The WHO has estimated that 295,000 maternal deaths occur globally from conception to childbirth and during the postpartum period (1, 2). The majority are from developing countries where there is inadequate access to skilled delivery (2–4). The provision of delivery services by skilled health personnel is essential to improving maternal health (4, 5). Over the years, the emphasis on maternal care in developing countries has been extended from the outmoded objective of reducing mortality and morbidity to wider goals, such as improving satisfaction (4, 6). This has earned acceptance to determine the standard of skilled delivery, reproductive care (2–4), and clinical practices. It helps healthcare management to develop policies to meet expectations in the course of improving healthcare delivery (7, 8). This is by the WHO's definition of health as “not just the absence of illness or disease but a state of absolute physical, psychological, and general health”(6). Thus, the WHO basis for quality healthcare services has been linked to the dimensions of providing skilled delivery with satisfaction (2, 9).

The satisfaction of postpartum mothers is the measure of their desired expectations, intentions, preferences, and experiences from skilled delivery (7, 8, 10, 11). Skilled delivery is a service provided in a structured facility by a certified health worker who has been trained to be proficient in the services required to improve the lives of expectant mothers during labor and the postpartum period (2, 12). Approximately 69–73% of maternal and neonatal mortalities could have been prevented among mothers if skilled delivery was made available and accompanied by satisfaction (2). The satisfaction of postpartum mothers has been presumed to be the preeminent adjudicator for the improvement of skilled delivery (5). Understanding the factors associated with the satisfaction of postpartum mothers is essential to provide standard skilled delivery in healthcare facilities (8, 13). The services provided in health facilities at the maternity department are essential to improving maternal and neonatal health to prevent mortality and morbidity due to complications from conception to childbirth (2, 12, 14).

Studies have found inadequate health professionals, inappropriate prognoses and therapeutics, inadequate needed capital, poor referral systems, preference of skilled personnel, and previous exposure to complications as health system barriers that affect skilled delivery to mothers (2, 5, 12, 15–17). Satisfaction of patients with skilled delivery has been reported to be associated with sociodemographic factors (Figure 1) (1, 4, 7–9, 14, 18, 19), long waiting time (4, 14, 19), treatment outcome (2, 18–20), availability, and preference of healthcare providers (2, 4). Having good health status is essential, particularly for mothers before and after childbirth for several reasons, i.e., the health of the mother and the well-being development of the child (6). Studies have shown that postpartum mothers undergo several psychiatric disorders, such as stigmatization, emotional, and psychological distress during pregnancy and childbirth (6, 9, 21).

The experience of having psychiatric illness has been a reported cause of emotional disorders from pregnancy to the postpartum period that affect satisfaction (22). In addition, the mother's health status before and after childbirth may be affected by factors related to pregnancy, infant health, and non-medical factors, such as sociodemographic characteristics (6, 9, 12, 21, 22). Many studies have assessed patient satisfaction as a general outcome (4, 5, 9, 18, 19, 23, 24), and others have assessed various dimensions with reported different satisfaction levels (general satisfaction, technical quality, communication, financial, responsiveness, and accessibility) (1, 3, 7, 10–12, 14, 16, 21, 25). The assessment of satisfaction in multiple dimensions and understanding the factors associated with women's pregnancy-related factors and health status before and after childbirth are significantly needed to develop appropriate health interventions (Figure 1) (21, 22). However, associations between these factors, such as parity, pregnancy status, mode of delivery, delivery procedure, and presence of complications with the satisfaction of skilled delivery, have not yet been adequately investigated.

In Ghana, an estimated 63–71% of postpartum mothers received skilled deliveries, likened to 80–95% who accessed antenatal care (ANC) from healthcare professionals (4) compared to 45% in Ethiopia (2). The overall service satisfaction of patients with healthcare delivery in the Volta was 61.7%; however, it was lower than the 83.0% in the Western Region and higher than the 55.0% reported in the Ashanti Region (26). Presently, there has been a swift decline in access to skilled delivery among postpartum mothers in the Akatsi South District based on annual health reports (27). This has been attributed to the following: (1) service dissatisfaction about the noncompliance of healthcare professionals with skilled delivery guidelines approved by their regulatory agencies, (2) previous experiences resulting in non-patronage of postnatal care (PNC), (3) perceptions about ANC, and (4) high utilization of home care after delivery. These problems have been presumed to be the cause of the low utilization of skilled delivery (46%), leading to increased maternal and neonatal mortality in the Akatsi South District (27).

The outcomes of this study would be used to improve attendance at healthcare facilities and address the issues regarding dissatisfaction. This would help the District Health Directorate of Akatsi South develop strategies that could increase the utilization of skilled delivery and significantly reduce maternal and neonatal mortality. It would also be supportive for healthcare regulators, administrators, scholars, and researchers to comprehend the degree to which they can plan different approaches to advance the satisfaction of postpartum mothers, thereby improving the quality of skilled delivery. Hence, our study assessed the association between pregnancy-related factors and health status before and after childbirth with satisfaction with skilled delivery in multiple dimensions among postpartum mothers in the Akatsi South District, Ghana.

