Respondents

This research focuses on the experiences of women with antenatal, birthing and maternity care living in deprived areas in the city of Rotterdam, the Netherlands. We used purposive sampling to assure that participants in the focus group interviews represented the important target groups of these deprived neighbourhoods (see Table 1 for an overview of their characteristics).

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Table 1. Respondent characteristics.

https://doi.org/10.1371/journal.pone.0210506.t001

Rotterdam is the second-largest city of the Netherlands with about 618,500 inhabitants. A former industrial city and still a port city, Rotterdam has a relatively high proportion of low-educated inhabitants, with relatively high levels of unemployment, income segregation and poverty compared to other large Dutch cities. [30, 31] Rotterdam has both attracted and recruited immigrants from all over the world. A high proportion of them are living in the city’s deprived neighbourhoods.

The largest non-western immigrant populations in Rotterdam originate from Turkey (8%), Surinam (8%), Morocco (7%), the Antilles (4%) and Cape Verde (2%).[32, 33] We made sure to include in the study representatives of all these groups. We included women meeting the following criteria: (1) native Dutch or first, second or third generation ethnic minority status other than the aforementioned countries, (b) pregnant or having children, (c) aged between 15 and 65 years and (d) preferably low educated [defined as childhood education, primary education, lower secondary education, upper secondary education, post-secondary non-tertiary education (ISCED, 2011)]. We included adolescents because of a higher prevalence of teenage pregnancies in Rotterdam in comparison with other large cities in the Netherlands, especially among Antillean and Surinamese adolescents.[34] We included the (grand)mothers because of their experiences with Dutch obstetric care in the past. We could thus investigate possible parallels between their experiences and that of the current reproductive population. The inclusion criteria outlined above were decided upon in consultation with a midwifery researcher and community health workers based in deprived areas in Rotterdam. Moreover, these field experts were involved in the recruitment of the women, and they were consulted in the interpretation of the results.

Recruitment strategy

We employed active recruitment methods, including by ‘verbal advertising’ and through social networks [35–37]. Firstly, the primary researcher visited: (a) peer education meetings organised by the community health workers, (b) primary schools during coffee breaks, (c) secondary schools and a community college during health(care) educational lessons and (d) neighbourhood community centres. Participants recruited through these methods were asked to connect us with other interested women (‘snow ball sampling’ strategy).[38]

Focus group interviews

We conducted 20 semi-structured focus-group interviews with 18 women with a Turkish background, 19 women with a Moroccan background, 10 women with a Surinamese background, 12 women with an Antillean background, 20 women with a Cape Verdean background, 12 women with a native Dutch background, and 9 adolescent and 6 pregnant women with various ethnic backgrounds. Each focus group consisted of participants with the same ethnic background, including adolescents and pregnant women. This is a strategy that creates group cohesion, which improves the quality of the discussion. [29]

Focus group methodology

The locations of the focus group sessions were chosen by the participants. Sometimes it was a private home and sometimes a meeting room of a primary school or community centre. At the beginning of each session, we gave the respondents information about the study, the structure of the session and the use of collected data. We explained to the respondents that we were interested in their experiences and satisfaction with antenatal, birthing and maternity care. We also made clear that any identifying information from the focus group sessions would not be transcribed. The sessions lasted on average 80 minutes. With the permission of the respondents, all sessions were tape-recorded. The first author and two public health experts conducted the interviews. All interviews were conducted in Dutch. Assistance was available for respondents with a limited Dutch language proficiency. If needed the aforementioned field experts and one of the moderators could help to interpret (languages: Papiamento, Turkish, Moroccan Berber, Portuguese and Moroccan Arabic) and further explain questions asked by the moderator.

To verify if we had succeeded in our purposive sampling, we asked all respondents to fill in a short questionnaire about their background [age, ethnic minority status– 1^st, 2^nd, 3^rd generation, marital or relational status, gestational age in weeks (if applicable), number of prior pregnancies (if applicable), number of children (if applicable), educational attainment and self-reported Dutch language proficiency]. The interview protocol [see S1 Table.] focused on care related experiences based on the domains of responsiveness of care as shown in Box 1.[26, 39–41] During the course of a focus group session the chronology of the interview protocol could be slightly adapted based on the respondents’ preferred topics of discussion.

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Box 1. The eight responsiveness domains, description and subdomains.

https://doi.org/10.1371/journal.pone.0210506.t002

Informed consent and ethics

The legal use of the anonymized background data and the voice recording of the focus group sessions were based on verbal informed consent of all participants. Also verbal consent was obtained from the parents of the minors included in the study via the community health workers who contacted the minor. In our opinion verbal consent by the participant, given and recorded at the beginning of the interview to be the most appropriate manner within the low literate study population. Furthermore written consent may be seperated from the actual recording, whilst the consent on the recording itself will not. Based on consultation of the Medical Ethical Committee of the Erasmus Medical Centre, the study meets the standards of the Dutch Central Committee on Research Involving Human Subjects (CCMO) for research that is not included in the scope of the Medical Research Involving Human Subjects Act (WMO).[42] For privacy reasons we altered the names of the women in the illustrative quotes provided in the Results section of this article.

