Women's narratives on quality in prenatal care: a multicultural perspective

Patient-Provider Satisfaction and Communication in U.S. Prenatal Care: A Systematic Review

INTRODUCTION

This is a systematic review on patient-provider satisfaction in U.S. prenatal care by addressing the following research question: What factors influence patient-provider satisfaction during prenatal care?

METHODS

Thirty six online databases were searched for peer-reviewed research from February to September of 2018 using 10 key terms published in English on U.S. populations between the years 1993-2018 on the topic of provider communication skills and patient satisfaction in the prenatal context. Searches yielded 2563 articles. After duplicates were reviewed and eligibility determined, 32 articles met criteria and were included in the final content analysis. All reported study variables were entered into EXCEL, data reported in each study were analyzed by two people for inter-rater reliability and included in the qualitative content analysis. Two researchers also utilized assessment tools to assess the quality of the articles.

RESULTS

Results indicate the importance of good patient-provider communication, that patients have a need for more information on a plethora of topics, and that Hispanic and African American women reported less satisfaction.

DISCUSSION

We recommend that future studies measure potentially significant themes not adequately present in the reviewed studies such as practitioner demographics (e.g. gender, years of experience, or race/ethnicity), mothers under 18 years of age, inclusion of religious minorities, patients with differing immigration statuses, and patients with disabilities.

Communication Between Pregnant People of Color and Prenatal Care Providers in the United States: An Integrative Review

INTRODUCTION

Racism and discrimination negatively affect patient-provider communication. Yet, pregnant people of color consistently report being discriminated against, disrespected, and ignored. The purpose of this integrated review was to identify studies that examined communication between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication.

METHODS

We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were eligible for inclusion if they reported on primary research conducted in the United States, were written in English, and focused on patient-provider communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic, Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and organized into 3 a priori categories: factors, outcomes, and recommendations.

RESULTS

Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then identified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, continuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly, culturally congruent care, provider training, and workforce development were categorized as recommendations.

DISCUSSION

Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research about digital prenatal health communication is necessary to ensure equitable prenatal care.

Patient-Perceived Patient-Centeredness During Pregnancy

OBJECTIVES

Although patient-centeredness is a pinnacle in high-quality healthcare, there is a lack of research measuring patient-centeredness from the perspective of the patient in the context of perinatal care. Therefore, the objectives of this study were to (1) measure patient-perceived patient-centeredness from pregnant people receiving prenatal care in Nova Scotia, and (2) explore potential correlates of patient-perceived patient-centeredness.

METHODS

Participants completed an e-survey through REDCap software. Questions comprised of the Patient-Perceived Patient-Centeredness (Revised) (PPPC-R) questionnaire and demographic questions. The PPPC-R total score was calculated. Descriptive statistics were calculated to describe the sample, and inferential statistics were conducted. Linear regression analysis was used to determine how the independent variables predicted the PPPC-R total score.

RESULTS

A total of 98 patients participated in the survey to completion. The mean PPPC-R total score was 62.2 (SD 10.5), equivalent to a score of 3.45/4. No significant correlates of the PPPC-R total score were identified; however, trends were observed related to age, parity, Body mass index, race/ethnicity, and education.

CONCLUSIONS

Participants in our study rated their clinicians' patient-centeredness very highly. There was no significant difference in PPPC-R score among pregnant people based on the independent variables we collected.

Contextualizing the experiences of Black pregnant women during the COVID-19 pandemic: 'It's been a lonely ride'

The emergence of the COVID-19 pandemic significantly changed the prenatal care experience, specifically regarding medical appointments and social opportunities. It is critical to capture this change through the narratives of pregnant people, particularly those of marginalized populations, whose voices may often be underrepresented in the literature. This mixed-methods paper summarizes the experiences of 40 pregnant Black/African American (AA) women during the COVID-19 pandemic. A cross-sectional, online survey was administered between 2020 and 2021 to assess prenatal health and the impacts of the COVID-19 pandemic on patients' pregnancy experience. Coping behaviors during the pandemic were self-reported using the COPE-IS. Univariate analyses were conducted. An additional analysis of participants (n = 4) was explored through a week-long qualitative exercise using a photo documentation procedure. Photo-Elicitation Interviews (PEI) were conducted to capture and center their pandemic pregnancy experiences. Sources of stress during the pandemic varied, with the most common being financial concerns (n = 19, 47.5%). Over half of the sample (n = 18, 54.5%) self-reported increases in their positive coping behaviors during the pandemic, such as communicating with friends and family, talking to healthcare providers, listening to music, and engaging in spiritual practices-such as prayer. The four PEI study participants reflected on the impacts of social distancing on their prenatal experience and mentioned hospital and provider-related weariness due to their race. The findings of this study suggest that during the COVID-19 pandemic, Black/AA pregnant women in Charlotte, NC used social support, mindfulness practices, self-advocacy, and health literacy to navigate challenges present during their prenatal health experience. This paper highlights the personal, social, and structural experiences of pregnant women during a public health crisis so that responsive and effective programs or policies can be planned in the future.

Innovations and Opportunities in Care for Black Mothers and Birthing People

In recent years, there has been increased attention given to how racism fuels health inequities, including the inadequacy of prenatal care (PNC) that Black women and Black birthing people receive. This increase of attention has brought notable advancements in research, practice, and policy that intend to better understand and address these systemic inequities within the health care system. This review aims to provide an overview of promising developments in the study of Black mothers' and birthing people's experiences in PNC and delivery, to detail current research surrounding interventions to improve quality and mitigate bias in obstetric care, and to offer ways in which legislation can support such strategies targeting the root causes of inequities in care.

