: 3? . 3.! I4 Ii! 5 as. Lasts}; .D f I ‘K’E‘. .. 2y . .. : $33.93 a: ., 3: k 33....» 1 L1. 30.! .93 1 . I 3..."..MH... .2.;.v¢. . I .. . .t... . . 1» .v...? :r .2 5. 3 :1... t: 7 3.1.1. [qw‘llvsl:. -. ‘ ‘ . {Tn-III! THESlS 7 kc ill/limit?Will ‘ This is to certify that the thesis entitled Relationship Between Payor Source, Expectation of and Satisfaction with Prenatal Care presented by Mary Lorraine Zuker Blackmer has been accepted towards fulfillment of the requirements for Master's degree in Nursing 00 Major professor Date July 1, 1995 MS U is an Affirmative Action/Equal Opportunity Institution LIBRARY Mlchigan State Unlverslty PLACE DI RETURN Boxmmwombmwflmyum. 1’0 AVOID FINES Mun on or More data duo. DATE DUE DATE DUE. DATE DUE MSU I. An Afflnnattvo Action/EM Opportunity Institution Wanna-m RELATIONSHIP BETWEEN PAYOR SOURCE, EXPECTATION OF AND SATISFACTION WITH PRENATAL CARE by Mary Lorraine Zuker Blackmer A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTERS OF SCIENCE IN NURSING College of Nursing 1995 ABSTRACT RELATIONSHIP BETWEEN PAYOR SOURCE, EXPECTATION OF AND SATISFACTION WITH PRENATAL CARE BY Mary Lorraine Zuker Blackmer This study examined the relationship between payor source and expectation of, and satisfaction with prenatal care. The sample consisted of 307 Medicaid and 213 private insured women. Women had moderate levels of expectations and were generally satisfied. Significant differences were found in four expectation dimensions and seven satisfaction dimensions. Correlations between expectations and satisfaction were weak and generally negative. Similar correlations in both groups were found between expectation of information and multiple satisfaction dimensions. The groups differed in correlations between expectation of one provider and accessible quality care with multiple satisfaction dimensions. The Nurse in Advanced Practice can use these findings to clarify expectations of prenatal care and to improve information delivery to all women. In addition, advocacy to improve system factors may affect Medicaid women's satisfaction with prenatal care. ACKNOWLEDGEMENTS I would like to express my deep appreciation to my thesis chairperson, Rachel Schiffman, for her incredible professional expertise, continuous words of encouragement and assistance in seeing me through my project. I would like to also thank my thesis committee members, Patty Peek and Jackie Wright for their guidance and support throughout my program and during this project. I would further like to express my love to Rick, Nicholas and Courtney, my family and my friends. Words can not adequately express my appreciation for their patience, words of encouragement, assistance and support throughout my program. iii V‘smv‘ g I‘L“ .g“ ,A.\Yf\v- V“ VL ‘/?~~., . >- .H&‘.. ‘51! I"! (I) ( TABLE OF CONTENTS LIST OF TABLES . . LIST OF FIGURES INTRODUCTION . . Statement of the Problem . CONCEPTUAL DEFINITIONS OF VARIABLES Prenatal Care Expectation Prenatal Care Satisfaction Payor Source CONCEPTUAL FRAMEWORK REVIEW OF LITERATURE . Payor Source and Prenatal Care. Expectation of Prenatal Care Satisfaction of Prenatal Care Summary of Literature METHODS Research Design . . . Sample . Operational DefinitiOns of the Variables Instrumentation Data Analysis . Protection of Human Subjects Research Assumptions Research Limitations RESULTS Description of the Sample Answer to Research Questions Expectation . . . Satisfaction Relationship Between Expectation and Satisfaction DISCUSSION Sample . Expectation of Prenatal Care by PayOr Source iv .vi vii b+d 37 39 41 44 47 49 Yfifl‘l‘ V. h an S H; “a. 3 Am Table of Contents (Cont.) Satisfaction of Prenatal Care by Payor Source . . . 53 Relationship between Expectation of and Satisfaction With Prenatal Care by Payor Source 59 Discussion of Result as Related to the Conceptual Model . 64 Implication for the Nurse in Advanced Practice in Primary Care . . . 69 Recommendations for Further Research . . 79 SUMMARY . . . . . . . . . 80 REFERENCES . . . . . . . . 83 APPENDICES Appendix A. Patient Satisfaction with Prenatal Care Survey . . 88 Appendix B. Procedure for Survey Administration and Data Collectibn 104 Appendix C. U. C. R. I. H. S. . . . . 107 Table Table Table Table Table LIST OF TABLES Alpha Reliability of PSPCII Instrument: Expectation and Satisfaction Dimensions Frequency of Sample Demographics by Payor Source . . . Mean Prenatal Care Expectation Scores by Payor Source Mean Prenatal Care Satisfaction Scores by Payor Source Correlations Between Subscales of Expectation and Satisfaction by Payor Source . . vi 34 38 40 42 45 LIST OF FIGURES Figure 1: Conceptual Framework adapted from King . 13 Figure 2: Conceptual Framework for Expectation of and Satisfaction with Prenatal Care by Payor Source, adapted from King. . . . . . vii .C «L Q» .‘d 7 a ?~. 5 C .C Q ‘ s $s Introduction The United States spends more money per person for prenatal care than any other industrialized nation (Machala & Miner, 1991). The rank of the United States in infant mortality rates, however, remains 19th among industrialized nations (Johnson, Primas, & Coe, 1994). Infant mortality has been viewed as a primary indicator of the health status of a nation as well as of the quality and the availability of the health services that are provided to the people (Schwartz, 1990). Low birth weight has been identified as one of the major indicators for increased infant mortality and morbidity, yet 7% of the total births in the United States are documented as low birth weight deliveries (Higgins, Murray, & Williams, 1994). Early and regular prenatal care is a major factor in reducing low birth weight babies (Piper, Ray, & Griffin, 1990; York, Williams, & Munro, 1993). The importance of early prenatal care was emphasized by the Public Health Service (Fingerhut, Makuc, & Kleinman, 1987). Variables that contribute to differences in prenatal care include accessibility, availability and the perceived desirability (Johnson et al., 1994). How a woman perceives the care she expects to receive, may influence her use of l that 5 care 5' v . ..