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Patient Satisfaction with Prenatal Care
Services in a Rural Setting: Time

presented by

Dee Marie Six

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1198 chlRC/DdoDuopGS—p.“

 

PATIENT SATISFACTION WITH PRENATAL CARE
SERVICES IN A RURAL SETTING: TIME

BY

Dee Marie Six

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT

PATIENT SATISFACTION WITH PRENATAL CARE
SERVICES IN A RURAL SETTING: TIME

BY

Dee Marie Six

Adequate prenatal care for rural low income pregnant
women is of concern. One factor identified in the
literature that has been related to decreased prenatal
attendance is dissatisfaction with the amount of time spent
at the office/clinic, which may be affected by the type of
prenatal care provider. The purpose of this secondary data
analysis was to determine if the type of provider [Certified
Nurse Midwife (CNM) or Physician] affects rural low income
pregnant women's satisfaction with the total time spent at
the office/clinic. King's dynamic interacting systems was
the conceptual framework utilized in this study. Women
receiving care from the CNM spent a longer total time at the
office/clinic despite no significant difference in
satisfaction with total time spent at the office/clinic by
provider type. One significant difference did occur: women
who spent less time at the office/clinic (less than or equal
to 30 minutes) were more satisfied with the total time spent
at the office/clinic than women who had a greater length of
time (> 30 minutes). Information from this study can assist
the Advanced Practice Nurse to enhance issues of

satisfaction with prenatal care services.

This study is lovingly dedicated to my husband, Bryan,

and my children, Jacob and Samuel.

iii

ACKNOWLEDGMENTS

This author gratefully acknowledges the skilled
guidance of Mildred A. Omar, RNC, PhD. Her dedication and
perseverance to produce a quality product is greatly
appreciated. Diane Krasnewich was an integral part in
assistance with the statistical analysis. Her time and
effort was invaluable. Thanks is also due to Rachel
Schiffman, RN, PhD, and Jacqueline Wright, RN, MSN, for
their collaborative assistance.

This author would also like to distinguish the
insurmountable love and patience from family and colleagues
while awaiting the completion of this project, without whom

it would not have been possible.

iv

TABLE OF CONTENTS

LIST OF TABLES . . . . . . . . . .
LIST OF FIGURES . . . . . . . . .
INTRODUCTION . . . . . . . . .
Background of the Problem . . . . . .
Statement of the Problem . . . . . .
Research Questions . . . . . . . .
Importance of Study . . . . . . . . .
Conceptual Definitions of the Variables

Type of Provider . . . . . . . . .
Physician Prenatal Care Providers

Certified Nurse-Midwife Prenatal Care Providers

Total Time Spent at the Office or Clinic Visit .

Satisfaction With the Prenatal Care System: Total

Time Spent at the Office/Clinic .
Conceptual Framework . . . . . . . .

Review of the Literature . . . . . .

Satisfaction with Time: Healthcare 8
Satisfaction with Time: Prenatal Care System
Prenatal Care System: Satisfaction with Total
Amount of Time spent at the Office/Clinic by

Type of Provider . . . . . . . .
Critique of the Literature Review

Methods . . . . . . . . . . . .

Research Design . . . . . . . . .
Sample . . . . . . . . . . . . . .
Setting . . . . . . . . . . .

Operational Definitions of the Variables

Instrumentation . . . . . . . . .
Data Analysis . . . . . . . . . .
Research Assumptions . . . . . . .

stem

QQQO‘O‘ 0|

\0

11

14
15
16

20
22

24
24
25
26
26
28
29
3O

Results . . . . . . . .

Discussion . . . . . . . . .

LIST OF REFERENCES . . . . . . . . . . . .

TABLE OF CONTENTS (cont.)

Research Limitations . . . . . . . . . .
Protection of Human Subjects . . . . . . .

Description of Sample . . . . . . . . . .
Analysis of Research Questions . . . . . . .

Sample . . . . . . . . . .
Total Time Spent at the Office/Clinic . . . .
'Satisfaction with Total Amount of Time Spent
at the Office/Clinic . . . . . . . . . .
Discussion of Results within the Conceptual
Framework . . . . . . . . . . . . . . . . . .
Implications for Advanced Practice Nursing in
Primary Care . . . . . . . . . . . . . . . .
Recommendations for Further Research . . . . .
Summary . . . . . . . . . . . .

O O O O

30
30

31
31
33
34
34
37
37
39
42
43
45

47

APPENDICES .

Appendix A: Patient Satisfaction with Prenatal Care
Instrument . . . . . . . . . . . . . . .

Appendix B: Procedures for Data Collection . . . . .

Appendix C: UCRIHS Approval . . . . . . .

Appendix D: Alpha Reliabilities and Factor Loading
for the Dimensions of the Satisfaction
with the Prenatal Care Delivery System
Scale of the PSPC II Instrument . . . .

vi

Table

Table

Table

Table

LIST OF TABLES

Page

Frequencies of Sample Demographic Variables by
Provider Type . . . . . . . . . . . . . . . . . 32

Crosstabulation of Total Time Spent at the
Office/Clinic and Provider Type . . . . . . . . 34
Analysis of Variance of Patient Satisfaction
with Total Time Spent at the Office/Clinic
and Type of Provider . . . . . . . . . . . . . 35
Means Score for Interaction Effects of Total

Time Spent at the Office/Clinic and type of
PrOVider O O O O O O O O O O C O O O O O O O O 35

vii

LIST OF FIGURES

Page

Figure 1: An Adapted Conceptual Framework for
Satisfaction with the Prenatal Care System:
Dynamic Interacting Systems . . . . . . . . . 13

Figure 2: A Revised Conceptual Framework for

Satisfaction with the Prenatal Care System:
Dynamic Interacting Systems . . . . . . . . . 40

viii

INTRODUCTION

Background of the Problem

Prenatal care is recognized as the cornerstone of
preventive health care for the pregnant woman (Kogan,
Alexander, Kotelchuck, Nagey, & Jack, 1994). Yet, in spite
of the recognized value of prenatal care, some women still
receive less prenatal care than what is currently
recommended (York, Williams, & Munro, 1993). Various
factors influence lack of continuity of prenatal care
(Higgins, Murray, & Williams, 1994). One factor cited is
women's dissatisfaction with the total time spent at the
prenatal visit (Oakley, 1992; York et al., 1993). Time has
been identified as a factor influencing women's satisfaction
with the prenatal care system (Oakley, 1992). The provider
type, certified nurse midwife or physician, may affect the
length of time spent at the office, which in turn, may
affect the degree of patient satisfaction with prenatal
care. The longer the wait to be seen by the provider, as
well as the total time spent at the office or clinic the
woman has for her prenatal visit, may influence the woman's
decision to return for scheduled prenatal visits to the
office or clinic (Oakley, 1992). The amount of time spent

at the prenatal visit may be a barrier to care for rural

1

2
women, especially if they are traveling great distances for
prenatal care services. Identifying factors which promote
satisfaction with the delivery of prenatal care services
could favorably affect enrollment in the utilization of
prenatal care.

The concept of patient satisfaction with prenatal care
has been linked with prenatal care utilization.
Dissatisfaction with the delivery of prenatal care services
may occur with time spent waiting to be seen and the total
time spent at the office or clinic if the woman is losing
work time. The total amount of time a woman is gone from
her job may result in a loss of income (Minden, 1994). For
low income women, this may be substantial. Child care may
add an additional cost with an extended wait in the office
or clinic (Tranter, 1989). Due to child care costs, loss of
wages, and limited resources rural low income women may deem
that the amount of time spent at the prenatal office or
clinic is unacceptable and, therefore, choose not to receive
consistent prenatal care (Barger, 1990).

The amount of time spent waiting to receive prenatal
care is often lengthy in underserved rural areas (Barger,
1990). Rural areas suffer from limited health care
resources, including prenatal care providers (Barger, 1990).
Many rural areas have few, if any obstetricians, who provide
prenatal care (Knoll, 1990). Prenatal care for rural women
is often provided by family or general practice physicians

or certified nurse midwives (CNMs). Certified nurse

3
midwives are able to provide comprehensive prenatal care to
women, including attending the delivery of the infant
(Knoll, 1990). Satisfaction with the amount of time spent
waiting to be seen by the provider may be influenced by the
type of prenatal care provider, i.e., physician or CNM (York
at al., 1993). A patient waiting to be seen by a certified
nurse midwife may have an increase in total time spent with
the patient. It is important to understand rural low income
pregnant women's perception of satisfaction with the
prenatal care delivery system, especially the total time
spent at the office or clinic by provider type (physician or
CNM), because patient satisfaction has been correlated to
compliance and continuity of care.

The purpose of this study, using a secondary data
analysis, was to: a) describe low income women's perception
of the total time spent at the office or clinic and their
satisfaction with their total time spent at the office or
clinic; b) compare pregnant women's satisfaction with total
time spent in the office or clinic by type of provider
(certified nurse midwife or physician) with total amount of
time spent at the office or clinic; and c) determine if an
association exists between total amount of time spent at the
office or clinic, type of prenatal care provider, and
satisfaction with total amount of time spent at the office
or clinic for rural low income pregnant women in Benzie
County, Michigan. This may provide reliable information to

enhance prenatal care utilization.