Data analyses

The audiotaped data of the focus groups were transcribed verbatim. We used the observational notes of the sessions about non-verbal communication and general impressions of the respondents.

Next, the first author and a group of experts consisting of midwifery researchers, public health experts and field experts, checked all transcripts on interpretation of the audiotaped data. Fig 1 shows the three steps of the coding process. The first step consisted of assigning all quotes to a relevant care phase (antenatal, birthing or postpartum). In the second step, all quotes were coded for the relevant WHO responsiveness domains. For this step we applied the directed content analysis approach in which key concepts from the literature were used to create codes for the analysis.[43] In the third step, all quotes were labelled as either positive or negative. A quote was defined as positive when it contained words such as “good”, “adequate”, “nice” and “sufficient”. A quote was interpreted as negative when it contained words or phrases such as “bad”, “inadequate”, “not sufficient” and “not nice”.

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Fig 1. Focus group data analysis.

* n = 1 transcript was excluded from the study because of a voice recording error. ** Nvivo 11 Pro Windows. Respons.: responsiveness.

https://doi.org/10.1371/journal.pone.0210506.g001

Furthermore, all positively and negatively coded quotes were merged into one dataset, and sub classified according to the phase of care (antenatal care, birthing care and maternity of care), the WHO domains of responsiveness and the background characteristics of the focus group respondents.

Lastly, we conducted a variable-oriented analysis. In this analysis particular variables (such as ethnicity of the respondents) were investigated on their value as a determinant for experienced care during the antenatal, birthing and postpartum phases. [44] Individual level background characteristics were linked to the transcribed quotes. This analysis was performed with the qualitative analysis software Nvivo 11 Pro Windows.

Respect for persons responsiveness domains

The respondents expressed opinions about the freedom of decision making and the communication with the caregiver during antenatal care. These opinions were related to the level of satisfaction with antenatal care concerning the domains ‘autonomy’ and ‘communication’ (see Fig 2). Regarding birthing care the respondents had the most dominant views about the domains ‘communication’ and ‘dignity’ (see Fig 3). Regarding the experienced maternity care, the respondents felt most strongly about the ‘communication’ domain (see Fig 4).

Client orientation responsiveness domains

The way in which care was provided and the timing of care during all phases of pregnancy, labour and childbed, was experienced as most important by all women. This opinion was related to the level of responsiveness concerning the WHO domain ‘prompt attention’ (see Figs 2, 3 and 4). This domain falls under the responsiveness category ‘client orientation’.

Key findings

Overall, when comparing the different phases of care, women were most positive about the care they received during the antenatal phase. However, this study showed that generally, respondents with a non-Western ethnic background and low education had a negative opinion about Dutch health care responsiveness during all phases of antenatal, birthing and maternity care.

The findings concerning the ‘communication’ domain in all three phases of care are in line with research by Degrie et al. These researchers conducted a systematic review of qualitative research with a focus on healthcare provision to immigrants and the user’s perspective on the received care.[45] In the present study the negative judgment on ‘communication’ especially by first generation non-western ethnic minority women seems to spring from their low-educational attainment and limited Dutch language proficiency level. Previous studies have demonstrated that these maternal factors play an important role in this negative sentiment. These maternal factors are related to communication problems such as (1) cultural differences in explanatory models of health and illness, (2) differences in cultural values, (3) problematic or conflicting relations between acculturation orientations of caregivers and patients, and (4) linguistic barriers.[46, 47]

The negative judgment of ‘prompt attention’ by non-western and low-educated respondents was consistent with other research in the field.[16, 48] These studies show that reasons for care utilization problems and the negative view on obstetric care include inappropriate timing and incompatible opening hours, transport and mobility problems, indirect (unintentional) discrimination and caregivers’ lack of knowledge about cultural practice.

Discussion of ‘respect for persons’ responsiveness domains

For the respondents in our study, the ‘respect for persons’ domain of ‘confidentiality’ had no importance in either a positive or negative sense. In previous quantitative studies, this domain performed better than other domains and was judged to be more important than the other domains within the category ‘client orientation’ (also see Box 1). [27, 49] Possible explanations for these differences in study outcomes are the differences in used study designs. The aforementioned studies used questionnaires and structured interviews, which required participants to rate the ‘confidentiality’ domain. Also, our study population differed from that in other studies, in terms of a higher number of women with a non-western ethnic background and low educational attainment.