Migrant and native women's perceptions of prenatal care communication quality: the role of host-country language proficiency

BACKGROUND

Despite the potentially significant impact of women-prenatal care provider communication quality (WPCQ) on women's perinatal health, evidence on the determinants of those perceptions is still lacking, particularly among migrant women.

METHODS

We aimed to examine the effect of women's host-country language proficiency on their perceived WPCQ. We analyzed the data of 1210 migrant and 1400 native women who gave birth at Portuguese public hospitals between 2017 and 2019 and participated in the baMBINO cohort study. Migrants' language proficiency was self-rated. Perceived WPCQ was measured as a composite score of 9 different aspects of self-reported communication quality and ranged from 0 (optimal) to 27.

RESULTS

A high percentage of women (29%) rated communication quality as "optimal". Zero-inflated regression models were fitted to estimate the association between language proficiency and perceived WPCQ. Women with full (aIRR 1.35; 95% CI 1.22,1.50), intermediate (aIRR 1.41; 95% CI 1.23,1.61), and limited (aIRR 1.72; 95% CI 1.45,2.05) language proficiencies were increasingly more likely to have lower WPCQ when compared to natives.

CONCLUSIONS

Facilitating communication with migrant women experiencing language barriers in prenatal care could provide an important contribution to improving prenatal care quality and addressing potential subsequent disparities in perinatal health outcomes.

Black women's experiences with professional accompaniment at prenatal appointments

U.S. public health statistics report dismal Black infant and maternal mortality rates. Prenatal care alone, while essential, does not reduce such disparities.

OBJECTIVES

The purpose of the study was to explore Black women's experiences when a perinatal support professional (PSP) accompanies them to prenatal medical appointments.

DESIGN

This research used a phenomenological approach, using data from in-depth individual interviews to explore the essence of 25 Black women's experiences.

RESULTS

We identified three major themes from the data that together, show that PSPs served as communication bridges for their clients. Clients said their PSPs helped them to understand and feel seen and heard by their medical providers during their prenatal appointments. The third theme was the deep level of trust the clients developed for their PSPs which made the first two themes possible. PSPs' intervention resulted in reduced stress and uncertainty in medical interactions and increased women's trust in their providers' recommendations.

CONCLUSIONS

Including a trusted, knowledgeable advocate like a PSP may be an important intervention in improving Black women's prenatal care experiences, reducing stress associated with medical interactions, and ultimately reducing pregnancy-related health disparities.

A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women

OBJECTIVE

To examine the qualitative literature on low-income women's perspectives on the barriers to high quality prenatal and postpartum care.

DATA SOURCES AND STUDY SETTING

We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 to 2021.

STUDY DESIGN

Systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past two years and identified as low-income at delivery.

DATA COLLECTION / EXTRACTION METHODS

Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes.

PRINCIPLE FINDINGS

We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy also interfered with timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common.

CONCLUSIONS

Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage may help overcome these challenges.

Assessing Perception of Prenatal Care Quality Among Black Women in the United States

INTRODUCTION

There has been little attention to measuring quality of prenatal care from a Black person's perspective. We examined validity and reliability of the Quality of Prenatal Care Questionnaire (QPCQ) and perceptions of the quality of prenatal care among pregnant Black women.

METHODS

A total of 190 women had complete data on the postpartum questionnaire containing the QPCQ within 8 weeks after birth. Internal consistency reliability was assessed using Cronbach's α. Construct validity was assessed through hypothesis testing using select questions from the Pregnancy Risk Assessment Monitoring System (PRAMS) and Pearson's r correlation.

RESULTS

The mean (SD) maternal age was 26.5 (5.5) years, and 85.3% of births were term (>37 weeks' 0 days' gestation). The total mean (SD) QPCQ score was 191.3 (27.9) points (range 46-230), and the mean (SD) item score for the subscales ranged from 3.88 (0.80) points to 4.27 (0.64). The Cronbach's α for the overall QPCQ score was .97 and ranged from .72 to .96 for the 6 subscale scores, which indicated acceptable internal consistency reliability. All but one subscale had a Cronbach's α higher than .80. The Approachability subscale had a Cronbach's α of .72. Construct validity demonstrated a moderate and significant positive correlation between the PRAMS items and the QPCQ (r = .273, P < .001).

DISCUSSION

To our knowledge, this is the first study to examine the validity and reliability of the QPCQ and perceptions of quality of prenatal care among Black women from the United States. The results indicate that participants rate the quality of their prenatal care highly and that the QPCQ is a reliable and valid measure of the quality of prenatal care. Use of a convenient and reliable instrument to measure the quality of prenatal care rather than prenatal care satisfaction or utilization may help to elucidate the factors of prenatal care that are protective specifically among Black women.

Racial and Ethnic Minority Pregnant Patients with Low-Income Experiences of Perinatal Care: A Scoping Review

Purpose: The maternal mortality ratio for the United States (US) has consistently risen over recent decades. This mortality is especially pronounced within minority populations who experience a maternal mortality and morbidity rate that are much higher than their non-Hispanic white counterparts. Qualitative data are critical in gaining true insight from minority pregnant and postpartum persons. Such data should serve as the basis for building interventions and programs that seek to eradicate perinatal inequities. This review examines the qualitative literature on racial and ethnic minority pregnant patients with low income and their experiences during perinatal care (PNC) to identify recurrent themes that can be addressed through targeted interventions.

