In this study, we assessed the satisfaction of pregnant and postnatal women regarding the quality of PMTCT of HIV services they received in the Oti Region of Ghana. Our findings revealed that the most PMTCT services received were HIV testing (94.4%) and counselling (94.0%). High rates of HIV counselling and testing have been reported in other studies conducted in Ghana over the years . HIV counselling and testing seems to be the most popular PMTCT services offered in most African countries. For instance, studies carried out in Ethiopia  and Uganda  show that HIV testing is the service most received by pregnant mothers as PMTCT service. In Ghana, the current policy guidelines governing PMTCT require that HIV counseling and testing be integrated into reproductive and child health services. Also, all pregnant women accessing reproductive and child health services need to be counselled and tested for HIV by trained counsellors and nurses . Considering the guidelines, there has been missed opportunities for all pregnant women and postnatal mothers to be counselled and tested in the current study, and thus fall short of expectations. Missed opportunities to counsel and test pregnant women for HIV and also initiate those who are positive on ARTs across the country pose challenges to the quest to eliminate mother-to-child transmission of HIV .
Satisfaction with PMTCT services was assessed based on satisfaction with tangible and intangible services received. With regards to satisfaction with tangible PMTCT services, respondents were satisfied with all the variables assessed: thus, comfortability of the waiting and counselling rooms, privacy in the counselling rooms, sanitation and hygiene and the quality of interaction they had with service providers. Clients’ satisfaction with intangible PMTCT services such as waiting time, adequacy of counseling time, language barrier and beneficence of counselling were also found to be encouraging. It could therefore, be said that PMTCT services provision in the Oti region is satisfactory as clients were satisfied with both tangible and intangible PMTCT services they received. The finding suggests that there is good ambience in health facilities providing PMTCT services in the Oti region as well as good service delivery. This is welcoming, as the role of the quality of tangible and intangible PMTCT services cannot be underestimated. For instance, Lyatuu at al.  found that clients’ dissatisfaction with PMTCT services in the Dodoma district of Tanzania, was as a result of the poor quality of the tangible and intangible services such as lack of privacy and long waiting time. Other tangible services such as physical structures and warm reception have also been found to influence clients’ satisfaction with health services and utilization . Overall, the satisfaction with PMTCT services was 42.7% in the present study. Thus, although respondents said they were satisfied with the individual PMTCT services they received, cumulatively, they were not satisfied with such services. The current finding disagrees with those of other studies carried out on the continent that showed a higher level of satisfaction with PMTCT services compared to our study [13, 14, 27, 28]. The reason for the differences could however be attributed to differences in health systems settings and support across various African countries. Our findings however, fill a knowledge void by empirically ascertaining the actual level of satisfaction with PMTCT services offered in the Oti region of Ghana. The implication of our finding, compared to literature, is that the quality of PMTCT services offered in the region and in the country by extension, should not be assessed as units but as an aggregate, if a true reflection of clients’ satisfaction is to be ascertained. It could also be said that if the low level of satisfaction found in the present study is not improved, client utilization of PMTCT services could be affected . Therefore, healthcare providers and authorities in charge of PMTCT services in the Oti region should strive to improve the quality of both tangible and intangible PMTCT services they offer.
With reference to socio-demographic variables that influenced satisfaction with PMTCT services, we found that pregnant women and postnatal mothers who lived in urban areas were 2 times more likely to be satisfied with PMTCT services than those living in rural areas. This finding is not in line with results of a study conducted by Yaya et al. in Ghana  which reported no significant differences in level of satisfaction among respondents in rural and urban areas. Also, on the contrary, Farmer et al.  from their study conducted in Scotland, reported that clients in rural areas were better satisfied with service provision than those in urban areas. The high likelihood of satisfaction found among urban dwelling respondents in the present study could be as a result of disparity in the quality of health facilities found in urban and rural Ghana . Comparatively, hospitals equipped with better resources are found in urban Ghana while poorly-resourced health centres and Community-based Health Planning and Services (CHPS) compounds are found in rural parts of the country . Moreover, health care facilities in urban areas are often manned by competent health workers compared to rural health facilities, and this could influence client satisfaction with the quality of service received in these facilities .
Respondents without any language barrier were 2 times more likely to be satisfied with the PMTCT service provision. Though a diverse region with varied languages, language barrier seemed not to be a problem in the delivery of PMTCT services. Language barriers pose challenges in terms of achieving high levels of satisfaction among medical professionals and patients, providing high quality healthcare and maintaining patient safety . Findings from a systematic review revealed that language barriers in healthcare lead to miscommunication between the medical professional and patient, reducing both parties’ satisfaction and decreasing the quality of health care delivery and patient safety . Deducing from the findings, policy makers in the region should endeavor to address the minor language barrier issues that exist in PMTCT facilities to holistically improve on the overall satisfaction with PMTCT services.
Moreover, respondents who received services at health centers and hospitals were 67% and 59% less likely to be satisfied with PMTCT services compared to those who received services from the CHPS compounds. The CHPS initiative aims to make healthcare services including maternal and child health services easily available to rural communities in Ghana . The CHPS compounds are health posts in rural communities that serve as first level of primary care for rural areas, often manned by a nurse or a midwife or both . Hence, there is a lot of interpersonal interaction between CHPS staff and the community members translating into client satisfaction with PMTCT services compared to hospitals, which serve a large number of people per day from different geographical backgrounds. Meanwhile, the issue of dissatisfaction with health care services across hospitals and health centres in Ghana has been a problem of public health concern for some time  and often linked to the attitude of hospital staff towards clients. Interpersonal relationship between hospital staff and clients need to be improved if dissatisfaction with PMTCT services rendered at the hospital level is to be addressed. It has also been suggested that dissatisfaction on quality of care at hospitals could be improved by adequate structures, supplies and logistics as well as good communication skills .
Furthermore, the present study found that respondents who waited for up to an hour or more to access PMTCT services were 59% less likely to be satisfied, as compared to those who waited for less than 30 minutes. Waiting time and dissatisfaction with healthcare provision has been well researched [40–42]. As clients have other pressing matters, such as economic ventures, to attend to, spending more time to receive PMTCT services could easily lead to dissatisfaction, as it may lead to loss of income. In order to shorten waiting time, the clinics may be structured such that clients access PMTCT services strictly by appointment. This may ensure that clients do not do not spend more than thirty minutes at health centres to access PMTCT services.
Lastly, respondents who indicated that they will not recommend PMTCT services to others were 75% less likely to be satisfied with PMTCT services. Recommendation of a service or product to others signifies trust and confidence in such a service or product. The findings suggest that PMTCT service providers do not have loyal clients as a result of dissatisfaction with the quality of services they render. According to Reibstein et al. , when a brand has loyal customers, it gains positive word-of-mouth marketing, which is both free and highly effective. This is not the case in the present study as dissatisfied clients are not willing to offer free word-of-mouth marketing of PMTCT services in the Oti region. Client satisfaction should be prioritised by PMTCT service providers in the Oti region in order to improve the uptake of such services and lead to effective prevention of mother to child transmission of HIV in the region.
Potential limitation of this study is that, although measures were taken to interview clients in privacy, conducting the interviews at the various healthcare settings may have given room for response bias in favour of the service providers due to fear of victimisation.