Predictors of prenatal care satisfaction among pregnant women in American Samoa

Obesity, either before or during pregnancy, is an established risk factor for a number of maternal and fetal health complications [1‐3]. Obesity in pregnant women is associated with increased incidence of preeclampsia, gestational diabetes, fetal macrosomia, and stillbirth [4]. In spite of this, the proportion of United States women of reproductive age who are overweight or obese at the time of conception continues to climb, mirroring trends among the general population; approximately 60% of women of reproductive age are overweight or obese [5‐7]. Comparatively, as a result of rapid demographic and nutritional transition, almost 90% of American Samoan women of childbearing age are overweight or obese [8].

American Samoa is an unincorporated island territory of the United States located ~2400 miles southwest of Hawaii. The population receives benefits from its affiliation with the US such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Medicaid access, but the island remains a medically underserved and health care professional shortage area [9, 10]. Prenatal care is considered essential for a healthy pregnancy [11] but is particularly important in the American Samoan setting to ensure that women enter prenatal care early and receive quality care so that some of the risk associated with overweight/obesity during pregnancy can be mitigated. Gestational diabetes and hypertensive disorders of pregnancy, related to overweight/obesity, are both prevalent issues among those of Samoan ethnicity [12, 13] and require early detection and continued management.

Hawley et al. [14] used clinical record data from American Samoa to describe prenatal care utilization among women receiving care at the main hospital and one of the community health centers in American Samoa between 2001 and 2008. Using Kotelchuck’s criteria for adequacy of prenatal care [15] they found that few women (less than 25%) received adequate care during pregnancy, based on the timing of entry into care and the number of appointments attended.

Several factors determine pregnant women’s utilization of prenatal care services during pregnancy. Known barriers to prenatal care in American Samoa mirror those that have been established globally, such as financial barriers (unemployment, lack of transportation), lack of child care for other children, and late pregnancy recognition [14]. However, one factor that has not yet been explored as a barrier to adequate prenatal care utilization in American Samoa is satisfaction with prenatal care services. In other settings it has been shown that a woman who is dissatisfied with her prenatal care, specifically with the patient-provider interaction, is less likely to follow the prenatal care regimen; she is also less likely to utilize prenatal care in future pregnancies [16‐19]. In addition, across all types of medical care, Chemir, Alemseged, and Workneh [20] explain that, “a satisfied patient will recommend [a] center’s services, expressing their satisfaction to four or five people, while a dissatisfied patient, on the other hand, will complain to twenty or more”, suggesting that dissatisfaction with prenatal care may impact both individual behavior and the behavior of a woman’s peers. Prior research exploring prenatal care satisfaction in other settings has found that socio-demographic characteristics such as race/ethnicity, occupation, educational attainment, and religion are significantly associated with satisfaction with care [20‐24]. These factors have not been investigated in American Samoa.

This paper describes factors associated with satisfaction with prenatal care in American Samoa and identifies specific patient groups that are less satisfied with their care. By identifying these groups, initiatives can be developed to address their specific needs. Furthermore, this study incorporates qualitative data to elucidate more about the prenatal care experience for pregnant women in American Samoa.

The average age of participants in the sample was 26.7 years (Table 1). Over 70% of the participants were married or cohabitating with a partner. Over three quarters of the sample were residents of American Samoa, with non-residents mostly from neighboring Samoa. Approximately 57% of the sample was in their third trimester at the time of the survey, which reflects the general prenatal care population at LBJTMC [8, 14]. Eighty-one percent reported having received all of their care at LBJ and over 90% reported having attended all the appointments scheduled for them. For most women this was not a first pregnancy, with the average parity of the sample being 2.7 births.

The PCA analysis identified three ‘domains’ of satisfaction. The items that clustered within each component suggest that component one represented satisfaction with “clinic services”, component two represented satisfaction with “clinic accessibility”, and component three satisfaction with “physician interactions”. The questions within the “clinic services” component, the “accessibility” component and the “physician interactions” component and overall satisfaction all had high internal consistency with Chronbach’s alphas 0.96, 0.89, 0.93 and 0.97 respectively.

Table 3 presents the normalized mean satisfaction scores for each domain. Mean satisfaction was lowest for “Accessibility” (58.5 points out of 100) and highest in the “Physician Interactions” domain (76.4 points). Overall satisfaction had a normalized mean of 68.4 points out of 100.