Methods: PubMed, CINAHL, and Web of Science databases were searched for qualitative studies on racial and ethnic minority pregnant patients with low income and their experiences during PNC. Twenty-two articles were included for analysis. Thematic synthesis was performed to identify categories and recurring themes in each article.

Results: Five major categories were identified as consistent experiences of pregnant patients with PNC clinicians: support, education, connection, communication, and trust. Of these, clinician support was the most consistently coded category. Eighteen of the 23 articles discussed tangible support patients had received from their clinicians, such as care coordination and referrals to support services. The second most coded category was education, which was represented in 16 articles. Education was mostly represented negatively as lack of adequate perinatal care education given during the perinatal period. Finally, the categories of connection, communication, and trust were represented by 18, 17, and 17 articles, respectively.

Conclusions: These qualitative studies provided specific examples of what racial and ethnic minority pregnant patients with low income deemed positive and negative during the perinatal period and outline ways that these experiences can be improved. Future studies can take the experiences reported in this review to help inform interventions to improve patient experiences and health outcomes that minority persons face in the perinatal period.

The prenatal triad: The importance of provider-patient communication with expectant fathers throughout the prenatal care process

Previous research has primarily focused on the relationship between providers and expectant mothers as a key element of quality prenatal care. Significantly less attention has been directed toward expectant fathers and the importance of their communication with prenatal care providers and involvement in the prenatal care process. Much of this limited existing literature emphasizes the health benefits including fathers would bring for mom and baby, but rarely is the potential benefit to fathers' health included in the conversation. This discussion aims to highlight the value of this line of research for both communication and medical researchers and consider potential avenues for studying and promoting father engagement in prenatal care.

Identifying Barriers and Facilitators to Prenatal Care for Spanish-Speaking Women

BACKGROUND Early access to quality prenatal care is an essential component of improving maternal and neonatal outcomes as it allows for early intervention and risk stratification. Women who receive late or infrequent prenatal care are at high risk for complications including preterm birth, infant death, and stillbirth. We sought to better understand the barriers Spanish-speaking women face in accessing quality prenatal care and to identify facilitators in obtaining timely quality prenatal care.METHODS We recruited a homogeneous group of 11 women with Spanish as their primary language who were pregnant or had given birth within the last six months. We then conducted two focus groups in Spanish. The focus groups were recorded, translated, and transcribed, and then coded using grounded theory.RESULTS In our cohort of participants, the three major themes included desire for psychosocial support, health care system logistics, and barriers due to Latinx ethnicity.LIMITATIONS Our study has several limitations, including a small sample size and single site design.CONCLUSION Latinx women experience unique barriers to care including language barriers, a lack of cultural competency on the part of health care personnel, and ethnic discrimination. Additional research is needed to develop patient-centered interventions to address these barriers.

What do women in Medicaid say about enhanced prenatal care? Findings from the national Strong Start evaluation

BACKGROUND

Medicaid pays for approximately half of United States births, yet little research has explored Medicaid beneficiaries' perspectives on their maternity care. Typical maternity care in the United States has been criticized as too medically focused while insufficiently addressing psychosocial risks and patient education. Enhanced care strives for a more holistic approach.

METHODS

The perspectives of participants in the Strong Start for Mothers and Newborns II initiative, which provided enhanced prenatal care to women covered by Medicaid or the Children's Health Insurance Program (CHIP) during pregnancy through Birth Centers, Group Prenatal Care, and Maternity Care Homes, are evaluated. Strong Start intended to improve care quality and birth outcomes while lowering costs. We analyzed data from 133 focus groups with 951 pregnant or postpartum women who participated in Strong Start from 2013 to 2017.

RESULTS

The majority of focus group participants said that Strong Start's enhanced care offered numerous important benefits over typical maternity care, including considerably more focus on women's psychosocial risk factors and need for education. They praised increased support; nutrition, breastfeeding, and family planning education; community referrals; longer time with practitioners; and involvement of partners in their care. Maternity Care Home participants, however, occasionally voiced concerns over lack of practitioner continuity and short clinical appointments, whereas Group Prenatal Care participants sometimes said they could not attend visits because of lack of childcare.

CONCLUSIONS

Medicaid and CHIP beneficiaries reported positive experiences with Strong Start care. If more Medicaid practitioners could adopt aspects of the prenatal care approaches that women praised most, it is likely that women's risk factors could be more effectively addressed and their overall care experiences could be improved.

Women's Perceived Quality of Care and Self-Reported Empowerment With CenteringPregnancy Versus Individual Prenatal Care

OBJECTIVE

To compare perceived quality of prenatal care and pregnancy-related self-reported empowerment between women participating in CenteringPregnancy versus those receiving individual prenatal care provided by certified nurse-midwives in the same clinic.

DESIGN

Nonexperimental, longitudinal, descriptive feasibility study of two independent groups.

SETTING/LOCAL PROBLEM

A prenatal clinic in northern Texas where all care is provided by certified nurse-midwives.

PARTICIPANTS

The study assessed 51 women receiving self-selected prenatal care in the form of individual prenatal care (n = 37) or CenteringPregnancy (n = 14).