4
Statement of the Problem

There exists an underutilization of prenatal care
services in Benzie County for 1994 with 34% of women
receiving less than adequate prenatal care (KIDS COUNT in
Michigan, 1994; MDHP, 1994). It has not been determined
what factors may have prohibited these women from obtaining
adequate prenatal care. Even when financial and
transportation barriers were removed, some women still did
not receive adequate prenatal care. One implied reason may
be a woman's dissatisfaction with the delivery of prenatal
care services, especially the total amount of time spent at
the office or clinic (Lia-Hoagberg, Rode, Skovhalt, Oberg,
Berg, Mullett, & Choi, 1990).

Benzie county is located in Northwestern Michigan
having a population of 12,200 in 1994, with 152 registered
number of live births (KIDS COUNT in Michigan, 1994, MDHP,
1994). Benzie County has no inpatient facility for women to
deliver. Women who are receiving prenatal care from general
practice physicians in Benzie County must transfer care
early in the third trimester to another prenatal care
provider in a nearby county. All women who receive care
from the nurse-midwifery services also must travel to the
nearby county for their entire prenatal care. This may
increase the pregnant woman's time spent at the office or
clinic and influence the woman's satisfaction. By
understanding the woman's satisfaction with the total amount

of time spent in the office or clinic, the prenatal care

5
system can address issues to better_meet the needs of the
women they serve.
Research Questions

1. Is there a difference between rural low income pregnant

women's perception of the total amount of time spent at

the office or clinic when seen by certified nurse

midwife providers as compared to physician providers?
2. Is there an association between type of provider, the

- total amount of time spent at the office or clinic, and
satisfaction with the total time spent at the
office/clinic for prenatal visits?
Importance of the Study

Adequacy of prenatal care is of great importance to the
advanced practice nurse (APN). When providing prenatal care
services, it is imperative to acknowledge women's
satisfaction with prenatal care. If an association exists
between total time spent in the office or clinic and level
of satisfaction, the prenatal care provider can address this
issue within the prenatal care system. Reduction of
unnecessary lengthy waiting periods before being seen by the
provider and/or reduction of total time spent at the office
or clinic may be one way to address the delivery of prenatal
care. Addressing the contributing factors that lead to
dissatisfaction with the total time spent at prenatal visits
may change pregnant women's perceptions. If a woman
believes that the provider and prenatal care system value

her time, she may be more satisfied and thus receptive to

6
receiving prenatal care resulting in adequacy of care with
an increased opportunity for risk assessment and health
promotion. The purpose of this study was to add to the body
of knowledge by examining if there was an association with
total time spent at the office/clinic, type of provider, and
level of satisfaction. The APN working with rural low
income pregnant women may use this information to help
promote attendance of prenatal care. This could be achieved
by discussing with pregnant women provider options and
issues regarding time in the delivery of prenatal care
services.
Conceptual Definitions of the Variables

This section includes the conceptual definitions of the
study variables. The conceptual model using King's 1981
interactive model is described.
WI

For the purpose of this study, the type of provider was
defined as either a physician or a certified nurse-midwife.
All providers of prenatal care fulfill the requirements to
deliver prenatal care according to the standards set by the
American College of Obstetricians and Gynecologists
(Merkatz, Thompson, Mullen, & Goldenberg, 1990), as well as
the providers own specialties, i.e., American Academy of
Family Practitioners or the American College of Nurse
Midwives (Freemont & Poland, 1992; Yankov, Peterson, Oakley,
& Mayes, 1993). Yet each provider type has certain innate

differences (Knoll, 1990).

7

MW. A physician is a
person who has successfully completed the prescribed course
of studies of medicine in a medical school officially
recognized by the country in which it is located. This
individual has acquired the requisite qualifications for
licensure in the practice of medicine (Merkatz et al.,
1990). Physicians follow the medical model when caring for
patients. They diagnose and treat the condition. They may
not always look at the patient as a holistic individual that
is affected by her environment. For the purpose of this
study physician prenatal care providers were defined as
anyone who is licensed to practice medicine in the state of
Michigan who care for and treat women's conditions during
pregnancy as well as any complications of the prenatal and
postnatal periods. This provider group includes general
practitioners, family practitioners, and obstetricians.

C2IIiiiad_nnISB:midWiie_DI£naIal_£dnfi_nZQMid2ns. For
the purpose of this study a certified nurse-midwife was
defined as a registered nurse who independently manages the
care of mothers and babies throughout the maternity cycle,
including the postpartum period (Merkatz et al., 1990). The
certified nurse-midwife attains the knowledge and skill
required to provide this service via an organized program of
study that is recognized by the American College of Nurse
Midwives (Merkatz et al., 1990). Their scope of practice is

recognized to be that of healthy, uncomplicated pregnancies,

8
as well as care of non-pregnant women seeking gynecological
services.

. Certified nurse-midwives practice collaboratively with
physicians and other members of the health care team
according to standards defined by the American College of
Nurse Midwives (Knoll, 1990). The philosophy of the
certified nurse-midwife is to encompass safety for women and
infants, competent care, client and family participation in
the health care process, and patient satisfaction (Knoll,
1990). The certified nurse-midwife utilizes the nursing
model when caring for patients, viewing them as holistic
individuals interacting within their environment. They
often spend increased time with patients during office
visits for education and counseling services. The goal of
the certified nurse-midwife is to promote wellness and
prevent illness (Knoll, 1990).

T! 11. S ! Ill :EE' :1. . Hi 'I

Time, according to Taber's Cyclopedic Medical
Dictionary (Thomas, 1990), is the interval between beginning
and ending. The theory of patient time spent at the office
or clinic began as a queuing theory that today is applied to
service many different businesses (Minden, 1994). The
management of the patient's perception of total amount of
time spent at the office/clinic can greatly affect one's
satisfaction (Minden, 1994). For the purpose of this study,
the degree, or measured duration, in minutes, the rural low-

income pregnant woman spent in the office or clinic for

9
prenatal care, was defined as the total time spent at the
office or clinic visit. The beginning was initiated by the
first contact with the receptionist and was concluded with
the exit from the office or clinic. Total time spent at the
office/clinic consists of all of the interactions that take
place within the processes of the prenatal visit. This
includes interactions with all members of the healthcare
team, and is affected by: a) the pregnant woman's own
availability in leading her own individual lifestyle, travel
time, time away from work, childcare; b) the availability of
the prenatal care provider; and c) the availability and

responsiveness of the prenatal care system.

0. ‘ Q Q‘ ' -.. . . ‘ ‘u' o . ;uo . o

Satisfaction of the patient is an important criteria
for successful care (Minden, 1994). To better understand
the concept of patient satisfaction one must know how it is
defined. “Human satisfaction is a complex concept that is
related to a number of factors including lifestyle, past
experiences, future expectations, and values of both the
individual and society” (Carr-Hill, 1992, p. 237). Patient
satisfaction is described as the patient's perceptions based
on a set of expectations that are derived from beliefs about
ideal or anticipated care (Hsieh & Kagle, 1991). According
to Hoptom, Howie, and Porter (1993), patient satisfaction is
the evaluation, by the patient, of the different care

received. Patient satisfaction has also been defined as a

10
practical gauge to measure effectiveness and efficiency of
care (Alexander, Sandridge, & Moore, 1993).

Organizational features associated with antenatal care
have been singled out as an important aspect of the user
perspective in many studies (Oakley, 1992). Patient
satisfaction with the system has been described as a
disconfirmation paradigm. This paradigm links the patient's
attitudes and feelings with satisfaction. Confirmation and
disconfirmation are terms used to describe the outcome of a
service encounter (Thompson & Yarnold, 1995). According to
this paradigm, patient satisfaction is determined by the
magnitude and direction of the gap between the patient's
expectations and perceived satisfaction of care received
(Thompson & Yarnold, 1995). A factor that has been
identified in the literature relating to satisfaction with
the prenatal care system is lengthy time spent in the
office/clinic (Kojo-Austin, Malin, & Hemminki, 1993). Some
feelings that affect satisfaction of total time spent at the
office or clinic are unoccupied time, anxiety, unexplained
waits, unfair waits, and value of the service (McComas,
Kosseim, & Macintosh, 1995). For the purpose of this study
patient satisfaction with total time spent at the office or
clinic was defined as the pregnant woman's positive or
negative attitude and feelings toward the total amount of

time spent at the office or clinic.

11
Conceptual Framework

-King's dynamic interacting systems was the conceptual
framework utilized in this study. The goal of King's
systems framework is helping pregnant women maintain their
health. King's (1981) framework for nursing is based on
several assumptions regarding individuals as perceiving
beings. One of King's assumptions about human beings is
that they are open systems in transaction with the
environment (prenatal care delivery system). Another
assumption is that the prenatal care delivery system is an
organized boundary system of social roles, behaviors, and
practices developed to maintain values and the mechanisms to
regulate the practices and rules (King, 1981).