Our study shows that the performance of ‘autonomy’ in antenatal care was experienced more positively by respondents that have lived in the Netherlands for a longer period of time, had a second immigrant generation background and were employed. The respondents in our study who had migrated to the Netherlands only recently, experienced decreased ‘autonomy’ in antenatal care. This is in line with prior studies. [15, 16, 50, 51] A longer duration of residence in the Netherlands may have led to better acculturation and greater chances of employment. This impression is consistent with previous studies demonstrating that a higher socioeconomic status of non-western immigrants resulted in more ‘autonomy’ in the utilization of antenatal care. [15, 16, 50, 51] It seems that a higher level of acculturation, which positively correlates with socioeconomic status, contributes to the ‘autonomy’ aspect in the use and provision of obstetric healthcare.

The results of the present study indicate that respondents with Dutch or Cape Verdean ethnicity and those who were unemployed experienced ‘communication’ as more positive than did other respondents. For the Dutch respondents this can be explained by their language proficiency and their knowledge about the Dutch healthcare system. Nevertheless, Cape Verdean women have lower levels of self-reported Dutch language proficiency.[52] Being unemployed and having low educational attainment are conditions associated with health literacy issues.[15] However, unemployment as an individual risk factor does not have to lead to interaction difficulties with healthcare providers. Prior studies demonstrated that having more time for health care appointments due to unemployment can have a positive effect on interaction with healthcare providers.[53, 54]

Based on our study findings, the communication aspect in the provision of Dutch obstetric care is not suitable for women with a first-generation non-western immigrant background (especially Surinamese and Turkish). Several previous studies have also underlined the strong association between a first generation background and communication problems in obstetric care.[15, 16] Our findings for the Turkish women were consistent with previous research that demonstrated a negative association with having a first generation Turkish immigrant background and having to communicate about medical topics with the caregiver.[55] Literature provided no confirmation for the findings of the Surinamese group concerning the inadequate communication in obstetric care. Possibly their negative opinions were influenced by the caregivers’ directive and culturally unadjusted communication skills and the fact that the content of given information did not meet their cultural and religious views on health and healthcare. [56]

Our study results indicate that the non-western (especially Cape Verdean) respondents and low-educated respondents perceived a lack of respect in obstetric care, particularly during labour. Previous studies confirm that women with a non-western immigrant background perceived a lack of respect from the healthcare system whilst they were giving birth. [57, 58] This inadequate fulfilment of ‘dignity’ is in line with prior studies that show that especially women with a low socioeconomic status background had to deal with a lack of respect from obstetric caregivers during labour. [58]

It seems that the current obstetric healthcare system in the Netherlands is insufficiently capable to act in a culturally competent manner, resulting in inadequate cross-cultural communication. The negative view of the second-generation immigrant respondents concerning the communication component in particularly maternity care, is in concordance with previous studies conducted in the Netherlands and United Kingdom.[8, 59]These studies described a lack of knowledge about the concept of maternity care and postpartum health by immigrant women (first and second generation) as a reason for interaction difficulties in the provision of maternity care.

Discussion of ‘client orientation’ responsiveness domains

The focus group respondents judged the ‘client oriented’ responsiveness domains ‘quality of basic amenities’, ‘choice of care provider’ and ‘access of social support’ to be unimportant. The lack of importance of three of the four domains in this category is in line with the findings of another study about the quality of the obstetric care system. In that study the ‘client orientated’ category was found less important than the ‘respect for persons’ domains.[27]

In the present study, prompt attention (which falls in the ‘client oriented‘ category) did heavily influence the experience of responsiveness of the Dutch obstetric care. The more acculturated respondents and the low-educated respondents experienced ‘prompt attention’ in obstetric care most positively. This is due to better health literacy and financial resources within the more acculturated groups and lower expectations about the provided obstetric care within low-educated groups. These aspects makes it easier for the healthcare system and its caregivers to provide adequate care to these groups. [15, 60–64] This association was also found in another study concerning factors affecting patient satisfaction.[65] People with higher levels of education are more health conscious, more aware of their consumer rights, ask more questions and more often experience prompt attention in care. [53, 66]

Our negative finding concerning ‘prompt attention’ in obstetric care for respondents who had lived for more than 20 years in the Netherlands is in contrast with other research.[66] These women have higher levels of health literacy and therefore may have higher expectations about obstetric care. [15, 16] Specifically the Surinamese negative views on ‘prompt attention’ in obstetric care may be linked with the Surinamese perception of pregnancy, the birth process and care for new borns, which is influenced by traditional medicine, culture and religion. [56] Prior studies showed a decreased use of antenatal care by multiparous Surinamese-Creole women in comparison with other ethnicity groups. In our study population the Surinamese respondents had a Creole background.[17, 67] The aforementioned study describes a higher cumulative risk for preterm birth within this ethnic group and therefore more provision of urgent and high risk care, which influenced the expectations about the prompt attention in obstetric care.