INTERVENTION/MEASUREMENTS

Outcomes analyzed included perceived quality of prenatal care and pregnancy-related self-reported empowerment.

RESULTS

The results showed no statistical significance between the individual prenatal care and CenteringPregnancy groups with regard to perceived quality of prenatal care or pregnancy-related self-reported empowerment.

CONCLUSION

CenteringPregnancy has the capability to provide women with quality of care equal to that achieved through traditional prenatal care. Despite the lack of statistically significant findings, this study exposes several areas of interest and provides guidance for future studies evaluating prenatal care.

Autism Disparities: A Systematic Review and Meta-Ethnography of Qualitative Research

Racial, ethnic, and socioeconomic disparities associated with autism spectrum disorder (ASD) are evident across many service domains including access to early assessment, diagnosis, and therapeutic interventions. To better understand the complex social and structural factors contributing to these disparities, this article offers a systematic review of peer-reviewed qualitative research conducted from 2010 to 2016 in the United States that investigates autism disparities experienced by marginalized communities. Based on these criteria, we identified 24 qualitative research studies and conducted an analysis using meta-ethnography and an intersectional interpretive lens. We identified three interdependent themes contributing to autism disparities, including familial, cultural, and structural barriers. Omissions in the literature were also evident, including a lack of research on underserved adults with ASD and the gendered inequities of caregiving. We discuss the implications of our findings and offer new questions that take an intersectional approach using qualitative research to investigate autism disparities.

Social and economic influences on infant and child feeding practices in a Marshallese community

OBJECTIVE

The present study aimed to examine the key influences on infant and child feeding practices among a Marshallese community at each social ecological level. It is the first study to examine the key influences on infant and child feeding practices with Marshallese immigrant women in the USA and helps fill a gap in the previous literature that has included other immigrant women.

DESIGN

Community-based participatory research design with twenty-seven participants taking part in four qualitative focus groups.

SETTING

The study took place within the Marshallese community in Arkansas, USA.ParticipantsParticipants included Marshallese women with children aged 1-3 years and/or caregivers. Caregivers were defined as someone other than the parent who cares for children. Caregivers were often older women in the Marshallese community.

RESULTS

There were five primary themes within multiple levels of the Social Ecological Model. At the intrapersonal level, mothers' and caregivers' autonomy emerged. At the interpersonal level, child-led and familial influences emerged. At the organizational level, health-care provider influences emerged; and at the policy level, the Special Supplemental Nutrition Program for Women, Infants, and Children emerged as the most salient influence.

CONCLUSIONS

Marshallese immigrant women's infant and child feeding practices are influenced at intrapersonal, interpersonal, organizational and policy levels. Understanding these multidimensional influences is necessary to inform the creation of culturally tailored interventions to reduce health disparities within the Marshallese community.

Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community

Objectives Pacific Islanders are disproportionately burdened by poorer perinatal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care. The aim of this study is to examine Marshallese mothers' beliefs, perceptions, and experiences of prenatal care and to identify potential barriers. Methods Three focus groups were conducted with Marshallese mothers, who were 18 years or older, and living in Arkansas. Focus groups focused on mothers' beliefs, perceptions, and experiences of prenatal care. A thematic qualitative analysis was conducted to identify salient themes within the data. Results The results demonstrated that negotiating health insurance, transportation, and language barriers were all major structural barriers that constrain prenatal care. The social-cultural barriers that emerged included a lack of understanding of the importance of seeking early and consistent prenatal care, as well as how to navigate the healthcare process. The more complicated challenges that emerged were the feelings of shame and embarrassment due to the perception of their age or being unmarried during pregnancy not being acceptable in American culture. Furthermore, the participants described perceived discrimination from prenatal care providers. Lastly, the participants described fear as a barrier to seeking out prenatal care. Conclusions for Practice This study identified both structural and socio-cultural barriers that can be incorporated into suggestions for policy makers to aid in alleviating maternal health disparities among Pacific Islander women. Further research is needed to address the Marshallese mothers' perceived discrimination from maternal health care providers.

More Than a "Number": Perspectives of Prenatal Care Quality from Mothers of Color and Providers

INTRODUCTION

African American mothers and other mothers of historically underserved populations consistently have higher rates of adverse birth outcomes than White mothers. Increasing prenatal care use among these mothers may reduce these disparities. Most prenatal care research focuses on prenatal care adequacy rather than concepts of quality. Even less research examines the dual perspectives of African American mothers and prenatal care providers. In this qualitative study, we compared perceptions of prenatal care quality between African American and mixed race mothers and prenatal care providers.

METHODS

Prenatal care providers (n = 20) and mothers who recently gave birth (n = 19) completed semistructured interviews. Using a thematic analysis approach and Donabedian's conceptual model of health care quality, interviews were analyzed to identify key themes and summarize differences in perspectives between providers and mothers.

FINDINGS

Mothers and providers valued the tailoring of care based on individual needs and functional patient-provider relationships as key elements of prenatal care quality. Providers acknowledged the need for knowing the social context of patients, but mothers and providers differed in perspectives of "culturally sensitive" prenatal care. Although most mothers had positive prenatal care experiences, mothers also recalled multiple complications with providers' negative assumptions and disregard for mothers' options in care.