King's conceptual framework is based upon three
interacting systems: personal systems, interpersonal
systems, and social systems (King, 1981, 1992). Each system
has specific goals, needs, and values that affect the
interaction process. The focus of this study was on the
interaction process of the personal system and the social
system. The personal system is comprised of the rural low
income pregnant women. The social system consists of the
prenatal care delivery system (total amount of time spent at
the office/clinic) and the type of provider of prenatal care
(certified nurse-midwife/physician).

The permeable boundaries of King's framework exhibit
the interaction the pregnant woman has with her environment

(King, 1992). The broken lines represent this interaction

12
with the other systems (Figure 1). The arrows represent the
openness of the systems to one another. To achieve goal
attainment (adequacy of prenatal care utilization, the
elements of satisfaction with total time spent at the
office/clinic must be addressed within the personal system
(pregnant woman) and the social system (prenatal care
delivery system).

The major concept related to the personal system is
perception (King, 1992). The social beings in this system
are the rural low income pregnant women. The pregnant woman
has perceptions that give meaning to her prenatal
experience, represent her image of reality, and influence
her behavior. The rural low income pregnant woman's past
experience with the prenatal care system, and her
perceptions of her needs, goals, and values of prenatal
care, may influence her behavior. She may bring positive,
negative, or both positive and negative perceptions with her
into the prenatal care system.

The social system is an organized boundary system of
social roles, behaviors, and practices developed to regulate
practices and rules (King, 1981, 1992). In this system,
human beings have defined roles. In the prenatal care
system, the concept of power is the ability to control
events, such as the total amount of time spent by women to
receive prenatal care. In the social system, the concept of
power is the ability to reduce resistance and use, and to

mobilize resources to achieve goals, one being consumer

13

Social Systems \

(Society)

Prenatal Care System: Total Amount of Time Spent
atthe Office/Clinic

Interpersonal System
(Groups)

K Personal Systgm— |
| (Individuals) I I

:3 l
I Rural Low Income |
: Pregnant Women I |
I

-— -.- — -.- — —1
| Satisfaction/ u
Pimatiéizctier‘.

Eignzg_1. Adapted Conceptual Framework for Satisfaction
with the Prenatal Care System: Dynamic Interacting Systems.
From I.M. King, A Theory for Nursing: Systems, Concepts,
Process. New York: John Wiley & Sons, 1981, p. 11.

14
satisfaction with services. With the pregnant woman's
satisfaction with the total amount of time she spends to
receive prenatal care, she may recognize, accept, and keep
the recommended prenatal visits. The prenatal care delivery
system is a social system with power to control resources
and access to prenatal care to pregnant women. The
resources within the prenatal care delivery system include
the prenatal care provider and access within the prenatal
care delivery system include the prenatal care provider and
access within the prenatal care delivery system and the
availability and responsiveness of the prenatal care system
in directing the total amount of time spent at the office or
clinic. The members of the prenatal care delivery system
need to be aware of the impact they have on the pregnant
woman and help her achieve the goal of consumer
satisfaction. They may do so by keeping her informed of
delays, update her educational needs to fit her situation,
and allow her to schedule times that may best fit her
schedule (see Figure 1).
Review of the Literature

There is limited literature which examined patient
satisfaction with prenatal care in rural settings with low
income women in general and total amount of time spent at
the office/clinic specifically. There have been, however,
some studies which examined satisfaction with total amount
of time spent at the office/clinic with the health care

system, including the prenatal care delivery system

15
(Alexander et al., 1993; Minden, 1994). Time emerged as a
recurrent variable affecting satisfaction with prenatal care
(Buhler, Glick, & Scheps, 1988; Heins, Nance, Webster,
McCarthy, & Efird, 1990). These studies are reviewed
followed by a critique of the existing literature.

A study by Minden (1994) identified two elements
related to satisfaction with amount of wait time. Data were
collected by survey in an office setting with dental
patients. Clients were satisfied when waiting time was kept
under 13 minutes and when scheduling of routine appointments
occurred in less than two weeks. The study findings
supported that when access problems were controlled for,
such as waiting time and scheduling, the total amount of
time spent in the office was reduced and patient
satisfaction increased.

The total time spent in a health care visit was a
recurrent concern among pediatric patients in a study by
McComas et al. (1995). Patient dissatisfaction with waiting
time was perceived as: a) long unoccupied waiting time; b)
pre-processing waiting time; c) unexplained waiting time; d)
indefinite waiting time; and e) unfair waiting time (when
newly arrived patients were seen before those already
waiting). McComas et al. (1995) also reported that the more
valuable the clients perceived the service, the longer they

were willing to wait. Even when total time remained short,

16
a violation of any of these perceptions resulted in
dissatisfaction.

Numerous factors have been stated to directly affect
patient satisfaction in the literature, one being amount of
time spent at the prenatal office or clinic (Buhler et al.,
1988; Heins et al., 1990; Rowley, Hensley, Brinsmead, &
Woldarczk, 1995). These studies concluded that an increased
amount of time spent in the office or clinic often
contributed to a decrease in patient satisfaction.

Two studies (Alexander et al., 1993; Seguin, Therrien,
Champagne, & Larouche, 1989) examined the concept of total
time spent in the office for prenatal care and its
association with patient satisfaction. Both studies
identified that a lengthy total time decreased the degree of
satisfaction with prenatal care. Neither addressed the
significance of satisfaction with total time or pursued its
relevance any further. One of the limitations of these
studies was that satisfaction with prenatal care was
determined postpartally. Alexander et al. (1993) and Seguin
et al. (1989) have indicated that patient satisfaction with
prenatal care measured retrospectively, e.g., after the
delivery, may not accurately reflect true satisfaction with
prenatal care, rather the birth outcome may influence the
level of satisfaction reported.

Oakley (1992) identified that lengthy total time spent

at the office was a negative influence on satisfaction in a

17
study of women's attitudes toward antenatal care. In this
study the researcher attributed a decrease in kept
appointments with dissatisfaction with long waits. A study
by Mellor and Chambors (1995) of 52 antenatal women, stated
that a lengthy total wait time may negatively affect women's
satisfaction with prenatal services received. Both of these
studies identified a lengthy total time spent at the office
as a possible causative factor in pregnant women's decreased
satisfaction with prenatal care. Both, however, failed to
determine the statistical relevance of the variable of total
time with respect to satisfaction with prenatal care.

A study conducted by Omar and Schiffman (1995) examined
components of pregnant women's perceptions of prenatal care.
This study addressed satisfaction with the prenatal care
delivery system. One focus was directed to specific aspects
of the office or clinic environment where the women received
prenatal care services. The dimensions that the pregnant
women identified as important to their satisfaction or
dissatisfaction with the prenatal care delivery system were:
a) healthcare provider consistency; b) accessibility and
scheduling; c) waiting time; and d) other services provided.
Of the four dimensions, waiting time was identified as the
major source of dissatisfaction. Results revealed that
pregnant women spent between thirty minutes to three hours
at the prenatal care office or clinic. Women reported more

satisfaction with total time if they really liked their

specific provider. They admitted, however, that they were
still dissatisfied by having to wait a long period of time.

A study conducted by Dennis, Flynn, and Martin (1995),
found that the longer amount of time that the pregnant women
had to wait for the doctor, the less likely they were to
look forward to their prenatal care visits. Dennis et al.
(1995) stated that the increased patient wait time, median
amount of 19 minutes, extended the total time spent in the
office or clinic and resulted in patient dissatisfaction
with prenatal care.

Kojo-Austin et al. (1993) examined pregnant women's
views and waiting experiences with prenatal care. Of the 61
women interviewed, the majority of the women in this study
(n=56) reported long time spent at the office or clinic was
a negative aspect of the prenatal clinic. Results indicated
that longer times spent at the office or clinic for the
women produced dissatisfaction with the prenatal care
system. The authors suggest that the women's
dissatisfaction with the prenatal care system leads to
decreased compliance and subsequently less prenatal care,
but had no data to support this hypothesis.

When relating pregnant women's patient satisfaction
with total time and expectations, Thompson and Yarnold
(1995) hypothesized that pregnant women were least satisfied
when the total time spent at the office or clinic was longer
than they had expected. The data from the study (n=1,574

pregnant women) supported the hypothesis and also revealed

19
that pregnant women were relatively satisfied when total
amount of time spent at the office/clinic was perceived as
equal to their expectations, and highly satisfied when total
time spent was shorter than expected. An overall measure of
perceived total amount of time spent at the office/clinic
and its asspication with expectations revealed a moderate
association of satisfaction with total time spent at the
office or clinic. Del Mar and O'Connor (1994) reported
similar findings in a retrospective study collected one to
two days postpartum by a survey with 288 postpartum women.
These authors reported that women valued having a
sufficiently short time spent at the office or clinic to
receive prenatal care.