>\ r n I .‘.‘ .. s e Ru W n.” nu AV .1¢ h 8 9i; NIH a #5 Y. a ”N F. .1. a n b c e W pt. .1. A“ r. arena 8 an a C 5 Nu m». #1» min «a a. A“ \O L C 2 that service. The perception and utilization of prenatal care services seem vital to favorable pregnancy outcomes. With increasing consumer awareness of preventative health care services, it is important to understand what factors influence patients to return for further services (Hinshaw & Atwood, 1981). With competing dollars for health care, it is vital to retain patients to survive in the medical care services arena (Ross, Frommelt, Hazelwood, & Chang, 1987). Satisfaction with care from a medical provider has been seen as an indicator in the patient returning and continuing services with that provider (Bowling, 1992; Oberst, 1984; Rooks, Weatherby, & Ernst, 1992). Thus, increasing satisfaction and compliance with regular care (Weiss, 1988) would affect the outcome, and in turn, influence the level of satisfaction for future encounters with health care (Bowling, 1992). By increasing satisfaction with prenatal care services it would be hoped to improve regular prenatal care services and improve pregnancy outcomes. Low income women were more likely to have a higher rate of poor infant outcomes (Hansell, 1991; Schwartz, 1990; Scupholme, Robertson, & Kamons, 1991). Many authors believe that a lack of insurance or finances was a major barrier in regards to delayed or no prenatal care (Braveman, Bennett, Lewis, Egerter, & Showstack, 1993; Hansell, 1991). In an effort to increase the accessibility of prenatal care, the ‘ reins: +L 5.. l .: 2. S .s‘ .3 e r a a A c 3 United States Congress expanded the Medicaid guidelines to include a broader range of coverage to low socioeconomic pregnant women (Mawn & Bradley, 1993; Piper et al., 1990) for prenatal care expenses. But, many prenatal care providers found malpractice too costly or Medicaid reimbursement less than private insurance, so many providers limited their Medicaid clientele, refused Medicaid recipients or stopped obstetric care (Curry, 1990). This left private insured women more "desirable" to have in a private practice as patients (Inglis, 1991). Women, receiving Medicaid were often left to utilize health departments or regional clinics. Thus, the gold standard of receiving prenatal care at a private obstetricians office is not available to many Medicaid insured pregnant women. Even with Medicaid'coverage expansion, other risk factors must influence the lack of utilization of services (Haas, Udvarhelyi, & Epstein, 1993; Piper et al., 1990). A disparity must exist between some aspect of the prenatal care that low socioeconomic women, represented as Medicaid recipients, perceive differently than middle or high economic women. Perhaps something in the expectations and satisfaction of the care these women receive is an important factor. Many people look unfavorably upon recipients of services from the Department of Social Services. Perhaps this is perceived by the women. Sociodemographic characteristics ( A.) \_. sl‘fi‘,“ OAUU- care as? ‘5 b socie 4 should not theoretically alter the quality of the medical care services provided to a patient (Hansell, 1991). Yet, our health care delivery system is a subsystem of our society and incorporates many unfavorable biases. With the documentation that early and regular prenatal care saves infants' lives, it is imperative to understand those factors that influence women to delay or not obtain prenatal care (Lia-Hoagberg et al., 1990). Multiple factors have been speculated but as a nation with offensively high infant mortality, the importance of decreasing the rate is vital to our health care system. Statement of the Problem The purpose of this study was to see if a difference existed between women's payor source of prenatal care, and the expectation of prenatal care and the level of satisfaction with prenatal care. The research questions were: (1) Is there a difference in expectations of prenatal care between women who have Medicaid and women who have private insurance? (2) Is there a difference in satisfaction with prenatal care between women who have Medicaid and women who have private insurance? (3) What is the relationship between expectation of and satisfaction with prenatal care and payor source? 5 This information should be useful to the nurse in advanced practice in the delivery of prenatal care services. If a relationship exists between expectations and level of satisfaction, perhaps specific characteristics of clients' expectations could be evaluated and used in marketing or in education to improve expectations and then perhaps improve satisfaction. If expectations differ between Medicaid women and privately insured women, specific interventions could be implemented to meet both groups' needs. If expectations are not met during prenatal care it is likely that women will be less than satisfied. If women with a specific payor source are less satisfied with the care they receive, it would be appropriate and necessary to adapt services and interventions to increase the satisfaction and thus, hope to improve early and regular prenatal care. Improving prenatal care services could ultimately improve infant mortality and morbidity within the United States. Conceptual Definitions of Variables Prenatal Care Expectation Expectation is a concept that is somewhat subjective. Expectation has been defined by Greeneich (1993) as responses which are situation specific, influenced by environmental factors, past experience and specific attributes of the situation. Expectations are unique for each individual. 