Unadjusted mean satisfaction scores for “clinic services” were associated with participant’s employment status, the driving time to the clinic, and the average time spent at the clinic during each appointment (Table 4). Unadjusted satisfaction with “clinic accessibility” was also associated with driving time to the clinic and the average time spent at the clinic, but also with participant’s resident status. Significant differences in unadjusted mean satisfaction score for “physician interactions” were found with participant employment status and driving time to the clinic. With regards to overall satisfaction, driving time to the clinic, participant employment status, and average waiting time at the clinic were all associated significantly with satisfaction score.

Adjusted linear regression models are presented in Table 5. The “clinic services” satisfaction score was 20.3 points lower among women who waited, on average, two hours or more before they saw the doctor compared with women who waited less than 30 min. Importantly, women who reported not attending all of their appointments were approximately 16 points (95% CI: -28.8, −3.1) less satisfied with “clinic services” than women who did report attending all of their appointments.

Participants living 20 min or further away from the prenatal clinic they most regularly visited were significantly less satisfied with “clinic accessibility”, “physician interactions” and overall, than women who lived less than 10 min from the clinic (satisfaction scores were between 10.3 and 14.7 points lower).

Satisfaction with “physician interactions” was negatively associated with employment. Women who were employed/on maternity leave were 9.2 points (95% CI: -17.4, −0.9) less satisfied with their interactions with their physician than women who were unemployed/students. Among only those women who had been pregnant before, women who had previously lost a pregnancy were 11.2 points (95% CI: -21.6, −0.7) less satisfied than those who had never experienced a pregnancy loss.

Overall satisfaction was significantly associated with waiting time at the clinic; women who waited on average two hours or more were 14.1 points less satisfied than women who waited less than 30 min (95% CI: -25.9, −2.3). Pearson’s correlation tests indicated that the average amount of time spent speaking with a physician during prenatal care visits was positively associated with satisfaction with “clinic services” (r² = 0.22, p = 0.006), “physician interactions” (r² = 0.19, p = 0.017) and overall satisfaction (r² = 0.214, p = 0.007) (Table 6).

Our results confirm that specific maternal characteristics are associated with prenatal care satisfaction overall and with specific domains of satisfaction. These characteristics go beyond basic demographic traits and take into account the social and environmental characteristics of women’s prenatal care experiences. Clinic distance, specifically living more than 20 min driving time from the clinic most frequently attended, was significantly associated with lower satisfaction with “clinic accessibility”, “physician interactions” and overall satisfaction. Being employed or on maternity leave was significantly associated with lower satisfaction with “physician interactions” and approached significance in the same direction in the “clinic services” and overall satisfaction domains. Average time spent at the clinic for a prenatal care appointment, particularly spending two hours or more at the clinic, was associated with “clinic accessibility”, “clinic services” and overall satisfaction. Previous pregnancy loss emerged as a pertinent predictor of lower satisfaction with “physician interactions”. Non-resident status was the only positive predictor of satisfaction with higher satisfaction among non-residents than residents with “clinic accessibility”.

Other studies of satisfaction with prenatal care have reported similar findings. In Ethiopia, Chemir et al. [20] found that dissatisfaction with prenatal care was primarily due to long waiting times, overcrowding in the clinic during the morning, and poor laboratory services. Handler et al. [21] suggested that, to improve satisfaction, prenatal care providers should focus on improving provider-patient communication, clinic cleanliness, waiting times, and availability of ancillary services based on their study of low-income pregnant women in the US.

The time required to attend prenatal care seemed to be a key determinant of satisfaction among participants in this study: time spent traveling to the clinic, waiting time at the clinic, the amount of time spent with the physician, and time taken away from employment to attend appointments. The “clinic accessibility” domain, which reflected satisfaction with clinic location, waiting times, and opening hours, received the lowest mean satisfaction scores from study participants. The distance between a participant’s home village and the clinic they used most frequently was a strong predictor of satisfaction with “clinic accessibility”. Although the island of Tuituila, where this study was conducted, is small, most people rely on public transportation, so a driving distance of 20 min to get to a prenatal care appointment may require a much greater time investment, depending on bus schedules or availability of family to offer transport. The finding that distance to a clinic was associated with “physician interactions” may reflect those who traveled further feeling that they got less ‘value’ for their travel time investment for a comparatively short time spent with the physician (~18 min on average) than women who had a much shorter travel time. Indeed, the distance between a patient’s home and their prenatal care provider has been consistently demonstrated to be a key factor in both satisfaction with prenatal care and prenatal care utilization in other settings [30].