The present study assessed the association between pregnancy-related factors and health status before and after childbirth with satisfaction with skilled delivery in multiple dimensions among postpartum mothers in the Akatsi South District, Ghana. This study showed that overall more than half of the postpartum mothers were satisfied with the skilled deliveries. This would help to increase the utilization of services and treatment compliance and promote good relations and evaluation of healthcare providers based on the perspective of the mothers. Our finding contradicts earlier studies conducted in Ethiopia and Nigeria (3, 8) but agrees with studies performed in Turkey, Ethiopia, Ghana, and China (5, 9, 14, 25).

The disproportion across the studies could be the sample size, the cut-off point used, the study setting, and the subjectivity of the postpartum mothers in determining their satisfaction. Another justification for these disparities in the results could be that the quality of services rendered in various countries and within countries from one setting to another setting might inform the measurement of satisfaction using different methods. Similar studies conducted in Nepal, Nigeria, the Netherlands, Ghana, and Australia assessed patient satisfaction in several dimensions, but the overall satisfaction scores were not calculated (7, 10–12, 21). The discrepancy could be due to the availability of services rendered in our study setting compared to those in previous studies.

This study found good satisfaction in five dimensions of skilled delivery out of the six dimensions assessed and overall satisfaction. This implies that postpartum mothers have confidence and trust in the services being provided, and they are likely to continue assessing healthcare services from these health facilities or may not be because of their dissatisfaction in the financial dimension. These findings collaborate with studies conducted in Ethiopia, Nigeria, Nepal, and Australia (7, 10, 11, 14) but oppose studies done in Ghana and the Netherlands (5, 21). These differential satisfaction scores could be due to the unavailability of anticipated services, inadequate healthcare facilities, and lack of healthcare providers in these study settings.

It could also be due to the variances in healthcare locations, funding systems, and the precedence specified to mother satisfaction by regulatory bodies. Not surprisingly, our study reported dissatisfaction with the financial dimension of skilled delivery, which contradicts studies done in Nepal and Australia (7, 10). The probable reason could be that most of the postpartum mothers in our study were dissatisfied with paying for bills more than they could afford, although the government of Ghana instigated an NHIS to offer free healthcare to all citizens.

In our study, the OR showed that postpartum mothers aged between 25 and 40 years and above 40 years were more likely to be satisfied with skilled delivery than those aged below 25 years in the dimensions of communication and responsiveness, respectively. Our findings confirm studies conducted in Nepal and Australia (7, 32) but differ from studies performed in Ethiopia and Turkey (8, 9). These disparities could be due to many factors. First, the possible reason could be the metamorphoses in the treatments provided of which the older population is likely to accept based on their experiences than the younger population (7). Second, the older populace is generally more relaxed with the authoritarian type of care rather than patient-centered care (7). Additionally, the older population was more sociable, respectful, had low expectations, and tolerant toward healthcare providers than the younger population (8).

Our study showed that postpartum mothers who were multiparous were more likely to be satisfied with skilled delivery than those who were primiparous, particularly, in the dimension of responsiveness. Similar findings were found in studies conducted in Nepal, the United States of America, and the Netherlands (1, 21, 33). In contrast to our study, researches conducted in Lebanon and Australia (34, 35) found that primiparous women were more satisfied with maternal services. The possible reason could be that the multiparous mothers had experience and had a better understanding of the challenges of skilled delivery, which confidently impacted their delivery skills. Another probable reason could be that multiparous mothers have fewer expectations from healthcare providers, which influence their decision-making during labor.

This study found that postpartum mothers who delivered at private healthcare facilities were more likely to be satisfied with skilled delivery than those who delivered at government facilities, explicitly in the dimension of communication. This finding opposes a study done in Nepal (1). These variations might be due to several reasons. First, it could be due to the health insurance services handled in these study settings, although in Ghana, it is not restricted directly either to the government or private healthcare facility, which means that citizens are required to use the services by registration. Second, private facilities might not have enough money to subsidize the medical cost and other services available, but the communication and the relationship between the patients and healthcare providers might increase their satisfaction. Another probable reason could be that private health facilities might have many services required for skilled delivery that are unavailable in government facilities.

Our study showed that postpartum mothers who had preterm pregnancies before delivery were more likely to be satisfied than those who had a full-term pregnancy, specifically with the dimension of communication of skilled delivery. This could be attributed to many factors. The likely justification could be that postpartum mothers with preterm pregnancies are aware of having premature babies that mostly end up with major illnesses. Another probable reason could be that postpartum mothers with preterm pregnancies are not worried about staying longer in the healthcare facility because their babies need to be monitored for neonatal danger signs before being discharged home. Our findings indicate the impact of pregnancy status on the satisfaction of postpartum mothers with skilled delivery, although no studies were found to compare the findings. Henceforth, another study is recommended to verify our findings.