In conducting an analysis to reduce the patient wait
time for prenatal care services, Tranter (1989) found that
prolonged patient waits resulted in fraying tempers and
frustrated staff. In efforts to reform the prenatal care
clinic various scheduling changes were instituted. These
included amalgamating visits such as the history portion
with the medical examination and eliminating unnecessary
visits such as the history portion with the medical
examination and eliminating unnecessary visits in normal
healthy pregnancies. The changes were implemented in a four
phase process which significantly reduced the total time
spent at the prenatal clinic for care. Results revealed a
decrease in the number of complaints as well as an increase

in the number of scheduled prenatal appointments kept

20
(Tranter, 1989). Pregnant women perceived their prenatal
visits were more purposeful. The overall outcome was that

the degree of patient satisfaction with the prenatal care

services increased.

.. '. . - .. ‘u'. . . o. , 0 o :. .‘,||O . o n

Having a shortage and maldistribution of prenatal care
providers may directly affect the amount of time a woman
spends for a prenatal care visit, particularly for women
residing in rural areas (Knoll, 1990). In a study comparing
certified nurse-midwives (n=1,759) and family/general
practice physicians (n=1,179) in the provision of prenatal
care services, results indicated there was less overall
total amount of time spent at the office/clinic when
prenatal care was delivered by physicians as the provider as
compared to certified nurse-midwives. Women had the longest
overall total amount of time spent at the office/clinic when
seen by obstetricians as compared to family and general
practice physicians. The mean length of the total time for
the CNN was 23.7 minutes, with 6 minutes spent on education
and counseling and 2.5 minutes in family centered
activities. The study was limited due to the lack of
determination of how time was spent with the physician
providers. The study concluded that patient satisfaction
was'increased with the total time spent at the office or

clinic when the prenatal provider was a certified nurse

midwife.

21

In the study by Gravely and Littlefield (1992), it was
found that increasing the availability of low-risk prenatal
care professionals through use of non-physician maternal
health providers, with a physician available for
collaboration, decreased the amount of time spent waiting to
be seen by the prenatal care provider and decreased total
time spent at the office/clinic. The results found that
women who were seen by certified nurse-midwives as their
prenatal care providers had less patient wait time, which in
turn increased continuity of care and compliance.

Ultimately the decreased patient wait time with the
certified nurse-midwife as the provider resulted in an
increase in satisfaction of the pregnant woman despite an
increase in total time spent at the office.

In_a study where women received prenatal care from
either a general practitioner or‘a certified nurse-midwife,
results revealed that the majority (n=52) preferred the
individualized appointment system that the certified nurse-
midwives utilized compared to the lengthy wait of the
general practitioners, even when they were seen for the same
amount of time by both types of providers (Mellor &
Chambers, 1995). Results from this study revealed an
increase in satisfaction with prenatal care and the total
time when the pregnant woman was seen by a certified nurse-

midwife for prenatal care.

22
W

There remain many issues that can contribute to
pregnant women's satisfaction with prenatal care. As
evidenced by the review of the literature, the recurrent
theme of total time spent in the office/clinic exists and
has some influence on patient satisfaction with prenatal
care, such that the more lengthy the total time spent at the
office/clinic, the less satisfied the pregnant woman was
(Kojo-Austin et al., 1993; Omar & Schiffman, 1995; Thompson
& Yarnold, 1995; Tranter, 1989). Only one study addressed
actual amount of time in minutes (Dennis et al., 1995). In
spite of total amount of time spent at the office/clinic
being identified as a factor of patient satisfaction with
the prenatal care delivery system, few studies utilized the
data for further analyses. Most studies simply stated that
total time spent at the office or clinic was identified as
part of the patient's concern or complaint when questioned
regarding patient satisfaction with prenatal care but did
not address it any further (Mellor, 1995; Oakley, 1992;
Petitti, Hiatt, Chinn, & Crougham-Minihane, 1991).

Other limitations of the studies were the retrospective
versus prospective nature of some of the studies (Alexander
et al., 1993; Del Mar & O'Connor, 1994; Kojo-Austin et al.,
1993; Seguin et al., 1989). Retrospective studies have been
shown to skew the data due to the halo effect since women

were reluctant to criticize the professional who provided

23
care for them, especially if the outcome was positive
(Alexander et al., 1993).

The lack of an adequate measurement tool limited
adequate analyses of satisfaction of prenatal care
(Alexander et al., 1993; Seguin et al., 1989). In some
studies, instruments that measured prenatal care were either
not identified, lacked psychometric analysis, or were
included as part of the patient's overall satisfaction with
perinatal care (Omar & Schiffman, 1992). Other limitations
were the lack of generalizability due to the majority of
studies done with middle/upper class women (Kojo-Austin et
al., 1993; Oakley, 1992; Seguin et al., 1989), as well as
small sample size (Omar & Schiffman, 1995).

There exists a need for further research of pregnant
women's satisfaction with the prenatal care services with
attention to rural low income pregnant women. The
information provided can assist in addressing issues related
to total amount of time spent at the office/clinic for this
population. The total time spent at the office or clinic,
if lengthy, can be inconvenient and decrease pregnant
women's satisfaction with prenatal care services. The
findings may provide a greater understanding for rural
communities, as they strive in their planning to improve
delivery of prenatal care services to improve adequacy of

prenatal care.

24
Methods
Reseamnesign

.The research design was a descriptive study of rural
low income pregnant women's perceptions of total amount of
time spent at the office/clinic and satisfaction with the
amount of time closest to the total amount of time spent at
the office or clinic visit by type of provider through a
secondary analysis of data previously collected by Omar,
Schiffman, and Bauer (1995) using the Patient Satisfaction
with Prenatal Care (PSPC) Instrument (Appendix A). The
purpose of this study was to describe the women's
satisfaction with the prenatal care system on one dimension,
waiting time, which included the total amount of time spent
at the office or clinic.

In the original study by Omar et al. (1995), women's
perceptions cf barriers, expectations about prenatal care,
satisfaction with prenatal care, prenatal care utilization,
and maternal and infant outcomes were evaluated in a sample
of 61 rural low income pregnant women in Benzie County,
Michigan. Three major satisfaction themes were addressed:
satisfaction with the prenatal provider, satisfaction with
the prenatal staff, and satisfaction with the prenatal care
system. The researchers recruited the participants from
childbirth education classes, three rural health
departments, and from private physicians' and CNMs' offices
and clinics. Data were collected between June, 1994, and

July, 1995. The PSPC instrument was developed by Omar and

25
Schiffman (1992) to measure patient expectations of and
satisfaction with prenatal care and prenatal care services.
See Appendix B for description of the data collection
procedures for the original study.
We

The sample for this study consisted of rural, low
income pregnant women, 35 of whom received prenatal care
from physician prenatal care providers, and 25 women
received prenatal care from certified nurse-midwives. The
original sample consisted of 61 low income pregnant women
residing in Benzie County, Michigan, and currently enrolled
in prenatal care services. Sixty-two women were approached
for inclusion in the study, result in a 98% participation
rate. For the purpose of this study 60 women for whom
complete data was available comprised the final sample for
the present study. One woman was excluded from the study
due to the fact that she identified that she saw both
provider types equally.

Inclusion criteria for the original study were: a)
third trimester of pregnancy with at least three prenatal
care visits; b) demonstration of literacy with the English
language; c) resident of Benzie County, Michigan; and d)
designated as low income status by meeting eligibility
criteria for Women, Infants, and Children (WIC) program,

which is at or below 185% poverty level (Omar et al., 1995).

26

Setting

The rural county used in this study has been designated
as a medically underserved area. The county has one
hospital, but obstetrical deliveries are no longer provided;
therefore, all women must travel out of the county for
prenatal care after 28 weeks gestation and for delivery
services. Some women traveled in excess of 100 miles round
trip (average of 64 miles) to receive prenatal services.
0 ll 1 E E' 'l' E I] M . l]

T¥DE_Q£_DIQ¥idez. The type of provider was defined as
the provider the pregnant woman identified on item number 87
of the Patient Satisfaction with Prenatal Care (PSPC)
Instrument (Appendix A) as the provider seen most often for
prenatal care. If the patient was seen by more than one
provider, she was instructed to choose the provider that she
saw most often. The provider type choices were: 1) doctor;
2) nurse-midwife; 3) nurse practitioner; 4) doctor and
nurse-midwife/nurse practitioner about the same number of
times; and 5) do not know (Omar & Schiffman, 1994). For the
purpose of this study, type of provider was defined as
doctor or nurse midwife since the women in this study did
not choose any of the other options. Since type of
physician provider was not identified in the PSPC, the
provider could have been any physician who provided prenatal
care, i.e., general or family practitioner, or obstetrician.

SaLiStdQIiQn_With_Lhe_2L§naLa1_£a:&_SY§I§m1_TQIal

WWW Patient

27

satisfaction with total amount of time spent at the
office/clinic was defined using one dimension of the
satisfaction with prenatal care system scale of the PSPC
instrument and consisted of one item on the PSPC instrument,
item 71. Item 71 addresses the total amount of time spent
at the office/clinic (Omar & Schiffman, 1994). This item
ascertains hbw satisfied the women are with the prenatal-
care system with respect to total amount of time spent at
the office/clinic. The scores indicate a degree of
satisfaction that the women have with their total amount of
time spent at the office/clinic, with a possible range from
1 (West) to 6 (W)-

W. Total
amount of time spent at the office/clinic was defined using
item 103 on the PSPC Instrument which elicits the amount of
time closest to the total amount of time the woman usually
spends at her clinic or office visit. Choices of total
amount of time spent at the office or clinic visit were: a)
less than 15 minutes; b)15-30 minutes; c) 31-45 minutes; 46-
60 minutes; e) 61 minutes_to 2 hours; and f) more than 2
hours (Omar & Schiffman, 1994). Total time spent at the
office/clinic was categorized into a dichotomous variable,
less than or equal to 30 minutes or over thirty minutes for

adequate numbers within each cell for meaningful analysis to

be done.