6 Oberst (1984) explains expectations as a combination of a variety of characteristics, attitudes, prior experiences, and knowledge which influences what the patient perceives in a given situation. This impacts on the level of satisfaction. Ross and colleagues (1987) reviewed the literature and found that many of the definitions for expectations were given specifically in relationship to services or treatment outcomes. Expectation is referred to as a global concept, yet must be individualized to what the patient expects will happen within a given situation. Expectation of prenatal care is that care which is anticipated to be received during periodic visits to an obstetric health care provider during a pregnancy, as recommended by the American College of Obstetricians and Gynecologists (Inglis, 1991). Omar and Schiffman (1992) noted these expectations include expectations about prenatal clinic/office staff and provider care and prenatal clinic/office services, which may include the number and type of providers, resource services, information given, availability of personalized care and the accessibility of quality care. For this study, expectation of prenatal care was conceptually defined as adapted from Omar and Schiffman's (1992) definition, as the pregnant woman's expectations of the prenatal care and services She anticipates receiving throughout her pregnancy. These expectations include F‘ I. . J "an .s- .- wdHQaS 5 A Y a 8 fi-» 3 ad r 4 f S n . i. . L . . .. m. a L r I C. t C. C .ch. a C a. - F. D. .. E T‘ V 1-‘ C a a a 3 7 expectations about prenatal clinic/office staff and provider care and prenatal clinic/office services, which include the number of providers, resource services, information given, availability of personalized care and the accessibility of quality care. Prenatal Care Satisfaction The literature refers to prenatal care satisfaction from a variety of perspectives. The literature presents satisfaction as not easily defined. Satisfaction is a multidimensional construct and cannot be validly assessed on a global basis (Oberst, 1984; Sequin, Therrien, Champagne, & Larouche, 1989). Different cultures attach different meanings to health care and the services that they receive. It was noted that cultural beliefs along with lifestyle and psychologic attributes can influence a women's attitude toward prenatal care (York et al., 1993). Further, since prenatal care is predominantly a women's issue, many cultures fail to justify that women have a valid opinion of the services that were received. In the United States health care services for women have gained increased recognition and represent a large portion of the services that are delivered within hospitals. The patient's perception of the services received is repeatedly seen in the literature. Hinshaw and Atwood (1981) define patient satisfaction as the patient's opinion of the care received from nursing staff. 8 LaMonica, Oberst, Madea, and Wolf (1986) and Risser (1975) while developing patient satisfaction scales defined satisfaction as "the degree of congruence between patients' expectations of nursing care and their perceptions of care actually received". Satisfaction is seen as a subjective concept. Satisfaction is identified by Higgins and colleagues (1994) as complex and multidimensional with psychosocial dimensions, a perception. Thus, the difference between perception of quality of care and the satisfaction with care are two different components. Prenatal care satisfaction was defined by Omar and Schiffman (1992) as a positive or negative feeling or attitude that a pregnant woman formed about prenatal care. Factors these authors identified that influenced satisfaction were prenatal clinic/office providers, clinic/office staff, and clinic/office service, which included the caring relationship, information provided, time waiting, facilities, scheduling ease, and consistency of provider seen. Satisfaction with prenatal care for this study was conceptualized as adapted from Omar and Schiffman (1992), as the pregnant woman's positive or negative attitude/feelings towards prenatal care and include positive or negative attitude/feelings about prenatal clinic/office providers, clinic/office staff, and clinic/office service, which .; a. f. . . c I . . L C 1.. l . c n. .1 C u a v. a :1 A... .: I. c S u a .2. m. ..... : a 2. A 1. o u r a. .. . . O A. o . m m m .a. A... s. m m ... .. H. n p e : s y s A L l i.’ b f. F 9 included the caring relationship, information provided, time, facilities, scheduling ease, and consistency of one provider. Payor Source Within the literature reviewed, only a loose conceptual definition of payor source was identified. The method of payment for medical bills was used to define what insurance status, or payor source, meant (Fingerhut et al., 1987). Further examples were given as to different types of payor source: private health insurance, public assistance, including Medicaid, state/local government assistance or no insurance. One study alluded to "health insurance unit", which is presented from the health insurance industry as the members that are receiving the insurance coverage under one policy (Long, 1987), and generally seen as a benefit of employment. A complex collection of payor sources are available in the United States. Schwartz (1990) defined a variety of pay sources: private or commercial insurance, Health Maintenance Organization (HMO), or military government sponsored. There is also Medicaid which has state and federal funding and guidelines. The government, in addition, has special federal and/or state funded programs with a sliding fee program for those not eligible for that state's Medicaid program. Further, self-pay as a payor 1.1 ’ 'lf ' 10 source, includes individuals without any outside source