ABSTRACT

Background: Midwife-led care (MLC) is a model of maternity service delivery in which a qualified midwife serves as the primary care provider for pregnant women, especially those with low-risk pregnancies. Patient satisfaction with midwife-led care is a critical quality indicator that influences antenatal attendance, healthcare utilisation, and ultimately maternal and neonatal health outcomes. Despite the documented benefits of midwife-led care, evidence on pregnant women's satisfaction with such services in Nigerian tertiary health institutions remains limited. Objective: This study assessed the level of satisfaction of pregnant women with midwife-led care services at Stella Obasanjo Hospital, Benin City, Edo State, and identified the factors associated with their satisfaction. Methodology: A descriptive cross-sectional survey design was employed. A total of 150 pregnant women attending the antenatal clinic at Stella Obasanjo Hospital were selected through systematic random sampling. Data were collected using a validated structured questionnaire covering sociodemographic characteristics, dimensions of midwife-led care, and overall satisfaction. Data were analysed using descriptive statistics (frequencies, percentages, means) and inferential statistics (chi-square test) at a significance level of p < 0.05. Results: The findings revealed that 74.7% of respondents expressed overall satisfaction with midwife-led care services. Satisfaction was highest with the interpersonal skills of midwives (78.0%) and midwives' technical competence (76.0%), while satisfaction with waiting time (55.3%) and physical infrastructure (60.7%) was comparatively lower. Significant associations were found between satisfaction and educational level (p = 0.032), parity (p = 0.041), and gestational age (p = 0.028). Conclusion: The majority of pregnant women attending Stella Obasanjo Hospital expressed satisfaction with midwife-led care services, though specific service dimensions particularly waiting time and facility infrastructure require targeted improvement. Strengthening these areas would enhance the overall quality of midwife-led care and contribute to improved maternal health outcomes in Edo State.

Keywords: Pregnant women, Patient satisfaction, Midwife-led care, Antenatal care, Stella Obasanjo Hospital, Edo State.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Maternal healthcare constitutes one of the most critical components of any public health system, serving as the cornerstone upon which the health outcomes of both mothers and newborns are built. Globally, the quality of care received during pregnancy is directly linked to maternal and neonatal survival, and patient satisfaction has emerged as a widely adopted measure of the quality of healthcare services (Olaoye et al., 2023). In the context of antenatal care (ANC), patient satisfaction reflects the degree to which maternal health services meet or exceed the expectations of pregnant women across dimensions such as interpersonal relationships, technical competence, provision of information, facility conditions, and timeliness of care.

Worldwide, significant attention has been directed towards midwife-led care (MLC) models as a viable framework for delivering high-quality, woman-centred antenatal and intrapartum services. The midwife-led care model is one in which a qualified midwife assumes primary responsibility for the health care of a pregnant woman, including booking appointments, routine antenatal monitoring, health education, labour support, and postpartum follow-up, with referral to specialist obstetricians when complications arise (Dabengwa et al., 2023). According to Ramu et al. (2025), who conducted a comprehensive scoping review of midwife-led care models, this model has been associated with significant improvements in maternal and fetal outcomes, including reduced rates of caesarean sections and episiotomies, higher rates of normal vaginal delivery, and greater women's satisfaction with the overall maternity care experience.

The World Health Organization (WHO) and the United Nations have consistently advocated for the scaling up of midwifery-led care, particularly in low- and middle-income countries (LMICs), as part of broader strategies to reduce maternal and neonatal mortality (Srofenyoh et al., 2018). The rationale is grounded in evidence showing that skilled midwives who provide continuity of care from pregnancy through to the postpartum period can avert approximately two-thirds of maternal and neonatal deaths (Demmers et al., 2023). The effectiveness of midwifery-led care on pregnancy outcomes in LMICs was confirmed by a systematic review and meta-analysis published in 2023, which found that midwifery-led care was associated with higher levels of maternal satisfaction and reduced unnecessary medical interventions (Demmers et al., 2023).

In sub-Saharan Africa, where maternal mortality rates remain disproportionately high, the role of midwives in delivering ANC services has become even more critical. The 2023 UN Trends in Maternal Mortality report revealed that nearly 28.5% of global maternal deaths occur in Nigeria, with a woman's lifetime risk of dying from pregnancy-related causes estimated at 1 in 19, compared to 1 in 4,900 in the most developed nations (Healthy Newborn Network, 2024). Nigeria's maternal mortality ratio (MMR) persists as one of the highest globally, driven by factors including inadequate antenatal care coverage, poor quality of care, health system fragmentation, and inequitable access to skilled health care professionals (FMoHSW, NPC & ICF, 2024).