CONCLUSIONS

Exploring strategies to strengthen patient-provider interactions and communication during prenatal care visits remains critical to address for facilitating continuity of care for mothers of color. These findings warrant further investigation of dual patient and provider perspectives of culturally sensitive prenatal care to address the service needs of African American and mixed race mothers.

Predictors of prenatal care satisfaction among pregnant women in American Samoa

Background

Pregnant women in American Samoa have a high risk of complications due to overweight and obesity. Prenatal care can mitigate the risk, however many women do not seek adequate care during pregnancy. Low utilization of prenatal care may stem from low levels of satisfaction with services offered. Our objective was to identify predictors of prenatal care satisfaction in American Samoa.

Methods

A structured survey was distributed to 165 pregnant women receiving prenatal care at the Lyndon B Johnson Tropical Medical Center, Pago Pago. Women self-reported demographic characteristics, pregnancy history, and satisfaction with prenatal care. Domains of satisfaction were extracted using principal components analysis. Scores were summed across each domain. Linear regression was used to examine associations between maternal characteristics and the summed scores within individual domains and for overall satisfaction.

Result

Three domains of satisfaction were identified: satisfaction with clinic services, clinic accessibility, and physician interactions. Waiting ≥ 2 h to see the doctor negatively impacted satisfaction with clinic services, clinic accessibility, and overall satisfaction. Living > 20 min from the clinic was associated with lower clinic accessibility, physician interactions, and overall satisfaction. Women who were employed/on maternity leave had lower scores for physician interactions compared with unemployed women/students. Women who did not attend all their appointments had lower overall satisfaction scores.

Conclusions

Satisfaction with clinic services, clinic accessibility and physician interactions are important contributors to prenatal care satisfaction. To improve patient satisfaction prenatal care clinics should focus on making it easier for women to reach clinics, improving waiting times, and increasing time with providers.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1563-6) contains supplementary material, which is available to authorized users.

Providers' perspectives of barriers experienced in maternal health care among Marshallese women

PROBLEM

Pacific Islanders are disproportionately burdened by poorer maternal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care.

PURPOSE

The purpose of this study was twofold: (1) to explore maternal health care providers' perceptions and experiences of barriers in providing care to Marshallese women, and (2) providers perceived barriers of access to care among Marshallese women. This is the first paper to explore perceived barriers to maternal health care among a Marshallese community from maternal health care providers' perspectives in the United States.

METHODS

A phenomenological, qualitative design, using a focus group and in-depth interviews with 20 maternal health care providers residing in northwest Arkansas was chosen.

FINDINGS

Several perceived barriers were noted, including transportation, lack of health insurance, communication and language, and socio-cultural barriers that described an incongruence between traditional and Western medical models of care. There was an overall discord between the collectivist cultural identity of Marshallese families and the individualistic maternal health care system that merits further research.

DISCUSSION

Solutions to these barriers, such as increased cultural competency training for maternal health care providers and the incorporation of community health workers are discussed.

Access to and Satisfaction with Prenatal Care Among Pregnant Women with Physical Disabilities: Findings from a National Survey

BACKGROUND

Previous qualitative studies suggest that women with physical disabilities face disability-specific barriers and challenges related to prenatal care accessibility and quality. This study aims to examine the pregnancy and prenatal care experiences and needs of U.S. mothers with physical disabilities and their perceptions of their interactions with their maternity care clinicians.

MATERIALS AND METHODS

We conducted the first survey of maternity care access and experiences of women with physical disabilities from 37 states. The survey was disseminated in partnership with disability community agencies and via social media and targeted U.S. women with a range of physical disabilities who had given birth in the past 10 years. The survey included questions regarding prenatal care quality and childbirth and labor experiences.

RESULTS

A total of 126 women with various physical disability types from 37 states completed the survey. Almost half of the respondents (53.2%) reported that their physical disability was a big factor in their selection of a maternity care provider and 40.3% of women reported that their prenatal care provider knew little or nothing about the impact of their physical disability on their pregnancy. Controlling for maternal demographic characteristics and use of mobility equipment, women who reported that their prenatal care provider lacked knowledge of disability and those who felt they were not given adequate information were more likely to report unmet needs for prenatal care.

CONCLUSIONS

The findings from this study suggest the need for training and education for clinicians regarding the prenatal care needs of women with physical disabilities.

Anatomy of Good Prenatal Care: Perspectives of Low Income African-American Women on Barriers and Facilitators to Prenatal Care

BACKGROUND

Although early, consistent prenatal care (PNC) can be helpful in improving poor birth outcomes, rates of PNC use tend to be lower among African-American women compared to Whites. This study examines low-income African-American women's perspectives on barriers and facilitators to receiving PNC in an urban setting.

METHODS

We conducted six focus groups with 29 women and individual structured interviews with two women. Transcripts were coded to identify barriers and facilitators to obtaining PNC; codes were reviewed to identify emergent themes.

RESULTS

Barriers to obtaining PNC included structural barriers such as transportation and insurance, negative attitudes towards PNC, perceived poor quality of care, unintended pregnancy, and psychosocial stressors such as overall life stress and chaos. Facilitators of PNC included positive experiences such as trusting relationships with providers, respectful staff and providers, and social support.

CONCLUSIONS

Findings suggest important components in an ideal PNC model to engage low-income African-American women.