of assistance to pay for health care services. Private insurance are generally provided by an employer or purchased by an individual through an employer, group or as an individual. Private insurance are offered in a wide variety of packages which cover different services at different reimbursement rates (Long, 1987). Private insurance, commercial insurance, or HMO (health maintenances organizations) are generally insuring the working, middle to upper class populations. Since having insurance affords women the opportunity to access private obstetric care, this often segregates, by payor source, where prenatal care can be obtained. Those women without private insurance, and eligible for Medicaid generally must seek services for prenatal care in public clinics. Medicaid programs are designed for those who are at, or below, an individual state's Department of Social Services (DSS) program guidelines, thus, individuals or families with lower income are the recipients. Low income is defined by the annually adjusted federal poverty income guidelines (Piper et al., 1990). Depending upon the state in which the recipient lives, specific program guidelines may vary. In 1990 the federal government required states to provide Medicaid coverage to women at or below 133% of the poverty level, and allowed for the extension of up to 185% of the poverty level (Haas, Udvarhelyi, Morris, & Epstein, 1993). SOCiO< 4. a.» nu. Tm; ‘oo‘v 11 In Michigan the expanded DSS program for women at or below 185% of poverty is referred to as MICH-Care. Thus, Medicaid is federal and state funded insurance for individuals and families at or below the income guideline for that state's program, generally a representation of the lower socioeconomic population. For this study payor source was defined as the primary source of payment for prenatal care, direct or indirect, and specifically for this study, Medicaid or private insurance. Conceptual Framework The theoretical model used as the basis for this study was King's theory and the model of interacting systems. This nursing theory evolved out of general system theory combined with knowledge and emphasis on human interaction (Hanchett, 1990). The dynamic interacting human system is the main focus of King's theory. She identifies persons, objects as well as events as interrelated phenomena (Hanchett, 1990), all which may influence a pregnant woman's interactions towards increasing perceptions, expectations, communication and satisfaction with a prenatal care provider and herself. King identifies three dynamic systems that are key to her theory. The three systems, personal or individuals, interpersonal or groups, social or society, interact constantly towards a level of health (King, 1989). Each .M t m“. C a C c 2 2. .. a a . . h .3 .a. S 2. i .1 e w I L .. . 1 mm. ”In K -mi. .wu C. O“ a a r. .3 1.. 4. S C .l .3 a. C. A... .. ‘. m3. : .3. (ill! (l 12 system is unique, yet in constant state of interaction and transaction with the other systems. Some of the explicit assumptions within King's model are that the central focus of nursing is the interaction of human beings and environment, with the goal being health for human beings; the interaction process is influenced by perceptions/expectations, goals, needs, and values of both the client and the nurse (Meleis, 1991). The assumptions emphasize the complexity of the goal of health for the nurse and client as well as how these interactions play a vital role in the goal of health. The basic concept in the discipline of nursing, as a profession, is health (King, 1989). There are many factors that may and can influence an individual's goal for a state of health. One of the most salient concepts noted for all three systems is the concept of communication (Hanchett, 1990) within the King model. It is the nurse's intent to utilize skills in communication to assist the individual with any deficits that may exist towards reaching the goal. Figure 1 depicts how the three open systems each have permeable boundaries which allow free interactions with one or both systems at any time. Each system maintains its own integrity, yet each system is in constant interaction and thus, change, never returning to an original state. The broken lines depict this influx. The arrows direct the easy availability of exchange from one system to another. l3 //’— SOCIAL SYSTEM -\\\ I availability of personalized care I accessibility to quality care ;/" ——————————————————————— “\\ INTERFERSONAL SYSTEM prenatal care staff prenatal care provider ——————————— I //f’ PERSONAL SYSTEM .\\\ : pregnant woman I I I I I ' — - I I l l .l/ __ /! ‘x /' ~t\\\ S l I \ / .4 . V / . . \ atisfaction Satisfaction \ \ I \l k given Figure 1. Conceptual framework adapted from King (King, 1971, p 6). /_____..._._________________ K I I I I I I I I I | I | | I I I I I I I J | I I I | l I CBE' A ‘ 9" v~ 14 The large segmented ovals (Figure 1) reflect the different payor sources, Medicaid and private insured, that a woman might have for her prenatal care. Because these two payor groups represent different socioeconomic groups, we cannot expect them to have identical components within the personal system. These populations of women typically have different experiences which influence their personal systems. The ovals have broken lines to depict the interactions that take place between the three systems. Expectation of prenatal care is unique for each woman. Broken lines depict the many influences by the systems which impact on the pregnant woman forming these unique expectations (Figure 1). Although unique, differences in socioeconomic status or insurance source, affords women different interactions with their systems and impacts their perceptions of prenatal care differently. Thus, expectations are depicted as small circles within each of the larger satisfaction ovals depicting different payor sources. Both payor sources interact with each of the three systems. Payor sources are rooted in the social system through eligibility criteria and legislation. Yet, the meaning of that payor source is influenced from other factors of the pregnant woman's unique background. The interpersonal system is included to show the interaction with accessibility, access and services received with @16- W y . F w 2'0: Par It" ’- Age. . e .F i flh \ E .1 . O . $.b a a p... S E . _.. “H. 5.... n... . sub “h a: ix r C . 