Within Nigeria, access to and quality of antenatal care services have gradually improved in recent years. According to the Nigeria Demographic and Health Survey (NDHS) 2023–24, ANC coverage increased from 57% in 2018 to 68% of women receiving at least four ANC visits in 2023 (FMoHSW, NPC & ICF, 2024). Despite this progress, the quality of care at many health facilities remains uneven, and patient satisfaction continues to serve as a crucial diagnostic indicator of service quality. Studies conducted in Nigerian tertiary hospitals including University College Hospital (UCH) Ibadan (Nwaeze et al., 2013), Plateau State Specialist Hospital Jos (Olaoye et al., 2023), and Primary Health Care Centres in Kaduna State (Raji et al., 2020) have demonstrated varying levels of satisfaction among pregnant women attending ANC services, with waiting time, communication, and facility infrastructure emerging as recurring determinants of dissatisfaction.

Stella Obasanjo Hospital (also known as the Specialist Hospital, Benin City), situated in Benin City, Edo State, is one of the foremost public health institutions in southern Nigeria, offering a wide range of obstetric and gynaecological services, including structured midwife-led antenatal care. As a referral centre serving women from across Edo State and neighbouring states, it is imperative to systematically evaluate the satisfaction of pregnant women with the midwife-led care services provided therein. Such assessments are indispensable for identifying service gaps, informing policy, and strengthening healthcare quality within the institution and similar facilities across Nigeria.

Despite the growing body of evidence on the significance of patient satisfaction in midwife-led care, there remains a paucity of empirical studies specifically focused on this dimension at Stella Obasanjo Hospital, Benin City. This research study therefore seeks to fill this gap by assessing the level of satisfaction of pregnant women with midwife-led care services at the hospital, with a view to providing evidence-based recommendations for improving service quality and maternal health outcomes.

1.2 Statement of the Problem

Nigeria bears a disproportionately high burden of maternal mortality, accounting for approximately 28.5% of all global maternal deaths, a figure that reflects systemic deficiencies in the availability, accessibility, utilisation, and quality of maternal healthcare services (Healthy Newborn Network, 2024). While the expansion of ANC coverage has been a key public health goal, the quality of antenatal services particularly in terms of how satisfied pregnant women are with the care they receive from midwives has received less systematic attention, especially in public hospitals in Edo State.

Midwife-led care has been globally recognised as an effective, evidence-based model for improving maternal and neonatal outcomes. However, the extent to which pregnant women attending Stella Obasanjo Hospital, Benin City, are satisfied with the midwife-led services available to them remains largely undocumented. Anecdotal evidence and informal observations suggest that long waiting times, inadequate communication of health information, limited facilities, and irregular staff attitudes may undermine women's satisfaction with ANC at the facility. These concerns are consistent with findings from comparable studies in other Nigerian hospitals (Nwaeze et al., 2013; Olaoye et al., 2023).

When pregnant women are dissatisfied with healthcare services, they are less likely to adhere to ANC schedules, less likely to deliver in health facilities, and more likely to disengage from the health system, thereby increasing their risk of pregnancy-related complications and mortality (Dula et al., 2024). The absence of locally generated data on pregnant women's satisfaction at Stella Obasanjo Hospital creates a gap that limits the capacity of hospital administrators, midwives, and policymakers to address service quality issues in a targeted and evidence-based manner.

This study was therefore designed to systematically assess the level of satisfaction of pregnant women with midwife-led care services at Stella Obasanjo Hospital, identify the specific dimensions of care that drive or undermine satisfaction, and examine the sociodemographic and obstetric factors associated with variations in satisfaction. The findings are expected to provide actionable insights for quality improvement efforts at the facility and contribute to the broader evidence base on patient satisfaction with maternal healthcare in Nigeria.

1.3 Objectives of the Study

The main objective of this study is to assess the level of pregnant women's satisfaction with midwife-led care services at Stella Obasanjo Hospital, Benin City, Edo State.

The specific objectives are to:

i. Determine the sociodemographic and obstetric characteristics of pregnant women attending antenatal care at Stella Obasanjo Hospital.

ii. Assess pregnant women's satisfaction with the interpersonal skills of midwives during antenatal care.

iii. Evaluate pregnant women's satisfaction with the technical competence of midwives at the hospital.

iv. Assess pregnant women's satisfaction with the information and counselling provided by midwives.

v. Examine pregnant women's satisfaction with waiting time and accessibility of midwife-led care services.