A Systematic Review of Patients' Experiences in Communicating with Primary Care Physicians: Intercultural Encounters and a Balance between Vulnerability and Integrity

Communication difficulties persist between patients and physicians. In order to improve care, patients’ experiences of this communication must be understood. The main objective of this study is to synthesize qualitative studies exploring patients’ experiences in communicating with a primary care physician. A secondary objective is to explore specific factors pertaining to ethnic minority or majority patients and their influence on patients’ experiences of communication. Pertinent health and social sciences electronic databases were searched systematically (PubMed, Cinahl, PsychNet, and IBSS). Fifty-seven articles were included in the review on the basis of being qualitative studies targeting patients’ experiences of communication with a primary care physician. The meta-ethnography method for qualitative studies was used to interpret data and the COREQ checklist was used to evaluate the quality of included studies. Three concepts emerged from analyses: negative experiences, positive experiences, and outcomes of communication. Negative experiences related to being treated with disrespect, experiencing pressure due to time constraints, and feeling helpless due to the dominance of biomedical culture in the medical encounter. Positive experiences are attributed to certain relational skills, technical skills, as well as certain approaches to care privileged by the physician. Outcomes of communication depend on patients’ evaluation of the consultation. Four categories of specific factors exerted mainly a negative influence on consultations for ethnic minorities: language barriers, discrimination, differing values, and acculturation. Ethnic majorities also raised specific factors influencing their experience: differing values and discrimination. Findings of this review are limited by the fact that more than half of the studies did not explore cultural aspects relating to this experience. Future research should address these aspects in more detail. In conclusion, all patients seemed to face additional cultural challenges. Findings provide a foundation for the development of tailored interventions to patients’ preferences, thus ensuring more satisfactory experiences. Health care providers should be sensitive to specific factors (cultural and micro-cultural) during all medical encounters.

Quality of prenatal care questionnaire: psychometric testing in an Australia population

BACKGROUND

The quality of antenatal care is recognized as critical to the effectiveness of care in optimizing maternal and child health outcomes. However, research has been hindered by the lack of a theoretically-grounded and psychometrically sound instrument to assess the quality of antenatal care. In response to this need, the 46-item Quality of Prenatal Care Questionnaire (QPCQ) was developed and tested in a Canadian context. The objective of this study was to validate the QPCQ and to establish its internal consistency reliability in an Australian population.

METHODS

Study participants were recruited from two public maternity services in two Australian states: Monash Health, Victoria and Wollongong Hospital, New South Wales. Women were eligible to participate if they had given birth to a single live infant, were 18 years or older, had at least three antenatal visits during the pregnancy, and could speak, read and write English. Study questionnaires were completed in hospital. A confirmatory factor analysis (CFA) was conducted. Construct validity, including convergent validity, was further assessed against existing questionnaires: the Patient Expectations and Satisfaction with Prenatal Care (PESPC) and the Prenatal Interpersonal Processes of Care (PIPC). Internal consistency reliability of the QPCQ and each of its six subscales was assessed using Cronbach's alpha.

RESULTS

Two hundred and ninety-nine women participated in the study. CFA verified and confirmed the six factors (subscales) of the QPCQ. A hypothesis-testing approach and an assessment of convergent validity further supported construct validity of the instrument. The QPCQ had acceptable internal consistency reliability (Cronbach's alpha = 0.97), as did each of the six factors (Cronbach's alpha = 0.74 to 0.95).

CONCLUSIONS

The QPCQ is a valid and reliable self-report measure of antenatal care quality. This instrument fills a scientific gap and can be used in research to examine relationships between the quality of antenatal care and outcomes of interest, and to examine variations in antenatal care quality. It also will be useful in quality assurance and improvement initiatives.

African American women and prenatal care: perceptions of patient-provider interaction

Poor patient-provider interaction among racial/ethnic minorities is associated with disparities in health care. In this descriptive, cross-sectional study, we examine African American women's perspectives and experiences of patient-provider interaction (communication and perceived discrimination) during their initial prenatal visit and their influences on perceptions of care received and prenatal health behaviors. Pregnant African American women (n = 204) and their providers (n = 21) completed a pre- and postvisit questionnaire at the initial prenatal visit. Women were also interviewed face to face at the subsequent return visit. Women perceived high quality patient-provider communication (PPC) and perceived low discrimination in their interaction with providers. Multiple regression analyses showed that PPC had a positive effect on trust in provider (p < .001) and on prenatal care satisfaction (p < .001) but not on adherence to selected prenatal health behaviors. Findings suggest that quality PPC improves the prenatal care experience for African American women.

What Makes for Good Collaboration and Communication in Maternity Care? A Scoping Study

BACKGROUND: Good communication and collaboration are critical to safe care for mothers and babies.

OBJECTIVE: To identify factors associated with good collaboration and communication among maternity care professionals and between both professionals and parents.

METHOD: Scoping study. We searched PubMed and Web of Science for peer reviewed, quantitative and qualitative, original, primary research in Western societies on communication and collaboration in maternity care among professionals (Search 1) and between professionals and parents (Search 2).

FINDINGS: The 40 studies (14 in Search 1; 26 in Search 2) that met our selection criteria highlighted several factors associated with good communication and collaboration. We grouped these factors into 6 categories: Expertise, Partnership, Context, Attitude, Trust, and Communication style. Studies of communication and collaboration among professionals foregrounded work-related aspects, whereas studies examining collaboration between professionals and parents paid more attention to interpersonal aspects. Before 2012, few studies covered positive aspects of communication and collaboration. We also found an underrepresentation of parents in study populations.

