Research has focused on improving access to quality prenatal care in order to reduce the incidence of low birthweight, adverse birth outcomes, and resultant infant mortality. Although satisfaction is a major contributor toward health care utilization, current literature on the subject is limited and often biased. Satisfaction with health care reflects both the patient’s perception of the care and the quality of care itself. Furthermore, utilization of health care is related to a person’s satisfaction with the care. Since minority, low-income women tend to utilize prenatal care services less than well-off, white women, changes in the prenatal care system environment to enhance satisfaction among minority, low-income women may help to bring these women into the health care arena. Information about characteristics of prenatal care related to low income women’s satisfaction might assist designing alterations to the current prenatal delivery system that could increase utilization and ultimately lead to more favorable pregnancy outcomes.

The goal of this pilot study was to investigate the association between characteristics of prenatal care and satisfaction among African American and Mexican-American Medicaid recipients. From 1994 to 1995, pregnant women in Chicago’s managed care program for pregnant Medicaid women were sampled prior to delivery. The study criteria for eligibility consisted of being primiparous, 18 years or older, and born or raised in the U.S. and having at least 3 prenatal visits with the same provider. A twenty-five minute telephone interview was conducted to obtain information on the subject's satisfaction with prenatal care, prenatal care characteristics, and socicodemographic characteristics. From the 1009 initial mailing, a final sample consisted of 101 subjects, 26 were Mexican-American, and 75 were African American.

Among the Mexican-American and African American study subjects who were non-adolescent, primiparas, on Medicaid, and utilized prenatal care services, the majority were less than 30 years of age, unmarried, had at least a high school education, unemployed, and had extremely low income. Furthermore, the majority of the women started prenatal care during the 13 gestational weeks or prior and were interviewed during or before the 28 week. Of the African American women, 27% reported that they had health problems during pregnancy, in contrast to 39% of the Mexican-American women. The Mexican-American women more often reported than African American women that they saw a practitioner other than an obstetrician. African American women were significantly more likely to report the availability of substance abuse services at their prenatal site than Mexican-American women. For African American women, satisfaction was positively correlated with having a white practitioner, while for Mexican-American women, onsite availability of child care and substance abuse services were positively correlated with satisfaction. The major determinant of satisfaction among all the women was whether the practitioner explained the prenatal procedure (contributed to 32% of total variance). Thus, for the Mexican-American women, satisfaction included two variables, whether the practitioner explained the procedure and availability of supplemental services. For the African American women, satisfaction was based upon four variables; whether the practitioner explained the procedure, having a male practitioner, waiting < 30 minutes, and having a white practitioner.

"In times of major change in the health care environment, enhancing satisfaction with care is becoming increasingly important because satisfaction is recognized as both an outcome of care as well a one measure of its quality." The primary determinant of satisfaction with prenatal care was the ability of the practitioner to communicate and less significant but also independently associated with satisfaction were short waiting time, availability of ancillary services, and male gender of the practitioner. However, caution must be taken with generalizing these exploratory results. The subjects represent a very select group of African American and Mexican-American low-income women. The response rate to the mailed survey was only 35%. The eligibility requirement of having at least three prenatal visits prior to interview may have biased the study since women who were satisfied with their care were selected into the study, while dissatisfied women may have left their prenatal care prior to three visits. The potential selection bias may be observed by the high overall satisfaction rate of 74%. Furthermore, the high overall satisfaction rate may possibly reflect the relatively lower expectation of health care access and quality among low-income, minority women. Thus, the study needs to be repeated over a larger sample of pregnant women from a variety of ethnic groups and socioeconomic classes as well as across various provider sites and care arrangements. A non-Hispanic white comparison group is desirable to observe if white women receive or perceive differential treatment and have a different threshold level of expectation than low-income minority women.

An intriguing finding of the study was the increased satisfaction among the subjects who reported having a male practitioner and also increased satisfaction among African American women who saw a white practitioner. This finding may have various interpretations. The women were separately asked to describe the ethnicity of their practitioner and also their satisfaction with care. Thus, although ethnicity and satisfaction are correlated it may not reflect a causal association. Also, if increased satisfaction is due partly to seeing a white practitioner, it may reflect previous experiences of the African American women and society's racist and sexist perception that high quality medical can only be provided by the dominant white male group. However, this study is approximately 5 or 6 years old and our society's perception may be changing with the advent of more minorities and females into the health care delivery system. Despite low generalizability, the study shows the importance of communication with the practitioner as the most significant factor affecting satisfaction among low-income, minority pregnant women.