1.4 Research Questions

The following research questions guided this study:

i. What are the sociodemographic and obstetric characteristics of pregnant women attending ANC at Stella Obasanjo Hospital?

ii. What is the level of satisfaction of pregnant women with the interpersonal skills of midwives providing antenatal care?

iii. To what extent are pregnant women satisfied with the technical competence of midwives at the hospital?

iv. What is the level of satisfaction of pregnant women with the information and counselling provided by midwives?

v. How satisfied are pregnant women with waiting time and accessibility of midwife-led care at the facility?

1.5 Research Hypotheses

The following null hypotheses were formulated and tested at the 0.05 level of significance:

H01: There is no statistically significant association between educational level and pregnant women's overall satisfaction with midwife-led care services at Stella Obasanjo Hospital.

H02: There is no statistically significant association between parity and pregnant women's overall satisfaction with midwife-led care services at Stella Obasanjo Hospital.

H03: There is no statistically significant association between gestational age and pregnant women's overall satisfaction with midwife-led care services at Stella Obasanjo Hospital.

1.6 Significance of the Study

This study bears multidimensional significance for maternal healthcare policy, clinical midwifery practice, health administration, and academic scholarship in Nigeria.

For healthcare policymakers and the Edo State Ministry of Health, the findings of this study will provide an evidence base to guide the formulation and implementation of policies aimed at improving the quality of midwife-led antenatal care in public health facilities. Identified gaps in service quality can inform targeted resource allocation, staffing decisions, and infrastructure investments at Stella Obasanjo Hospital and similar institutions.

For the management and midwifery staff of Stella Obasanjo Hospital, the findings will serve as a quality improvement tool, highlighting specific dimensions of care where patients' expectations are not being adequately met. This will enable the hospital to develop targeted interventions such as staff development programmes, waiting time management strategies, and improved communication protocols to enhance the satisfaction of pregnant women with midwife-led care.

For midwifery and nursing educators, the study underscores the importance of patient-centred care and service quality in midwifery education and training. The findings can be integrated into curricula to prepare midwives who are technically competent, communicatively skilled, and deeply committed to patient satisfaction.

For researchers and scholars, this study contributes to the growing body of literature on patient satisfaction with maternal healthcare in Nigeria and sub-Saharan Africa. It also establishes a baseline dataset against which future improvements in midwife-led care services at Stella Obasanjo Hospital can be measured.

Finally, for pregnant women and the wider community, the study contributes to the advocacy for higher standards of maternity care and the recognition of women's voices and preferences as central to healthcare quality.

1.7 Scope of the Study

This study is focused on the assessment of pregnant women's satisfaction with midwife-led care services at Stella Obasanjo Hospital, Benin City, Edo State. The study is geographically limited to the antenatal care clinic of Stella Obasanjo Hospital and covers only pregnant women who were attending ANC at the time of data collection. The study examined six specific dimensions of midwife-led care: interpersonal skills, technical competence, information and counselling, waiting time and accessibility, and physical environment and facilities. The study does not extend to intrapartum or postpartum services, nor does it cover other health facilities in Edo State or other states of Nigeria. The temporal scope of the study covers the period of primary data collection, which spanned [Data Collection Period].

1.8 Operational Definition of Terms

Antenatal Care (ANC): The medical, social, and educational care provided to pregnant women from the commencement of pregnancy until the onset of labour, aimed at ensuring the optimal health of both the mother and unborn child.

Midwife-Led Care (MLC): A model of maternity care delivery in which a qualified registered midwife is the primary care provider for a pregnant woman, assuming responsibility for assessment, planning, provision, and evaluation of care from early pregnancy through the postpartum period, with obstetric referral when necessary.

Patient Satisfaction: In the context of this study, patient satisfaction refers to the degree to which the antenatal care services provided by midwives at Stella Obasanjo Hospital meet the expectations, preferences, and needs of pregnant women, as measured across five dimensions: interpersonal care, technical competence, information and counselling, waiting time and accessibility, and physical environment.

Pregnant Women: All women in various stages of pregnancy (first, second, or third trimester) who are attending the antenatal clinic at Stella Obasanjo Hospital, Benin City.

Interpersonal Skills: The communicative, empathetic, respectful, and courteous behaviours demonstrated by midwives during interactions with pregnant women at antenatal visits.

Technical Competence: The clinical knowledge, procedural accuracy, and professional skill demonstrated by midwives in conducting antenatal assessments including vital sign measurement, foetal heart rate monitoring, fundal height measurement, and related clinical procedures.

Waiting Time: The total duration that a pregnant woman spends waiting to receive

midwife-led care services from the time of arrival at the clinic to the time of consultation with the midwife.

75 PAGES with References and Questionnaire.