This study revealed that postpartum mothers who had cesarean section were more likely to be satisfied with skilled delivery in the dimension of communication compared to mothers who had a spontaneous vaginal delivery. This finding disagreed with studies conducted in the Netherlands, Israel, Ethiopia, and China (21, 24, 36, 37) but was consistent with a study performed in Nepal (1). The likely clarification could be that undergoing a cesarean section of delivery is frequently linked with an undesirable labor experience. Another probable reason could be that the cesarean section of delivery is most often associated with complications that are expected to affect the satisfaction of skilled delivery because it requires wide collaboration.

Our study showed that postpartum mothers who rated their delivery procedures as fair and good were more likely to be satisfied mainly in the dimensions of communication and responsiveness, respectively, compared to those who rated theirs as poor. This finding is consistent with a study conducted in the Netherlands (21). These two studies emphasize that averting abuse and reaching optimum client-care provider communication and receptiveness during labor and childbirth are greatly significant. Courtesy of respectful skilled delivery is required to certify an optimistic experience for all women. Hence, dutiful service delivery must not only demand the avoidance of maltreatment during care.

Our study revealed that postpartum mothers who had complications after childbirth were more likely to be satisfied in the dimension of communication than mothers who had no complications after childbirth. Our finding is incongruent with studies conducted in Ethiopia (2, 24). In studies performed in Nepal, Ghana, and the Netherlands (1, 4, 21), no associations were found between complications after childbirth and the satisfaction of skilled delivery among postpartum mothers. The probable reason is that complications after childbirth require medical interventions and require more widespread and demanding interactions between postpartum mothers and care providers, which might affect their satisfaction with skilled delivery.

This study found no correlation between the overall satisfaction of skilled delivery and study variables, which contradicts a study conducted in Ghana (5). The possible reason could be due to the dissimilarity of the study population, study setting, and scoring point used. In our study, the overall satisfaction of postpartum mothers was significantly and positively correlated with the various dimensions of skilled delivery. Unfortunately, no studies have found assessing the correlation between the overall satisfaction of postpartum mothers with the dimensions of skilled delivery, and this generates problems of comparing our findings to provide appropriate justification. Although these dimensions of skilled delivery are firmly liberated from each other, they indicate the importance of providing equal services irrespective of the dimensions to postpartum mothers by healthcare professionals.

Our study was the first to assess the association between pregnancy-related factors and health status before and after childbirth with satisfaction with skilled delivery in multiple dimensions among postpartum mothers in the Akatsi South District, Ghana. Furthermore, because of the descriptive landscape of the sample used, the results of our study could be widespread to primary health facilities in the district and beyond. Our findings offer a pragmatic signal for Ghana Health Services and the Ministry of Health to encourage their representative health agencies to continue to provide patient-centered care to increase satisfaction at every healthcare facility. This study also provides empirical findings to the Health Directorate in Akatsi South District to evaluate the performance of their staff and award their outstanding facility.

Although our study added different standpoints in the zone of satisfaction of postpartum mothers in Ghana, it has limitations. First, in deducing our findings, it is significant to be aware that statistically significant disparities do not automatically signpost clinical application. Our findings should not be widespread above hospitals at the district level due to the disparities in the healthcare services provided. Third, the existence of a social desirability bias might equally be added to the difference within the interview-answered questionnaires. Other factors could have added to the satisfaction scores of postpartum mothers, which our study could not assess due to the unavailability of literature in the study setting. Additionally, the unattainability of appropriate findings from related studies in the district and the region hinders the comparison of our findings to define precise interventions; hence, our findings should be deduced and interpreted with cautiousness.

Overall, more than three-quarters of the postpartum mothers were satisfied with the skilled delivery. The dimension with the highest satisfaction level was technical quality, and the dimension with the lowest satisfaction was the financial dimension. Age, type of facility, parity, pregnancy status, mode of delivery, delivery procedure, and the presence of complications were significantly associated with satisfaction with skilled delivery. The Ghana Health Service should use these findings cautiously to deliver a policy for the continued improvement of skilled delivery. The Ministry of Health should conduct comparable studies frequently in different districts across the country to apprehend a broader illustration of the satisfaction of postpartum mothers with skilled delivery. The district health directorate should provide interventions that are targeted directly to mend the various dimensions of the satisfaction of postnatal mothers with skilled delivery with low scores. Further studies should assess other pregnancy-related factors and health statuses before and after childbirth to obtain innovative discernments on satisfaction from a standardized standpoint.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Research Ethics Committee (REC) of the University of Health and Allied Sciences (UHAS), Ho. Protocol identification number (UHAS-REC No: A.5 [78] 17-18) was granted. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

LT and CA conceptualized and designed the study. LT drafted and wrote the manuscript. LT, CSB, VK, JT, LA, MA, CB, and SS coordinated and participated in the data collection. LT, CA, and QL contributed to the data analysis, interpretation, and discussion. All authors reviewed the manuscript for intellectual content, and each author approved the final manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.