35F. C~ we «a S rs h... . «y e e & .BA 4.‘ «a C C a .C” 15 prenatal care. The pregnant woman, the personal system, interprets what her payor source means to her, and how that influences her expectations and eventually may impact on her satisfaction with her prenatal care. She may perceive specific social stigma as a result of the payor source of which she participates. She may see that one payor source holds higher social status or has advantages that another payor source may not. And thus, depending on payor source, expectations and satisfaction may be different. The ovals (Figure 1) also have a permeable membrane, maintaining dynamic interactions with all three systems. Satisfaction with prenatal care in influenced by the interactions she encounters within the different systems. Expectations of care begin with information and interactions with the social system subgroups. It is further impacted by the interpersonal system, relationships with family, friends, nurse in advanced practice (APN) as prenatal care provider and prenatal care staff. Expectations and satisfaction also intersect with the pregnant woman's personal system. For her attitudes and beliefs combined 'with her expectations are what will influence her satisfaction with her care. Each system is separate and unique, yet influences the <3ther. The social system encompasses the family systems, :firiends, neighbors, religious affiliation systems, work {ILace systems, educational system, health care services, as 16 well as the cultural, socioeconomic and demographic influences. Any influence that is within her social network and that interacts to help her form ideas and feeling/attitudes towards an issue is included, including prenatal care services. This interactions between herself and her social system influences the expectations towards what prenatal care may or may not include. The interpersonal system describes the ever changing interactions that an individual has within a dyad, triad or group (Husband, 1988). For the pregnant woman this would mean the father of the baby, if he was involved, or any other person that the pregnant women has a relationship with, both favorable or unfavorable. Members of her social system may or may not be included in her interpersonal system. The nurse in advanced practice, as prenatal care provider would hopefully transfer from the social system over to the interpersonal system as a relationship is established. Yet, how the provider and staff communicates may greatly influence the relationship as well at the satisfaction with the prenatal care services. The woman's payor source for prenatal care also interacts highly within this system. Depending upon her source of coverage, she needs to interact with different representatives of that system. Interactions may be positive or negative. The woman's perception may be influenced differently if enrollment is done through employment or through a public espe' and mm C e .r 1 O. .n V .t‘ I C. r C. D. <\ \ . Vs HIM“ gas. 2. a 17 agency. If enrollment is difficult and cumbersome, especially if she is poorly educated or in a rural area (McClanahan, 1992), interpersonal systems regarding payor source influence her expectation and satisfaction. Attitudes and beliefs of other members (neighbors, friends and family) within her interpersonal system regarding her source of payment for care can greatly influence the pregnant woman's expectations and satisfaction with her prenatal care experience and service. The personal system is an individual system that is in constant interaction with the adjacent systems. Each system contributes, exchanges and influences the attitudes and feelings that a pregnant woman may form. The pregnant woman's perceptions, expectations, and satisfaction with her pregnancy are all characteristics of her personal system. Because of the constant state of influx both in and out of the personal system, the exchange with the members of the other systems have opportunity to greatly influence the pregnant woman's expectations and satisfaction with her prenatal care. The nurse in advanced practice, as a human being, is a personal system as well as the pregnant woman. Thus, two personal systems, or a dyad are interacting. The nurse in advanced practice acts as the interpersonal system for the pregnant woman. The personal system as well as the . «iv T. . u .LI. Ht. 5 e e h T. C I 2. E .3 T . E V. m. C C .E a I 1.. C. C. e u a .3 t i s a m t. m l a o x C P c .1 ,. 