28
Instmmentatinn

The PSPC instrument was designed for use with subjects
at or below a sixth grade reading level and is a 108 item
self-report questionnaire using a six point Likert-type
scale (Omar & Schiffman, 1994). The primary co-
investigators developed the Patient Satisfaction with
Prenatal Care (PSPC) instrument as a measure of patient
expectations of the satisfaction with prenatal care.
Responses on the PSPC range from 1 (strongly_agree) to 6
(strong1¥_disagree). The PSPC contains five scales:
motivation, expectations, satisfaction with the provider,
satisfaction with the staff, and satisfaction with the
prenatal care system. The satisfaction with the prenatal
care system scale factored into four dimensions: access,
time, facilities, and organization. The subscale, time, was
utilized for this study and contains two items: satisfaction
with amount of waiting time to be seen by the provider, and
satisfaction with the total amount of time spent at the
office/clinic. Only one question relating specifically to
the total amount of time spent at the office/clinic was used
from the satisfaction with prenatal care system scale for
this study.

The PSPC Instrument has demonstrated acceptable
internal consistency of the scales (Appendix D). The alpha
reliability for the satisfaction with the prenatal care
system ranges from .78 to .90, with the time subscale having

the highest reliability at .90.

29
mm

Data analysis was done using the SPSS/PC+ computer
program. Demographics included on the PSPC instrument to
describe the sample were: age, race, marital status,
insurance type, work status, and the total number of times
the woman was pregnant. The gender of the provider was also
ascertained. Descriptive statistics, such as frequencies
and measures of central tendencies, were used to describe
the sample, the total amount of time spent at the prenatal
office or clinic, the provider type, and satisfaction with
the total amount of time spent at the office/clinic. Data
were computed for satisfaction with the prenatal care system
scale; time for both groups of providers.

Research_QuestiQn_1. Is there a difference between
rural low income pregnant women's perception of the total
amount of time spent at the office or clinic when seen by
certified nurse-midwife providers as compared to physician
providers? A 2 x 2 cross tabulation with chi square test
for homogeneity was used with two categories of providers
and two categories of time to determine if a proportional
difference existed.

Research_Qnestion_2. Is there an association between
type of provider, total time spent in the office/clinic, and
satisfaction with total time spent at the office/clinic for
prenatal visits? To answer research question 2, a factorial
analysis of variance was used to analyze the association

between type of provider, total time spent at the

30

office/clinic, and satisfaction with the total time spent at
the office/clinic. The dependent variable was the
satisfaction score for item 71 on the PSPC instrument. The
first factor was the two categories of providers, and the
second factor was the two total time spent at the
office/clinic categories. A level of significance
established at 0.05 was utilized for data analysis.
WM

There were two assumptions in this study. First, it
was assumed that the women understood the questionnaire and
answered the questions honestly. Second, it was assumed
that all data were accurately entered.
E l I' 'l l'

Several limitations are evident in this study. Having
a small sample size and lack of random sampling limit
generalizability. Using only one item on the PSPC to
measure satisfaction with total time spent in the
office/clinic may not have been the ideal measure.
Participating subjects may have been influenced by how they
felt at the time they completed the questionnaire.
E l l' E H i l' I

The original study (Omar et al., 1995) was approved by
Michigan State University's University Committee on Research
Involving Human Subjects (UCRIHS) (Appendix C). The data
are maintained on a disk by the principal co-investigators.

No subjects identifiers were utilized (Omar et al., 1995).

31
The subjects were entered into the data set with numerical
identification to prevent any link with any subject's name.
No potentially dangerous or adverse effects to the subjects
is known nor has been identified. Approval to conduct
secondary analysis for this study was obtained from Michigan
State University's UCRIHS prior to initiation of data
analysis (Appendix C).
Results

D . l' E S J

This study sample consisted of 60 pregnant women, with
a mean age of 24 years (SD=5.24), of which 42% (n=25) were
seen by certified nurse-midwife providers (CNMs) and 58%
(n=35) by physician providers for prenatal care services
(see Table 1). The total sample had 75% (n=45) married
women, the majority of whom were white/non-Hispanic (84%)
and 80% had a high school education or higher (n=48).
Sixty-three percent (n=38) reported they had Medicaid, yet
50% (n=30) reported working outside the home. Two
significant differences occurred between the two groups of
women. One is an expected finding, such that all CNM
providers were female, and 80% of the physician providers
were male. The second significant finding was that almost
half (49%) of the women who had physician providers reported
having private insurance as compared to only 16% of the

women in the CNM group, (1, n=60)=6.80. 2=.009.

32

 

 

Table 1.
-o|-. . o .Ilo ‘ D‘uog .0. o \‘e;
Insinl
Demographic Variable CNM Physician Total
n(%) n(%) n(%)
Race
White 21( 84) 32(91) 53(89)
Hispanic 2( ’8) 1( 3) 3( 5)
Native American 1( 4) 1( 3) 2( 3)
Other 1( 4) 1( 3) 2( 3)
Education Level
Less than high school 0( 0) 2( 6) 2( 3)
Some high school 7( 28) 3( 8) 10(17)
High school grad 12( 48) 13(37) 25(42)
Some college/tech 5( 20) 14(40) 19(32)
College graduate 0( 0) 2( 6) 2( 3)
Post graduate 1( 4) 1( 3) 2( 3)
Marital Status
Single 4( 16) 6(17) 10(16)
Married 18( 72) 27(77) 45(75)
Separated 1( 4) 1( 3) 2( 3)
Divorced 2( 8) 0( 0) 2( 3)
Other 0( 0) 1( 3) 1( 2)
Work Outside Home
Yes 10( 40) 20(57) 30(50)
No 15( 60) 15(43) 30(50)
Work Time
Full-time 5( 20) 11(31) 16(27)
Part-time 5( 20) 8(23) 13(22)
Medicaid
Yes 16( 64) 22(63) 38(63)
No 9( 36) 13(37) 22(37)
MICH-care
Yes 7( 23) 3( 9) 10(17)
No 18( 72) 32(91) 50(83)
Selfpay
Yes 0( O) 2( 6) 2( 3)
No 25(100) 3(94) 53(97)

33
Table 1 (cont.)

 

Demographic Variable CNM Physician Total
n(%) n(%) n(%)

 

Private Insurance

Yes . 4( 16) 17(49) 21(35)
No 21( 84) 18(51) 39(65)
Provider Gender 1
Female 25(100) 3( 9) 28(47)
Male 0( 0) 32(91) 32(53)

 

AnalYais_Qf_Besearch_QuestiQns

Research_Qnestign_l. Is there a difference between
rural low income pregnant women's perception of the total
amount of time spent at the office or clinic when seen by
certified nurse midwife providers as compared to physician
providers? A significantly higher proportion of women in
the CNM group reported a total time spent in the
office/clinic greater than 30 minutes, (1, n=60)=10.16,
n=-009 (Table 2).

Reseazgh_Questign_2. Is there an association between
type of provider, amount of time spent at the office/clinic,
and satisfaction with time spent at the office/clinic for
prenatal visits? This question used a 2 x 2 factorial
analysis of variance of satisfaction of total amount of time
spent at the office/clinic by the variables total amount of
time spent at the office/clinic and type of provider.

Results revealed there was no significant interaction

34

 

 

Table 2.

o ‘ .o . o. o o . u‘ 0‘. . 9 O Q .-
W

Provider Type
Total Time CNM Physician
n % n %

Total Time s 30 minutes . 6 (24) 23 (66)
Total Time 5 30 minutes 19 (76) 12 (34)

 

(Tables 3 and 4); however, the main effect of total amount
of time spent at the office/clinic was significant for
satisfaction with total time spent at the office/clinic.
Women who spent less time (s 30 minutes) were more satisfied
than women who spent more time at the office/clinic.
M=1.48, SD=.55; M=2.35, SD=1.01, respectively. Irrespective
of type of provider, both of these meas indicate that these
women were generally satisfied. The women most satisfied
with total time spent at the office/clinic were those I the
CNM group with total time spent at the office/clinic g 30
minutes; but when the total time spent at the office/clinic
was greater than 30 minutes, there was no difference in
satisfaction with time spent at the office/clinic for
prenatal visits by provider type (Table 4).
Discussion

Sample

In this secondary data analysis, a total of 60 rural

low income pregnant women's responses were analyzed on the

35
Table 3.

;.. e ‘ o g o ' Q

0‘. .‘ O . o o

 

Source of Variation

 

 

Di 2 MS

Total Amount of Time

2 way interaction 1 .804 .580
Main Effects

Time 1 6.649 4.798*
Provider 1 .572 .413
*p<.05
Table 4.