CONCLUSION: Our study is part of a growing trend of identifying the positive aspects of communication and collaboration in maternity care. As the study of collaboration in practice continues, researchers need to be sure to involve all stakeholders, including parents.

Maternal acculturation and the prenatal care experience

BACKGROUND

Acculturation may influence women's perceptions of health care experiences and may explain the epidemiologic paradox, whereby foreign-born women have lower rates of adverse birth outcomes than United States (US)-born women. We evaluated the relationship between maternal acculturation and specific dimensions of prenatal interpersonal processes of care (IPC) in ethnically diverse women.

METHODS

Cross-sectional analysis of 1243 multiethnic, postpartum women who delivered at Kaiser Permanente Medical Center in Walnut Creek or San Francisco General Hospital. Women retrospectively reported on their experiences in seven domains of IPC during their pregnancy pertaining to communication, decision making, and interpersonal style. The primary independent variables were four measures of maternal acculturation: birthplace, English language proficiency, the number of years residing in the US, and age at immigration to the US. Generalized linear models, stratified by infant outcome, measured the association between each maternal acculturation measure and specific IPC domains while adjusting for type of health insurance, demographic, and reproductive factors.

RESULTS

Approximately 60% of the sample was foreign-born, 36% reported low English proficiency, 43% had resided in the US <10 years, and 35% were age 20 years or older when they immigrated to the US. Over 64% of the women reported having public insurance during pregnancy. In adjusted analyses among women who delivered term and normal birth weight infants, less acculturated women and women with non-private health insurance were more likely to have higher mean IPC scores when compared to more acculturated or US-born women and women with private health insurance, respectively.

CONCLUSION

In a large and ethnically diverse sample of childbearing women in Northern California, less acculturated pregnant women reported better prenatal care experiences than more acculturated and US-born women, another dimension of the "epidemiologic paradox." However, the relationship between acculturation and IPC, as reported during the postpartum period, differed according to infant outcomes.

Quality of prenatal care questionnaire: instrument development and testing

Background

Utilization indices exist to measure quantity of prenatal care, but currently there is no published instrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ).

Methods

Data for this instrument development study were collected in five Canadian cities. Items for the QPCQ were generated through interviews with 40 pregnant women and 40 health care providers and a review of prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to establish its construct validity, and internal consistency and test-retest reliability.

Results

Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently were validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing approach; there was a significant positive association between women’s ratings of the quality of prenatal care and their satisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of the Prenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability (Cronbach’s alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient = 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stability testing confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum.

Conclusion

The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measure to compare quality of care across geographic regions, populations, and service delivery models, and to assess the relationship between quality of care and maternal and infant health outcomes.

Perinatal HIV testing among African American, Caucasian, Hmong and Latina women: exploring the role of health-care services, information sources and perceptions of HIV/AIDS

Perinatal HIV transmission disproportionately affects African American, Latina and potentially Hmong women in the United States. Understanding racially and ethnically diverse women's perceptions of and experiences with perinatal health care, HIV testing and HIV/AIDS may inform effective health communications to reduce the risk of perinatal HIV transmission among disproportionate risk groups. We used a qualitative descriptive research design with content analysis of five focus groups of African American, Caucasian, Hmong and Latina women of reproductive age with low socioeconomic status distinguished by their race/ethnicity or HIV status. A purposive stratified sample of 37 women shared their health-care experiences, health information sources and perceptions of HIV testing and HIV/AIDS. Women's responses highlighted the importance of developing and leveraging trusted provider and community-based relationships and assessing a woman's beliefs and values in her sociocultural context, to ensure clear, consistent and relevant communications. Perinatal health communications that are culturally sensitive and based on an assessment of women's knowledge and understanding of perinatal health and HIV/AIDS may be an effective tool for health educators addressing racial and ethnic disparities in perinatal HIV transmission.

Women's views and experiences of antenatal care in Iraq: a Q methodology study

Background

Understanding women’s experiences and perspectives of antenatal care services is particularly critical for enhancing effectiveness of services delivery and addressing women’s needs and expectations. As part of a comprehensive assessment of the maternity care services in Iraq, this study aimed to explore the views and experiences of antenatal care in a sample of women.

Methods

This explorative study was conducted in Erbil governorate, Iraq. Data were collected using Q methodology, a technique for eliciting subjective views and identifying shared patterns among individuals. A sample of 38 women of different educational and socioeconomic statuses were invited to sort a set of 39 statements reflecting different aspects of the available antenatal care services and issues related to their last pregnancies into a distribution on a scale of nine from “disagree most” to “agree most”. By-person factor analysis was used to derive latent views through centroid factor extraction and varimax rotation of factors.

Results

Analysis of the participants’ Q sorts resulted in identifying four distinct views and experiences of pregnancy and antenatal care services: (i) public maternity services second best: preference for, and ability to afford, private care, (ii) dissatisfaction with public maternity services: poor information sharing and lack of health promotion, (iii) satisfaction with public maternity service but information gaps perceived and (iv) public maternity services second best: preference for private care but unaffordable. The typical characterizations that were associated with each view were highlighted.

Conclusions

This study revealed different patterns of views and experiences of women of pregnancy and antenatal care services and recognized the particular issues related to each pattern. Different patterns and types of problems and concerns related mainly to inadequate provision of information and poor interpersonal communication, poor utilization of public services and a general preference to use private services were identified in the different groups of women.