0 .c. . a “my ‘0 “v; e L» {I AID L». . M 8 “SW «Wu .. \ «(V VI ‘1 § 1' I «Q 18 interpersonal system are both influenced by the social systems which maintain constant interaction. Review of the Literature Literature for studies related specifically to the expectation of and satisfaction with prenatal care by women receiving Medicaid or private insurance is very limited. Much of the literature surrounding prenatal care looked at adequate versus inadequate prenatal care (Leatherman, Blackburn, & Davidhizar, 1990; York et al., 1993), or barriers to receiving adequate prenatal care (Curry, 1989; Poland, Ager, & Olson, 1987) but not specifically expectation of and satisfaction with prenatal care. Another topic seen in the literature review was pregnancy outcome (Petitti, Hiatt, Chin, & Croughan-Minihane, 1991; Zlotnick & Gould, 1993). Studies were identified in the literature that dealt with the concepts of interest within this study individually. Payor Source and Prenatal Care Numerous articles in the literature address payor source within the context of a study. Unfortunately, none were found that specifically looked at payor sources and patient satisfaction with prenatal care. Oberg, Lia-Hoagberg, Hodkinson, Skovholt, and Vanman (1990) looked at prenatal care comparisons between payor source. They found that privately insured women (82% of the 50 insured women in the study) were more likely to receive - ‘ | U I . - a. l S .O .. L .. .3 I , . . a J 1. S e S C . a 4.. as e. .3 n. “L ”O F. L A T. I C H . F. .C O .a a .6. Wu I .m . a C l L c .. . c . C .l ‘C . a In re Cu p 19 adequate prenatal care than women with no insurance (59% of the 49 women without insurance), and women with Medicaid (50% of the 50 Medicaid recipients). Multiple factors were investigated as to why the disparity between groups. Ambivalence to being pregnant, unplanned pregnancy, consideration of termination of pregnancy, interruption of insurance coverage, and feelings of depression were some of their findings. A total of 19% of the women changed insurance coverage during the pregnancy, with most going from uninsured to Medicaid. If women with Medicaid continuously receive less than adequate prenatal care, more indepth research needs to be done to attempt to find these barriers and implement interventions for positive changes. The expansion of Medicaid coverage was reported to have increased minority access to maternal health care but, women with private insurance are still reported more likely to receive adequate perinatal health care (Inglis, 1991). Satisfaction of prenatal care services was not evaluated by payor source. Again, support is presented for the importance of looking at differences between women receiving Medicaid and women with private insurance that influence prenatal care. Higgins et al. (1994) found significantly more women without insurance had inadequate prenatal care than those with insurance or those with Medicaid. Lower socioeconomic status was associated with inadequate care and with women 20 starting care on the average, in the seventh month. Further, Higgins and colleagues (1994) found women with Medicaid, representing lower socioeconomic status, were poorly represented in the sample and collapsed into women with private insurance for analysis. Overall 53% of the women in the sample had no insurance, yet 42.5% had family incomes of less that $10,000 per year. The author of the present study wonders if these women were not eligible within that state, unaware of services, or if this was a true representation of low income population in that community. Overall, these studies revealed that low income women, generally represented by Medicaid, were in the group that received the greatest amount of inadequate care. Studies suggest that there are a variety of variables that contribute to why low income women receive less care. Little is identified however, as to if expectations of their care and satisfaction with their prenatal care is influenced by payor source. Expectations of Prenatal Care Few studies dealing with the concept of expectation were found in the literature. Studies using the concept of perception, views and desired information were found, but few linked directly with patient satisfaction. A broad study which looked at educational expectations was done between pregnant clients in a private clinic 21 (Q=135) and a public clinic (n=250) to determine patient perception of health care topics compared with health care providers (Freda, Andersen, Damus, & Merkatz, 1993). The findings revealed that 25% of the time a significant difference existed in health care topics between what the prenatal clients wanted to know and what the providers were offering. In addition, there was multiple significant differences between the two groups' interests in prenatal care education. If a pregnant woman expects information and does not receive it, her satisfaction with the prenatal services may be altered negatively. Expectations are thus an important factor that providers of service assume, rather than evaluate. Ross et a1. (1987) in a review of 21 studies related to expectations in patient satisfaction with general medical care found a difference in definitions of expectation and satisfaction within the instruments that were used to evaluate satisfaction. However, 17 of the 21 studies "supported an expectation-satisfaction relationship" (Ross et al., 1987, p. 22). Even though the definitions were worded slightly different, it was found that expectations of medical service were linked to patient satisfaction levels. Satisfaction with Prenatal Care For many years nursing researchers have been interested in what characteristics are present that predict patient satisfaction (Greeneich, 1993). Much of the research done 22 has looked at quantitative and not qualitative data. Few studies were found looking specifically at satisfaction with prenatal care. There are a multitude of factors that affect patient satisfaction with medical care in general in the literature. In a London study (n=100) (O'Brien & Smith, 1981), a variable found to influence a patient's satisfaction or dissatisfaction with prenatal care was continuity in care. Seeing only one or two professional providers was an important factor in satisfaction with care. The relationship that developed with the provider seems to have been an important factor of overall prenatal care satisfaction. Hall and Dornan (1990) using meta-analysis examined socioeconomic characteristics and patient satisfaction with medical care. Satisfaction was found to be significant or near significant in association with "being older, having