 

Appointment Time n M SD

 

Total time < 30 minutes

Physician 23 1.91 .67

CNM 6 1.50 .55
Total time > 30 minutes

Physician 12 2.33 .98

CNM 19 ' 2.37 1.01

 

variables, patient satisfaction with prenatal care system:
time, specifically satisfaction with total time spent at the
office/clinic, total amount of time spent at the
office/clinic and type of prenatal care provider. Twenty-
five of the women in this sample received prenatal care from

certified nurse midwife providers and three were seen by

36
physician providers for prenatal care. Overall, the women
who participating in the study were a fairly homogenous
group. The majority of the women were white/non-Hispanic,
married women who had attained a high school education or
higher. This is representative of the rural population in
Michigan (MDHP, 1994; Omar et al., 1995).

Not surprisingly, all of the CNM providers were female,
and most of the physician providers were male. The women in
the physician group represented a significantly higher
percentage of private insurance than those women in the CNM
group. Having some type of private insurance often affords
women more options in choice of prenatal provider and hence,
women may choose a physician provider (Knoll, 1990). Other
times CNMs have met obstacles when trying to expand into new
areas, including resistance from physicians, which may lead
to lack of their prenatal care services to women (Knoll,
1990). Other literature, however, has shown that there has
been a shift to increased use of the CNMs in the more
affluent pOpulation due to the philosophy and type of care
provided. Therefore, perhaps the women of Benzie County may
not be aware of the type of prenatal care provided by CNMs.
Women receiving care from the CNM provider group where they
were mandated to provide prenatal care only for women on
Medicaid. This is consistent with the literature as well
where CNMs were more likely to accept women enrolled in
Medicaid than their physician counterpart (Knoll, 1990).

Another possibility may be that women who had private

37
insurance chose physician providers because some of them
provided prenatal care within the county until 28 weeks of
gestation and this may have afforded the wOmen less travel
time.
W

This study has revealed a statistically significant
difference between total time spent in the office/clinic and
prOvider type. The findings showed that women spent a
longer time with the CNMs during prenatal visits. A major
component of nurse-midwifery care has been identified as
education and counseling during the prenatal visit (Knoll,
1990). This may account for the increase in total time that
the women spent at the office/clinic. Further, it was
identified that women in the physician group had a shorter
total time spent in the office. This may be attributed to
their diagnosis and style of practice (Knoll, 1990).

5 II E I. 'll I l J E I E Tl S l I ll
:EEI [:1. .

Despite the identified difference of total time spent
at the office/clinic by provider type, the women of this
study were generally satisfied with total time spent at the
office/clinic based on provider type. Research question 2
refers to an association between satisfaction with total
time spent at the office/clinic and the provider type. An
association was not found, however, a pattern was
significant for the amount of time spent at the

office/clinic and satisfaction such that women who spent

38
less time (less than 30 minutes at the office/clinic) were
more satisfied, and also that the women seen by CNMs and who
spent less than or equal to 30 minutes had the highest level
of satisfaction. This is consistent with the literature
such that a decrease.in patient satisfaction had been
associated with an increased length of time spent at the
office/clinic (Alexander et al., 1993; Seguin et al., 1989).
This variatiOn may have occurred due to the small number of
women receiving care by CNMs and spending less than or equal
to 30 minutes in the office/clinic and different group size.
However, when one observed the interaction between the study
variables, the degree of variance for total time spent at
the office/clinic over 30 minutes was twice as large as the
degree of variance for total time spent at the
office/clinic. The relationship with the provider may act
as a buffer, however, others were dissatisfied with total
amount of time spent at the office/clinic regardless of whom
their provider was, suggesting that the prenatal care system
needs to value women's time. The literature suggests that
women reported greater satisfaction even with a lengthy
total time spent at the office/clinic, if they believed that
the provider valued their time (Knoll, 1990).

However, of the studies that reported an association
between total time spent at the office/clinic for prenatal
care and patient satisfaction, none reported what the
significant specific total length of time spent at the

office/clinic was. Only one study actually included a

39
median amount of patient wait time of 19 minutes (Dennis et
al., 1995), which extended the total amount of time spent at
the office/clinic and resulted in patient dissatisfaction
with prenatal care. This study reported total time spent at
the office/clinic which included both waiting time and time
spent with the provider.

Since there was no significant difference found for
satisfaction with the total time spent at the office/clinic
based on provider type, one can imply that the pregnant
women were satisfied with the content or services received
during the visit/appointment. The literature supports
women's satisfaction with CNMs in the service of care which
is family centered, unhurried, and allows women to actively
participate in their care (Knoll, 1990).

El . E E 1! .II. ll 2 l J E l

The study's findings provided mixed support for the
adapted conceptual framework from King's dynamic interacting
systems (1981, 1992). The rural low income pregnant woman
(personal system) and the prenatal care delivery system,
comprised of the total amount of time spent at the
office/clinic (social system) came together within the
interaction of the social system. Due to the findings of
this study revealing no significant difference with
satisfaction of total time spent at the office/clinic by
provider type, provider type would not be included in the
social system of the revised model (Figure 2). Time was

spent during the interaction (prenatal visit) with the

40

Social Systems \

(SOCtety)

Prenatal Care System: Total Amount of Time Spent
atthe Office/Clinic

I

I

|

I

V- —————————————————— \
I Interpersonal System I
I (Groups) |

I Type of Provider: CNM/Physician

I _______ :>
I / Personal System \

I (Individuals)
I

l

|

|

I

I

I

I

I

I

I

I

I

I

|

I

I

'x

|

l

l

I

l

I

l

I

|

|

I

I

I I
| :> . I. . I
Satisf IlOll/DlSSBfleaCIlOD |

| l |
' I
| I
I

l

I

|

I

I

l

l

|

|

|

I

|

|

l
rSzIthEctiOnT ‘I
yieaesfenm.

Eignzg_2: A Revised Adapted Conceptual Framework for
Satisfaction with the Prenatal Care System: Dynamic
Interacting Systems. From I. M. King, A Theory for Nursing:

Systems, Concepts, Process. New York: John Wiley & Sons,
1981, p. 11.

41
provider and in the office/clinic. What was unable to be
determined was the amount of time spent with just the
provider; however, in spite of this limitation the model
still provided some direction for the study with total time
spent at the office/clinic. Each person, including the
pregnant woman, brought her own perceptions into the
interaction either positively or negatively affecting the
satisfaction with total time spent at the office/clinic.
The interpersonal system, while not a part of this study,
may affect satisfaction with total time spent at the
office/clinic through the interaction with the provider and
the pregnant woman. Since interaction is a reciprocal
process, the receptiveness to the provider may also need to
be considered and the model revised to include satisfaction
with the interpersonal system also (Figure 2). Other
aspects of the interaction between the women and the
prenatal care delivery system were not studied, e.g., time
spent with the provider, travel time, and time from work,
which are some of the other factors to consider.

Other factors to consider in the open interaction
system of King (1981) are the women's interactions with
other members of the health care team, whether positive or
negative. This could also affect satisfaction with total
amount of time spent at the office/clinic and how the women
may be using the time spent waiting in the office/clinic.
King's model helps to explain the complexity of the issues

surrounding total amount of time spent at the office/clinic

42
and is appropriate to continue to explore additional aspects

of interaction within the model and to revise the model

accordingly.
H. . .. . ;. .. -. - ; - ( :30 . - m. -

This study found that overall rural low income pregnant
women were satisfied with their care regardless of type of
prenatal care provider. Satisfaction was inversely related
to length of total time, such that satisfaction decreased
when total time spent at the Office/clinic was over 30
minutes as compared to total time spent at the office/clinic
was less than or equal to 30 minutes. The APN, therefore,
needs to be sensitive to total time spent at the
office/clinic issues within the prenatal care delivery
system that may affect patient's satisfaction with prenatal
care.

One major role for the APN is that of client advocate
regarding time issues within the prenatal care delivery
system. Identification Of time issues within the prenatal
care system need to be addressed, such as content of visit,
length of waiting time, ease of access ad scheduling
appointment times convenient for the women. One approach in
advocating for the pregnant woman may be to conduct an
assessment of total time spent at the office/clinic through
a time study which includes an exit interview of women's
satisfaction, evaluate the results and then plan, implement,
and evaluate the office/clinic flow, total time spent at the

office/clinic and women's satisfaction with the restructured

43
model of delivery of prenatal care. Included in this
revised model, regardless of the prenatal care provider
type, activities need to be planned for women while they are
waiting to be seen. Flyers can be developed and distributed
which identify the plan of prenatal care within the
office/clinic, how much time women should plan on spending
at the office/clinic, an account of how their time will be
spent at the office/clinic, and‘a description of planned
activities while women are waiting.