In spite of general dissatisfaction with clinic accessibility, being a non-resident was associated with greater satisfaction in this domain. The majority of non-residents who completed the survey reported being from neighboring Samoa. Birth tourism is common between Samoa and American Samoa; it may be that, given its association with the United States, American Samoa is perceived by women as having more resources for prenatal care than Samoa. Extended families are often spread across both islands and travel between the two is relatively inexpensive by plane or boat so many women from Samoa stay with family in American Samoa for the months immediately preceding their birth. They often choose to stay with family close to the hospital and are ineligible for employment during their stay, as such, they may have found accessing prenatal care less difficult than the American Samoan residents.

In 2009, the Department of Health opened community health centers in Amouli and Leone to expand access to care to residents in the Eastern and Western districts of American Samoa [14]. However, women are only able to attend these clinics until 28 weeks, after which they must go to LBJTMC for their final trimester care. This requirement, although designed with patient safety in mind, may be undermining satisfaction with prenatal care. If further, specialist, staffing was a possibility for these clinics, or if low-risk women could remain at their closest clinic until the time of birth under the care of midwives or qualified nurse practitioners, satisfaction may be improved.

Understandably, the average amount of time spent at the clinic per appointment was a strong predictor of satisfaction in all but the “physician interactions” domain. While satisfaction declined with increasing time spent at the clinic, only those who reported spending more than two hours at the clinic were significantly less satisfied than those who waited for half an hour or less. On average, women waited 57 min after check in at the clinic to meet with a doctor, so it may be that an appointment taking up to 90 min was expected and anything beyond that was unusual and possibly frustrating. Long waiting times are a well-known deterrent to seeking and remaining in prenatal care globally [31‐33]. The costs associated with long clinic wait times (lost wages, lost school time, and the costs of childcare for other children) can be burdensome over the course of pregnancy, particularly in low income settings such as American Samoa. Additionally, several studies have shown that women may consider long waiting times for prenatal care (or other healthcare services more generally) to indicate a disrespect by providers for the importance of their time, and that a short consultation with the doctor after a long wait time is particularly insulting [34, 35]. The fact that those women who were employed were less satisfied with “physician interactions” than those who were students or unemployed may indicate that employed women felt particularly strongly that physicians were not respecting their time. While the first-come-first-served system of appointment booking currently operated in American Samoa, with all women given the same early morning appointment time, may be efficient from the clinicians perspective (to avoid wasted time associated with missed appointments) an alternative model could be considered to improve patient satisfaction. To accommodate working mothers, clinic operating hours could be more flexible, perhaps with late/early opening offered on specific days to improve access to care for those women who find it hard to attend during regular working hours.

An additional predictor of satisfaction with physician interactions was previous pregnancy loss. Previous pregnancy loss has been demonstrated to have a profound impact on how a woman navigates and experiences health care [36]. Multiple investigators have documented increased symptoms of depression and pregnancy-related anxiety in pregnant women following a prior miscarriage or stillbirth [37]. With physician interactions so limited in American Samoa it may not be possible to provide the level of support and reassurance necessary to ensure satisfaction with and confidence in prenatal care. Within the “physician interactions” domain, participants ratings of the specific items “How would you rate the comfort shown to you by doctors?” and “How would you rate the concern shown to you by doctors?” were lower if they had experienced a prior pregnancy loss than if they had not, while there was no significant difference in responses to the other questions in the domain (data not shown). While utilization of care did not differ in this study based on prior pregnancy loss, it may be important to consider providing additional support services to these women outside of the physician interactions that could assist with building confidence in care.

While this was a cross-sectional study, and we cannot prospectively connect satisfaction with prenatal care with utilization, it was evident that those who had not attended all of their scheduled appointments prior to the survey were less satisfied with care – overall and in the “clinic services” domain – than those who had attended all of their scheduled appointments, indicating that satisfaction and utilization may have been linked. Satisfaction in general was lower than reported by Raube et al. [28] in the sample of low-income, US women whose data was used to create the measure of satisfaction used here (overall satisfaction was 73.8 in the original study versus 68.4 here) and lower than that reported among African American women in a managed care organization in the US Midwest (overall satisfaction: 80.3) [24]. This suggests that further attention should be paid to monitoring and improving satisfaction in this setting, to ensure continued attendance at the individual and community level. Our data suggest that efforts to this effect should be focused on improving organizational aspects of care in particular: improving waiting times and increasing accessibility.