Women's and care providers' perspectives of quality prenatal care: a qualitative descriptive study

BACKGROUND

Much attention has been given to the adequacy of prenatal care use in promoting healthy outcomes for women and their infants. Adequacy of use takes into account the timing of initiation of prenatal care and the number of visits. However, there is emerging evidence that the quality of prenatal care may be more important than adequacy of use. The purpose of our study was to explore women's and care providers' perspectives of quality prenatal care to inform the development of items for a new instrument, the Quality of Prenatal Care Questionnaire. We report on the derivation of themes resulting from this first step of questionnaire development.

METHODS

A qualitative descriptive approach was used. Semi-structured interviews were conducted with 40 pregnant women and 40 prenatal care providers recruited from five urban centres across Canada. Data were analyzed using inductive open and then pattern coding. The final step of analysis used a deductive approach to assign the emergent themes to broader categories reflective of the study's conceptual framework.

RESULTS

The three main categories informed by Donabedian's model of quality health care were structure of care, clinical care processes, and interpersonal care processes. Structure of care themes included access, physical setting, and staff and care provider characteristics. Themes under clinical care processes were health promotion and illness prevention, screening and assessment, information sharing, continuity of care, non-medicalization of pregnancy, and women-centredness. Interpersonal care processes themes were respectful attitude, emotional support, approachable interaction style, and taking time. A recurrent theme woven throughout the data reflected the importance of a meaningful relationship between a woman and her prenatal care provider that was characterized by trust.

CONCLUSIONS

While certain aspects of structure of care were identified as being key dimensions of quality prenatal care, clinical and interpersonal care processes emerged as being most essential to quality care. These processes are important as they have a role in mitigating adverse outcomes, promoting involvement of women in their own care, and keeping women engaged in care. The findings suggest key considerations for the planning, delivery, and evaluation of prenatal care. Most notably, care should be woman-centred and embrace shared decision making as an essential element.

[Advantages and disadvantages of incorporating qualitative methodology in the evaluation of health services. A practical case: evaluation of a high-resolution clinic]

OBJECTIVE

We examined the usefulness of incorporating a qualitative phase in the evaluation of the quality of care in a high-resolution medical service carried out with quantitative methods.

DESIGN AND METHODS

A quantitative research was performed using a structured questionnaire and selecting interviewees by systematic randomized sampling methods (n=320). In addition, a qualitative research was carried on through semi-structured interviews with patients selected by convenience criteria (n=11), observations in the care assistance circuit, and a group interview with health professionals working in the service. A multidisciplinary research team conducted an individual analysis of the information collected in both quantitative and qualitative phases. Subsequently, three meetings based on group brainstorming techniques were held to identify the diverse contributions of each of the methodologies employed to the research, using affinity graphs to analyse the different results obtained in both phases and evaluate possible bias arising from the use of qualitative methods.

RESULTS

Qualitative research allowed examining specific aspects of the health care service that had been collected in the quantitative phase, harmonizing the results obtained in the previous phase, giving in-depth data on the reasons for patient dissatisfaction with specific aspects, such as waiting times and available infrastructures, and identifying emerging issues of the service which had not been previously assessed.

CONCLUSIONS

Overall, the qualitative phase enriched the results of the research. It is appropriate and recommendable to incorporate this methodological approach in research aimed at evaluating the quality of the service in specific health care settings, since it is provided first hand, by the voice of the customer.

What young African American women want in a health care provider

The Institute of Medicine's report on racial and ethnic disparities in health care encourages enhancing patient-provider relationships by building trust. We explored factors important to 19- to 24-year-old African American women (N = 40) in choosing a health care provider. Eight focus groups were held in seven Ohio counties. Discussion was aided by photographs of client-provider interactions: two African American and two White providers (man or woman in each); in similar settings, attire, and pose; with a young African American woman client. Participants commented on what was happening in the photographs, how the woman felt, and their perceptions of each provider. Fongwa's Quality of Care model guided analysis. Women providers were favored; race was not of primary concern. Provider proximity, perceived interest, and understandability were persistent preferences. Trust, awareness of body language, interest in client, and conveying information clearly are critical for providers caring for young African American women.

A patient perspective in research on intercultural caring in maternity care: A meta-ethnography

The aim of this study is to explore and describe a patient perspective in research on intercultural caring in maternity care. In total, 40 studies are synthesized using Noblit and Hare's meta-ethnography method. The following opposite metaphors were found: caring versus non-caring; language and communication problems versus information and choice; access to medical and technological care versus incompetence; acculturation: preserving the original culture versus adapting to a new culture; professional caring relationship versus family and community involvement; caring is important for well-being and health versus conflicts cause interrupted care; vulnerable women with painful memories versus racism. Alice in Wonderland emerged as an overarching metaphor to describe intercultural caring in maternity care. Furthermore, intercultural caring is seen in different dimensions of uniqueness, context, culture, and universality. There are specific cultural and maternity care features in intercultural caring. There is an inner core of caring consisting of respect, presence, and listening as well as external factors such as economy and organization that impact on intercultural caring. Moreover, legal status of the patient, as well as power relationships and racism, influences intercultural caring. Further meta-syntheses about well-documented intercultural phenomena and ethnic groups, as well as empirical studies about current phenomena, are suggested.