The APN may discuss with rural pregnant women their
specific issues regarding time spent at the office/clinic
for prenatal care as well as their satisfaction and how
these may best be addressed during prenatal visits, such as
education during the previsit waiting period by other
members of the office staff/team, and convenient scheduling
of prenatal visits which reduces total time spent at the
office/clinic. The APN will need to work directly with
prenatal clients, as well as collaboratively with staff and
administration to affect satisfactory changes within the
prenatal care system. Valuing women's time is one factor
towards enhancing satisfaction with prenatal care.
Wm

This study failed to demonstrate an association between
prOvider type, total amount of time spent at the
office/clinic, and satisfaction with total amount of time
spent at the office/clinic. Previous studies have linked

amount of time spent at the office with the degree of

44
satisfaction with prenatal care. The failure of the present
study to find an association may be, in part, due to the
instrumentation of using a single item to measure
satisfaction, as well as the small sample size. Replication
of the original study with a larger sample size and
additional satisfaction items, which measure satisfaction
with the total time spent at the office/clinic may be
warranted. Assessment of pregnant women's expectations
regarding total time spent at the office/clinic may also be
warranted.

As forementioned, previous studies identified few
variables affecting patient satisfaction with prenatal care
services, especially among the rural low income pregnant
population. Additional research needs are suggested as
follows: a) studies evaluating variables within the prenatal
care system, including satisfaction with time spent with the
provider, total time spent with the provider, total time
spent waiting to be seen by the provider, and satisfaction
with total time spent waiting to see the provider, that
affect patient satisfaction. This may provide insight into
areas for improvement within prenatal care delivery; b)
exploration of why women are satisfied with the time spent
in the office/clinic with the CNM, despite the increased
length of time. This may provide insight into areas which
enhance satisfaction with care even if it takes longer; and
c) further comparison studies between provider type, time,

and satisfaction to expand on findings of this study.

45

This study identified the need to further delve into
the perceptions that may lead rural women to seek or refrain
from obtaining prenatal care services. The variables that
affect patient satisfaction may often change utilization of
prenatal care services. The literature has identified the
need to investigate these attributing variables (Minden,
1994). For this, if for no other reason, prenatal care
providers and policy makers must actively pursue the answers
to optimal prenatal services for rural women.

Summazx

This study compared two groups of prenatal care
providers, certified nurse-midwives and physicians, with one
dimension of satisfaction of prenatal care system: total
amount of time spent at the office/clinic. The study
supports other research that reveals women are equally
satisfied with the total time spent at the office despite
provider type. The study also revealed that patients
receiving care from the certified nurse-midwives spent a
longer total time at the office/clinic than those receiving
prenatal care from physician providers.

Competitive care environments as well as the increased
awareness for health promotion and preventive healthcare
require providers and policy makers to evaluate prenatal
care services. Cost effectiveness has given riSe to an
increased need for alternative prenatal care providers,
which have been successfully filled with advanced practice

nurses, especially with rural areas. For this reason

46
advanced practice nurses must identify areas for change and
actively integrate new knowledge into the prenatal practice
setting which may enhance prenatal care satisfaction and
utilization by rural low income women. Sensitivity to time

issues in the prenatal care setting is one area where change

can be implemented.

LIST OF REFERENCES

LIST OF REFERENCES

Alexander, L., Sadridge, J., 5 Moore, L. (1993).
Patient satisfaction: An outcome measure for maternity

services. JOurnal_9f_2erinatal_and_NeOnatal_Nnrsin91_1(2).
28- -39.

Barger, S.E. (1990). The nursing center: A model for

rural nursing practice. WWW) .
290-294.

Buhler, L., Glick, N., & Sheps, S. B. (1988). Prenatal
care and comparative evaluation of nurse-midwives and family
Physicians. Canad1an_Medical_lOurnali_139 397-403.

Carr-Hill, R. A. (1992). The measurement of patient

satisfaction. IOurnal_Of_2ubl1c_Health_Med191nei_14(3).
236-249.

Del Mar, C., & O'Connor, V. (1994). General
practitioners in public obstetrics-an underutilized
resource. Austral1an_and_New_Zea1and_lOurnal_Of_Qbstetrics
and_fixneceles¥1_34(1). 35-38.

Dennis, L.I., Flynn, B.C., & Martin, J.B. (1995).
Characteristics of pregnant women, utilization, and
satisfaction with prenatal care services in St. Petersburg,
Russia. Eubl1c_Health_Nursing1_12(6). 374- 377.

Freeman, P.K., & Poland, R.L. (1992). finidglines_fgz
p:gnata1_gaxe. (3rd ed.). American College of

Obstetricians and Gynecologists and American Academy of
Pediatrics.

Gravely, E. A., & Littlefield, J. H. (1992L A cost
effectiveness analysis of three staffing models for the
delivery of low-risk prenatal care. American_lgnrnal_gfi
WW). 180- 184.

Heins, H. C., Nance, N. W., McCarthy, B. J., & Efird, C. M.
(1990). A randomized trial of nurse-midwifery prenatal care

to reduce low birth weight. Obstetr19s_and_§¥necglng1
15(3), 341- 345.

47

48

Higgins, P., Murray, M.L., & Williams, E.M. (1994).
Self-esteem, social support, and satisfaction differences in
women with adequate and inadequate prenatal care. B1ztn1
21(1), 26-33.

Hopton, J.L., Howie, J.G., & Porter, M.D. (1993). The
need for another look at the patient in general practice

satisfaction surveys. Eam112_2racticei_19(1). 82-87.

Hsieh, M. 0., & Kagle, J. D. (1991L Understanding
patient satisfaction and dissatisfaction with health care.
Healrh_and_SOcial_HOrk1_1§(4). 281-290.

KIDS COUNT in Michigan. (1994). M1Qh1gan_kids_ggnt
being.

Kins. I.M. (1981). A_theQrx_for_nursin91_£¥stem31
cgngepts1_nzgcess. New York: John Wiley.

King, I. M. (1992L King's theory of goal attainment.
Nurs1ns_Sc1ence_Qnarterl¥1_5(1). 19-26.

Knoll, K. (1990). Certified nurse-midwives, nurse
practitioners, and family practice physicians in the
delivery of prenatal care.
gaze. New York: Elsevier.

Kogan, M.D., Alexander, G.R., Kotelchuck, M., Nagey,
D. A., & Jack, B. W. (1994). Comparing mother's reports on
the content of prenatal care received with recommended

national guideline for care. 2nb112_flea1th_3epgzts1_102(5),
637- -646.

Kojo-Austin, H., Malin, M., & Hemminki, E. (1993).
Women's satisfaction with maternity health care services in
Finland. SQc1al_Science_Med121nei_31(5). 633- -638.

Lia-Hoagberg, B., Rode, P., Skovholt, C.J., Oberg,
C. N., Berg, C., Mullett, S., & Choi, T. (1990). Barriers
and motivators to prenatal care among low-income women.
SOc1al_Sc1ence_Med1cinel_1Q(4). 487- -495.

McComas, J., Kosseim, M., & Macintosh, D. (1995).
Client centered approach to develop a seating clinic
satisfaction questionnaire: A qualitative study. The
Amer1can_IOurnal_Of_Qccunational_Theorxi_49(10). 980-985.

Mclcis, A.I. (1991). TheOret1cal_nursing1_nexelgnment
and_prggzess (2nd ed.). Philadelphia, PA: J.B. Lippincott.

49

Mellor, J., & Chambers, N. (1995). Addressing the
patient's ageda in the reorganization of antenatal and
infant health care: Experience in one general practice.

, 423-425.

Merkatz, I.R., Thompson, J.E., Mullen, P.D., &
Goldenberg, R.I. (1990).

(lst ed.). New York, NY: Elsevier Science.

Michigan Department of Public Health (MDPH). (1994).

Minden, N.J. (1994). Managing the perceptions of
patient wait time. IOurnal_Of_the_American_Dental

Assoc1at1nn1_12§, 84-87.

Oakley, A. (1992). Perspectives of users of the
service. °

Health_carei_&(1). 112-122.

Omar, M.A., & Schiffman, R.F. (1992). Patient

. East Lansing: Michigan
State University.

Omar, M.A., & Schiffman, R.F. (1994). Eat1en§
. . o. . Q o 'g. . ' 0 ll‘. 0.‘ ‘ OOII‘O

f1nal_zgpgzt. Unpublished manuscript.

Omar, M.A., & Schiffman, R.F. (1995). Pregnant women's
perceptions of prenatal care. - '

Journa11_23(4), 132-142.
Omar, M.A., Schiffman, R.F., & Bauer, P. (1995).

0‘0, 0009'... .‘.w'-.-o-_oau-‘u.o.o
. Final report presented

All University Research Initiation Grant Support, November
15, 1995. Unpublished manuscript.

.Petitti, D.B., Hiatt, R.A., Chin, V., & Croughan-
Minihane, M. (1991). An outcome evaluation of the content
and quality of prenatal care. Birth1_18(1), 21-25.

Rowely, M.J., Hensley, M.J., Brinsmead, M.W., &
Wlodarczyk, J.H. (1995). Continuity of care by a midwife
team versus routine care during pregnancy and birth: A
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151(18), 289-293.