Strength and limitations

The representation of a wide range of age groups (from adolescents to (grand)mothers) is an important strength of our study. Consequently, it was possible to gain insight in the different views on the satisfaction with Dutch antenatal, birthing and maternity care from the perspective of various generations and life phases. Other benefits of the study were the large study population and the fact that for most of the background characteristics data saturation (the point when incoming data produces little or no new information) was reached.[28, 29] Recruitment of focus group members by using active recruitment methods was appropriate for our study, because non-western immigrants and low-educated are frequently underrepresented in research. The focus group method was useful for these target groups, because they more frequently experience barriers to filling in questionnaires due to inadequate language proficiency and illiteracy. [28, 68, 69] Furthermore, the use of this method made it possible to execute several coding steps and a more in-depth analysis based on background characteristic.[27, 28]

Still, several limitations need to be addressed. First, despite interpreting by one of the moderators, field experts and other respondents in the focus groups for respondents with a lack or limited language proficiency level, some respondents may not have well understood all the questions. Second, it was not possible to check to what extent the respondents’ quotes about experienced antenatal, birthing and maternity care were influenced by the group dynamic (peer pressure) during the session. Because the focus groups consisted of a number of participants by design, the influence of peers on the views expressed by women cannot be ruled out. This is a difficult trade-off between the benefits and disadvantages of this form of research design. Third, although there was no specific difference in outcomes of the focus group sessions led by the different moderators, a possible influence of these professionals on the focus group results cannot be ruled out. Fourth, during the course of the study we measured the level of data saturation only superficially. During data analysis, however, the level of data saturation was found adequate. [28, 29]

Policy recommendations

Based on our study results and the known health inequities in between the group of low-educated native Dutch and non-western immigrants and the group of native Dutch and higher educated women, there is a need to provide more extensive care to the former group of, who already are vulnerable. The inequalities in responsiveness of the obstetric healthcare for non-western and low-educated women as observed in this study urges for improvement, in particular as these inequalities are in part responsible for the perinatal outcome gap in the Netherlands.[1,6] Since responsiveness of the healthcare system is getting more important and our study underlines the inadequateness of the responsiveness domains ‘autonomy’, ‘communication’, ‘dignity’ and ‘prompt attention’ in obstetric care for vulnerable women, we recommend focussing on cross-cultural communication and improvements in cultural competence in the obstetric healthcare system. Providing care that is adjusted to the pregnant women’s and new mothers’ cultural preferences starts with communicating with the women about their cultural history, their needs for health information on the basis of which they can make informed decisions in healthcare and identify their care goals.[70, 71] The domains of ‘autonomy’, ‘dignity’, and ‘communication’ can be hard to change, because these are influenced by professionals’ behaviour and can only be changed by self-reflection, intervision and training, which requires time and support of the obstetric caregivers. Changing the ‘client orientation’ domain ‘prompt attention’ requires organizational changes in terms of management coordination, whose implementation may take less time. Therefore, we advise to focus first on the ‘respect for persons’ domains and recommend the health educational institutes and obstetric healthcare organisations to integrate education about cross-cultural communication and cultural competence into the training of obstetric caregivers. The training should aim at increasing the obstetric caregivers’ insight and knowledge concerning: (1) how patients experience pregnancy, childbirth and the postpartum period and received care based on the influence of culture; (2) the elements of cross-cultural communication (self-awareness and respect for the pregnant women’s and new mothers beliefs and values); and (3) cultural competent healthcare provision (attention for cultural and religious beliefs of patients and cultural sensitive attitude of the caregiver). Furthermore, we recommend the Dutch local governments to facilitate peer health education programs focusing on the Dutch healthcare system and reproductive health. Health-related peer education is an approach whereby community members are supported to promote health-enhancing change among their peers. Conditional for implementation of aforementioned recommendations are incentives of the Dutch government and health insurance parties to motivate health educational institutes, obstetric healthcare organizations and caregivers to take up these recommendations.

Future research

In view of the study outcomes it would be relevant to repeat the focus group study exclusively with multi-ethnic, low-educated pregnant women and women who recently gave birth, so as to explore their recent experiences with the responsiveness of the antenatal healthcare system. Such a prospective study design would reduce the risk of recall bias. [72] In this future research it would also be interesting to compare characteristics of health care services in the countries of origin with the Dutch health care services. It would then be possible to elucidate whether this explains part of the negative perceptions of women. Moreover, in a future study it would be helpful to ask women to elaborate on how they believe health care could be improved to meet their needs.