the study and after signing the agreement form. The questionnaires were developed in English before translating into Sissali language and back to English by Mr. Batong Khalid of SILDEP, nongovernmental organization.
Data collection was carried out at the health facility.

| Measures for quality control
A pretest was conducted among 20 respondents in the Nabulo subdistrict who were not part of the study. This facility that was chosen shared similar characteristics with the respondents who were used in the study. This was done to confirm the appropriateness of the data collection tools. It was tested for clarity, and construction of the questions, and questions that are not clear will be revised. The principal researcher monitored the research team to ensure that the interviews were well conducted in the selected study areas.
Four research assistants were recruited and trained to assist the researcher in the administration of the questionnaire. Due diligence was done to ensure that the assistants collected complete data on each respondent. All returned questionnaires on each day were checked for completeness and data were entered into Microsoft Excel 2019 for analysis.

| Data management and statistical analysis
Collected data were entered, cleaned, and coded using Microsoft

| Proportion of general client satisfaction with delivery services
Respondents were asked to rate their general satisfaction with the delivery services in the various health facilities, the majority of them rated it as satisfactory (80.3%) while 19.7% rated as unsatisfactory ( Figure 1). Note: Data presented as frequencies and percentages.
3.3 | Proportion client satisfaction stratified by process-and structural-related factors during delivery services Of 346 women who were satisfied with general delivery services, over 90% were satisfied with process-related factors (95.1%). Of 85 women unsatisfied with general delivery services, majority (80.0%) were unsatisfied with process-related factors. A significant association was, therefore, observed between satisfaction with general delivery services and that of process-related factors (p < 0.0001) (Figure 2A).
Moreover, this study found a significant association between women satisfaction with general delivery services and structuralrelated factors of health facilities (p < 0.0001). This is due to over three-quarter women (77.6%) among those unsatisfied with general delivery services that were equally unsatisfied with structural-related factors (p < 0.0001) ( Figure 2B).   (Table 2).

| Association between processes-related factors and level of satisfaction with delivery services
Of the process-related factors, the reception given at the health facility Similarly, this study observed the level of assistance, attention and care given during and after delivery (p < 0.0001) significantly influenced satisfaction with delivery services at health centers. Thus, each processrelated factor contributes to a level of client satisfaction and must be monitored together for total client satisfaction with delivery services at various health facilities (Table 3). Note: Data presented as frequencies and percentages; p < 0.05 and bolded means statistically significant T A B L E 3 Association between processes-related factors and level of satisfaction with delivery services.  (Table 4).

| DISCUSSION
This study assessed clients' satisfaction with delivery services and their associated factors. Clients' satisfaction with general delivery services was rated as 80.3% and was significantly associated with process-related factors and structural-related factors of the health  facilities. This study found that health facility delivery services differ and were significantly associated with participant satisfaction.
Moreover, age group, occupation, kind of delivery, and delivery outcome were significantly associated with client satisfaction with delivery services. Of the process-related factors, the reception given at the health facility, the privacy provided during stay in the health facility and delivery, the level of respect received, the support given, the information given by the health workers during labor, delivery, and after delivery, and waiting time were significantly associated with the level of general client satisfaction with delivery services. Of the structural-related factors, a significant association was observed between medical examination, level of assistance, satisfaction with drugs prescribed, medical equipment available at the facility, hygiene at the facility, and level of general client satisfaction with delivery services.
Clients' satisfaction with general delivery services rated as 80.3% is in line with what was observed in a comprehensive evaluation of women's satisfaction with maternal services in underdeveloped countries. 23 The present study could have positive health outcomes for clients as satisfied clients are likely to patronize delivery and related services in the future. The satisfaction with general delivery services was significantly associated with process-related factors and structural-related factors of the health facilities. This finding is consistent with the present study in that the reception and support given at the health facility influence clients' satisfaction.
Privacy and confidentiality of clients in a health facility are deemed a relevant indicator of good service delivery and a key determinant of client satisfaction with the service provider as indicated by some studies. 23,26,28 The current study showed that respondents were satisfied with service delivery due to the privacy and confidentiality clients received in the study area. Gitobu

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All data generated or analyzed during this study are included in this article and can be requested from the corresponding author.

ETHICS STATEMENT
Ethics for the study was approved by the Kwame Nkrumah University of Science and Technology ethics board. An introductory letter was also obtained from the University for Development Studies, which was used in obtaining permission from the Health Directorate of the Upper West Region. Lastly, a component of an informed consent form was explained to the respondents and they agreed to participate in the study, and the form was signed by both the researcher and respondents to ensure confidentiality. Informed consent was obtained from the respondent after the consent form had been explained to the respondents on their rights in taking part in the study. Other aspects such as the privacy and confidentiality of respondents will also be highlighted to them. Respondents were also informed that participation in the study was voluntary and they agreed to participate. Data was stored in the cupboard/computer under keys and lock and only opened when necessary.

TRANSPARENCY STATEMENT
The lead author Ebenezer Senu affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.