Seguin, L., Therrien, R., Champagne, F., & Larouche, D.
(1989): The components of women's satisfaction with
maternity care. Birth1_1§(3), 109-113.

50

Thomas, C.L. (1990). ' '
dictionary. (15th ed.). Philadelphia: F.A. Davis.

Thompson, D.A., & Yarnold, P.R. (1995). Relating
patient satisfaction to waiting time perceptions and
expectations: The disconfirmation paradigm. Agndgmig
Emersencx_Med191neI_2(12). 1057-1062.

. Tranter, S. (1989). Reducing the wait. anging_mimg§1
35(51), 39-41.

Wise, P. H. (1994L What you measure is what you get:

Prenatal care and women's health. Amgzignn_lgnznai_gf
Pub11c_nealth1_84t9). 1374- 1375.

Yankov, D., Peterson, B., Oakley, D., & Mayes, F.
(1993). Philosophy of care: A pilot study comparing
certified nurse-midwives and physicians. lgnznni_gf_flnzfig
M1dw1f22¥+_18(3). 159- 164.

York, R., Williams, P., & Munro, B.H. (1993). Maternal
factors that influence inadequate prenatal care. Enhiin
Health_Nurs1n91_19(4). 241-244.

APPENDICES

APPENDIX A

51

Patient Satisfaction with Prenatal Care:

College Of Nursing
Michigan State University

Mildred A. Omar, RN, PhD.

Rachel F. Schiffman, RN, PhD.

You indicate your voluntary consent to participate in this study by completing and
returning this instniment. All responses to this survey will be kept strictly confidential.

Preparation of this instrument has been done with assistance from Sigma Theta Tau
International Honor Society of Nursing Research Grant, Mead Johnson Perinatal

Nutritionals Research Grant, and Michigan State University College of Nursing Research
Initiation Grant.

©

1 992

52

 

For the statements below, please check the response which best describes the provider you
see mnsLQfmn. that is, who measures you abdomen, does your pelvic exam, listens to
' your baby's heartbeat. If you see more than one provider, answer the following items for

whom you see mnsLthen.

 

87. The provider that I see mnsinfien for my prenatal exams is a :
_doctor
_nurse midwife
_nurse practitioner
_I see both a doctor and a nurse midwife/nurse practitioner
about the same number of times
_do not know

88. The provider I checked above is a:
_woman If you answered that your provider was a woman,
SKIP TO QUESTION #90.
man If you answered that your provider was a man,
GO TO NEXT QUESTION, #89.
I see both a male and a female provider
GO TO NEXT QUESTION, #89.

89. If the provider that you checked above is a man, would you say that:
_this made no difference to you
_this made some difference to you
_this bothered you a lot

PLEASE GO ON TO THE NEXT PAGE

53

Now we would like to know a little more about you. Please remember that all response
are mnfidential at no time will the researchers release any information linking you to the
survey. For each statement, please check the response that best describes m. Please
answer all the questions. Thank you for your help with this project.

 

92.

93.

94.

95.

96.

97.

Age (in years)

Race (check only one)
_Asian
_Black
__Hispanic
____Native American
_White (Non-Hispanic)
_Other (Please Specify)

 

Mark the highest level of education you have completed (check only one):
___Less than /high school
_Some high school
_High School Graduate/GED
_Some College/Technical School
_College Graduate
_Post College

Mark the response which currently describes your marital status (check only one):
_Single
_Divorced
_Married
_Separated
_Widowed
__Other (please specify)

 

Are you working outside the home?
_No
_Yes If yes, _Fulltime
_Parttime

What kind of insurance do you have? (Check all that apply)
_Medicaid
___Private Insurance
_Michcare
_None (Self Pay)

PLEASE GO ON TO THE NEXT PAGE

54

98. Counting this pregnancy, how many time have you been pregnant?

IF YOU ANSWERED " 1", SKIP TO QUESTION #99; IF YOU ANSWERED 2 OR
MORE ANSWER QUESTIONS 98A AND 988.

98a. If you have been pregnant more than once, did you seek prenatal care at this
Office/clinic for any of these pregnancies?
No Yes

98b. How many living children do you have?

99. How did you make your first prenatal appointment?
_by telephone
____in person
___Other (please specify)

 

100. From the time you called or went to the office/clinic, how long did you wait for your

first appointment? Identify the amount of time closest to the time you waited.
Please check only one category.

less than one week two weeks four weeks
one week three weeks more than four weeks. How many?

 

101. How far along in your pregnancy were you when you came for your first prenatal
visit (Check only one)

1-3 months
4-6 months

7-9 months

102. How many weeks pregnant are you now?

 

PLEASE GO ON TO THE NEXT PAGE

55

103. Identify the amount of time cleats]. to the total amount of time you usually spend at
your clinic or oflice visit.

less than 15 minutes 31minutes to 45 minutes 61 minutes to 2 hours
15 minutes to 30 minutes 46 minutes to 60 minutes more than 2 hours

104. Check the one that best describes how many times have you been to the office/clinic
prenatal care.

1-5 times
6.10 times
11 or more times

 

YOU ARE FINISHED
PLEASE RETURN THE COMPLETED SURVEY
TO THE PERSON WHO GAVE IT TO YOU.

THANK YOU FOR YOUR PARTICIPATION!

APPENDIX B

56

APPENDIX B

PROCEDURES FOR DATA COLLECTION
Original Study by Omar and Schimnan

Data collectors were selected and prepared by the principle co-investigators, Omar,
Schifinan, and Bauer (1995). Potential participants were identified by the data collector
in conjunction with the staff at local health departments, physician Ofices, and childbirth
education classes, and eligibility for participation was verified utilizing inclusion criteria.
Solicitation for participation was done by the data collector explaining the study tO
potential women in the waiting rooms of local health departments, physician offices, and at
childbirth education classes. Women were in their third trimester of pregnancy, but all had
completed at least three prenatal visits. Confidentiality was assured to all prospective
participants. Informed consent to voluntarily participate in the study was Obtained with a
signed consent form prior to survey distribution. Willing and eligible participants were
provided a cover letter explaining the study, the instrument, and an envelope in which to
place the completed questionnaire. The women read the cover letter and instructions, and
completed the instrument. The data collector was available to answer questions and
provide instructions. Participants placed the completed questionnaire in the envelope
provided, and received a cash incentive Of $10.00. The completed surveys were returned
to the primary investigators. Data collection commenced in June, 1994, and was

completed in July, 1995.

APPENDIX C

 

STUDIES

Unlvereity Committee 0
Research lmrehn
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517055-21”
FAX1517I432-1171

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57

MICHIGAN STATE

UNIVERSITY

July 11. 1997

 

TO: Mildred A. Omar
A-230 Life Sc1ences

RE: IRBI: 97-394
TITLE: PATIENT SATISFACTION WITH THE PRENATAL CARE
SYSTEM: TIME
REVISION REQUESTED: N/A
CATEGORY: - ~ ‘ 1-8
APPROVAL DATE: 07/03/97

The University Committee on Research Involving Human Subjects'lUCRIHS)
review of this project is complete. I am pleased to adv1se that the
rights and welfare of the human subjects appear to be adequately
rotected and methods to obtain informed consent are appropriate.

Egrefore, the UCRIHS approved this project and any rev1sions listed
a ve.

RENEWAL: UCRIHS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u te certification. There is a
maximum of four such expedite renewals ssible. Investigators
wishin to continue a project beyond tha time need to submit it
again or complete rev1ew.

REVISIONS: UCRIHS must review any changes in rocedures involving.human
subjects, rior to initiation of t e change. If this 1s done at
the time o renewal. please use the green renewal form. To
revise an approved protocol at an other time during the year
send your written request to the CRIHS Chair. requesting revised
approval and referenc1ng the project's IRB I and title. Include
in our request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROBLEMS/

CHANGES: Should either of the followin arise during the course of the
work. investigators must noti UCRIHS promptly: (l) roblems
(unexpected side effects, comp aints,-etc.) involving uman
subjects or (21 changes in the research environment or new
information indicating greater risk to the human sub'ects than
existed when the protocol was prev1ously reviewed an approved.

If we can be of any future hel , lease do not hesitate to contact us
at (517)355-2180 or FAX ($1714 2- 171.

Sincerely,

   
   

avid E. Wright, Ph.D.
UCRIHS Chair

DEW:bed
/'

‘féf'oee Marie Six

APPENDIX D

59

C O
. . II. C .I .
".' \. 4. . e.. Q O .0... . .' ...I .' O .‘ a e O.

Wm

 

Dimension Items Factor Loading Alpha

 

Time 70 (Amounts of waiting .98 .90
time to be seen by
provider)
* 71 (Total amount of time .73
at office/clinic)
Access 69 (Ease of rescheduling) .93 .78

68( Convenient scheduling) .66

Facilities 79 (Waiting room) .86 .78
80 (Exam room) .76
78 (Parking) .61
Organization 73 (Frequency see same .84 .78
provider)
72 (Choice of provider) .70

74 (Not have to repeat my .64

story)
Total Scale 10 Items .85

 

Note. * indicates item used in this study.