Several studies have examined alternative organizational models of prenatal care and measured satisfaction with care as an outcome. Randomized controlled trials in the UK [38], the US [39] and Zimbabwe [40] compared fewer, more objectively focused prenatal care visits with standard of care. Fewer visits should reduce the cumulative time spent traveling to the clinic and waiting, but satisfaction with these programs varied; satisfaction was increased in patients assigned to fewer visits in Zimbabwe and the US, but British patients reported lower satisfaction and more anxiety about pregnancy progress. Advancing this literature, a recent study in California tested a new model of care (OB Nest) and compared fewer prenatal care visits supported by virtual connections (8 office visits plus 6 telephone or online nurse visits) to twelve standard of care office visits [41] and preliminary results suggested that the program improved patient satisfaction (OB Nest = 95% versus usual care = 77%, p < 0.001) [42]. In very limited resource settings, reducing prenatal care visits has been associated with increased perinatal mortality [43] and American Samoa may not be equipped to facilitate virtual monitoring, so it would be hard to advocate for either of these as an option for improving prenatal care delivery in this setting. One option that may be feasible is group prenatal care. There is a building literature to suggest that nurse/midwife led prenatal care and education, delivered via facilitated discussion to groups of 8–12 women simultaneously, is associated with large improvements in satisfaction, utilization and pregnancy outcomes [23, 44, 45]. In American Samoa offering group prenatal care to ‘healthy’ pregnancies (those with no complications other than overweight) may improve satisfaction and also reduce burden on the practicing physicians, potentially reducing waiting times for others.

There are some limitations to our study. While we used a satisfaction questionnaire that had been previously validated for use in other settings [28] we only identified three specific domains of satisfaction compared to the seven that were extracted in the initial questionnaire development. The reasons why the questionnaire produced fewer domains requires further investigation. Our domains did demonstrate high reliability and good construct validity, but the fact that our final adjusted models explained between 10 and 24% of variation in satisfaction does suggest that there are other aspects of satisfaction that were not captured by the questionnaire. Further qualitative work may be necessary to understand women’s expectations of care and their satisfaction with it. Perhaps most pertinent of the limitations was that the questionnaire was limited in terms of its ability to explore cultural, social or linguistic factors that may be influencing women’s engagement with prenatal care. There is evidence that cultural beliefs about pregnancy and the appropriate provider of prenatal care may influence timing of initiation of care or the type of care Samoan women seek [26], but how these beliefs may influence satisfaction once a patient has enrolled in clinical care is still to be explored. Reports from neighboring independent Samoa have described ‘clashes’ between Westernized medicine and traditional birthing practices which prioritize women’s “social, cultural, and emotional safety” over their “biological safety” [26] but these issues have been little explored in American Samoa.

Similarly, language barriers between patient and provider have been associated with lower satisfaction with care [46]. Prenatal care clinicians in American Samoa are often from outside of the culture and are unfamiliar with the local language. The effect of provider ethnicity/primary language on satisfaction with care should be further explored in new research.

A further limitation was the self-report nature of the questionnaire, which may have introduced bias. Two pertinent issues arose: a lack of detailed information about the severity of pregnancy complications, which may have affected reports of satisfaction and the frequent misreporting of height (implausibility of values) which made it impossible to examine whether overweight or obesity impacted satisfaction or utilization. However, while weight status has been associated with differential prenatal care utilization in other settings [7, 47] we suspect that it is unlikely to be an issue in American Samoa since more than 90% of women are overweight or obese upon conception [8] and there is little stigma attached to pregnancy body size in this setting [48]. A significant strength to our study was the fact that we surveyed women during pregnancy, as opposed to many studies who have asked about satisfaction retrospectively, meaning that we may expect little bias based on birth experiences.

Prenatal care satisfaction is an important determinant of prenatal care utilization and in American Samoa, where many pregnancies are high risk, ensuring adequate utilization of prenatal care services is imperative. This study suggests that there is substantial room for improvement in pregnant women’s satisfaction with prenatal care in American Samoa, and that efforts to improve satisfaction should focus on improving waiting times and clinic accessibility. Further research is necessary to explore other social and cultural factors that may be impacting satisfaction with care and preventing optimal utilization of prenatal care services.