higher social status, being married" (Hall & Dornan, 1990, p. 811). If one correlates higher social status with having private insurance, this would reveal higher social status members are more satisfied with medical care. Specifics of what all services rendered under medical care was unclear as to if prenatal care was included. A Montreal study (Seguin et al., 1989) was concerned with the "halo effect" of trying to evaluate satisfaction with perinatal care. Unfortunately, none of the subscales 23 looked at prenatal care satisfaction specifically. In general, satisfaction was found to be correlated with participation with decision making during vaginal delivery and even higher with cesarean deliveries. If this level of satisfaction could be retrospectively correlated, women who are more involved with prenatal care would be more satisfied. Sullivan and Beeman (1982) also addressed the complexity of evaluating satisfaction of prenatal, labor and delivery care. They were cognizant that satisfaction is related to several factors: perception of caretakers, technical competence, emotional support and communication. The study found that satisfaction with prenatal care decreased for all women with decreasing amounts of time spent discussing problems and when less empathy was shown. In addition, Sullivan and Beeman (1982) found that the experience is the important component with maternity care, not the pregnancy outcome. Thus, the experience has great power on the level of satisfaction a woman might express regarding prenatal care. Satisfaction was looked at in conjunction with self- esteem and social support regarding adequate or inadequate prenatal care (Higgins et al., 1994). They used multiple questionnaires to evaluate satisfaction. The authors found that women who did have adequate prenatal care, among other factors, were more satisfied with their prenatal care and 24 had higher self-esteem. The retrospective design limited some of the findings of the study. Interestingly the authors propose that "perhaps women receiving adequate prenatal care expected to be satisfied" (Higgins et al., 1994, p. 31) but that additional research is indicated to help explain what factors influence satisfaction with prenatal care. Multiple variables have been demonstrated to influence p-3natal care satisfaction. Adequacy of care is a common thread. The lack of adequacy of care by low income women, or Medicaid recipients (Affonso, Mayberry, Graham, Shibuya, & Kunimoto, 1992; Braveman et al., 1993; Buescher & Ward, 1992) has been reported. Further, it has been reported that higher social status women receive more adequate care (Fingerhut et al., 1987) and are more satisfied (Hall & Dornan, 1990). An additional variable that is common is the relationship with the provider as an important factor in prenatal care satisfaction (Bowling, 1992; Oberst, 1984). Women expressed increased satisfaction with providers who spent more time with them and allowed them to be more involved, and less satisfaction with providers who were not empathic and did not listen to their concerns (Higgins et al., 1994; Robbins et al., 1993). Thus, the relationship with the provider of prenatal care seems to be an important aspect of many women's level of satisfaction with that care. 25 Summary of Literature Expectations of and satisfaction with prenatal care as they relate to payor source are poorly represented in the literature. Expectation of prenatal care is so poorly represented, that it makes one consider that perhaps it is taken for granted that all pregnant women should know what to expect with prenatal care services or sorely neglected within our high tech society as to the need to know basic information. Many factors were noted in the literature that influence satisfaction with prenatal care. No one factor was seen as a common thread throughout all of the literature. Even though women who received inadequate care were less satisfied, the literature lacked an explanation as to if women received less care because they were less satisfied or if other variables were present. Lower socioeconomic women, represented by recipients of Medicaid, continue to have the greatest percent of poor pregnancy outcomes. Large gaps occur in the literature to clearly define specific details as to what low income women feel interfere with regular prenatal care services, and how this may contribute to poor outcomes. This gap in the literature only lends further to the importance of this study. The link between expectation of and satisfaction with prenatal care as it relates to payor source seems a logical and necessary nursing research component to explore, tum 26 with hope to improve early and regular prenatal care by lower socioeconomic women. In summary of the literature, a multitude of research has been done to support what medical factors influence prenatal care. Yet, no studies were located specific to what women expect of their prenatal care, how satisfied they are with the care they receive, and how this is influenced by the payor source for their prenatal care Methods Research Design This study was a retrospective descriptive correlational design using data previously collected by Omar and Schiffman (1994) using the Patient Satisfaction with Prenatal Care Instrument (Appendix A). The original study done by Omar and Schiffman (1994) looked at pregnant women's perception of expectations about prenatal care and satisfaction with prenatal care services, with surveys distributed to subjects at multiple sites between November, 1992, and February, 1994. Subjects were recruited from childbirth education classes, prenatal care provider offices, and from a public health department in southern Michigan, and from a public health department in Idaho. The instrument, the Patient Satisfaction with Prenatal Care (PSPC) was developed and revised by Omar and Schiffman (1992). The procedures for the primary study are provided in Appendix B. 27 Sample For this study, the sample was comprised of 520 pregnant women in their third trimester who completed the Patient Satisfaction with Prenatal Care instrument in the original study (Omar & Schiffman, 1994). Only women who indicated they had Medicaid insurance or private insurance for payor source for their prenatal care were included. Sixty seven women were excluded from the sample of the original study because they had no insurance, were on MICH- Care, or their insurance source was omitted. The sample had 307 women receiving Medicaid and 213 women who were privately insured. Operational Definitions of the Variables The primary variables utilized within this study were prenatal care expectations, prenatal care satisfaction and payor source for prenatal care services. Prenatal Care Expectations Prenatal Care Expectations (PNCE) were defined as the total mean scores of the expectations subscales dimensions on the PSPC (Patient Satisfaction with Prenatal Care) instrument as noted in Appendix A (Omar & Schiffman, 1994). The PNCE scale in the original instrument assessed what the pregnant woman expected from her prenatal care. The scale was developed looking at five dimensions that were operationally defined as well. The first dimension, Expectations of One Provider, referred to the patient 28 expectation to receive consistent prenatal care and delivery from one provider (mean score for items 11 and 12). Second, Expectations of Other Service, referred to expected services offered by the nutritionist, social worker or public health nurse (mean score for items 19, 20, and 21). Third, Expectations of Information, referred to the amount of prenatal care the woman expected to receive (mean score for items 9 and 10). Fourth, Expectations of Personalized Care, referred to the expectations about individualized attention (mean score for items 13, 14 and 18). The fifth dimension, Expectations of Accessible Quality Care, referred to the perceived expectation of having difficulty obtaining prenatal care and the quality of that care, this item was reversed scored. This last dimension was reflected as a mean score for items 6,'8 and 16. In addition, the total of all items comprised the mean score that was utilized for the Prenatal Care Expectations total score (PNCE). The lower the score the more the pregnant women expected from that specific aspect of her prenatal care. The higher the score, the less the pregnant women expected from that aspect of her prenatal care. Prenatal Care Satisfaction Prenatal Care Satisfaction (PNCS) was defined by the scores of items 25 through 86 on the Patient Satisfaction with Prenatal Care (PSPC) instrument (Omar & Schiffman, 1992). There were three subscales in the original study: 29 Satisfaction with Provider, Satisfaction with Staff, and Satisfaction with Prenatal Care Services or System. Each subscale subsequently had concepts which were operationalized. In this study, these three subscales were used to analyze satisfaction with prenatal care. Prenatal Care Satisfaction with Provider. Prenatal care satisfaction with provider was defined as satisfaction with the doctor, nurse midwife, or the nurse practitioner who did most of the care the women received, reflected as Prenatal Care Satisfaction/Provider (PNCSl). Dimensions included Provider Caring, which reflected how the women felt they were treated by the provider (mean of items 29, 30, 32, 33, 42, 43 and 44). Provider Information reflected the explanations that the women were given by the provider regarding different aspects about their pregnancy (mean score of items 25, 26, 27, 39 and 40). The total of the Provider Caring and Provider Information dimension scales comprised the mean score for the Prenatal Care Satisfaction/Provider (PNCSl). The lower the score the more the pregnant women were satisfied with prenatal care regarding their provider. The higher the score, the less the pregnant women were satisfied regarding the provider of prenatal care. Prenatal Care Satisfaction with Staff. The second subscale, Satisfaction with Staff, was defined as satisfaction with the nurse, receptionist, aide, 30 nutritionist, social worker, lab technician and other people the pregnant women may come in contact with in the office or clinic, reflected as Prenatal Care Satisfaction/Staff (PNCSZ). The dimension concepts defined were Staff Caring - the way that the women perceived they were treated by the staff at the office or clinic (mean score of items 50, 51, 52, 53, 54 and 60), and Staff Information - the explanations that the staff gave the women regarding aspects of the pregnancy (mean score of items 48, 49 and 58). The total of the Satisfaction with Staff dimension scales comprised the mean score for the Prenatal Care Satisfaction/Staff (PNCSZ). The lower the score the more the pregnant women were satisfied with prenatal care regarding the staff. The higher the score, the less the pregnant women were satisfied regarding the staff with prenatal care. Prenatal Care Satisfaction with System. The third satisfaction scale, Prenatal Care Satisfaction with System (PNCSB), contained four dimensions. Waiting time referred to the amount of time women waited to be seen and the total amount of time spent at the office or clinic (mean score of .items 70 and 71). Access was reflected as the scheduling of Ixrenatal care appointments (mean score of items 68 and 69). 'Rhe Facilities referred to the waiting room, examination, rtxmms and facility parking (mean score of items 78, 79 and 80) . Organization looked at aspects of consistency of prxyvider and the choice the women had in picking a provider 31 (mean score of items 72, 73 and 74). The total of the mean scores of the dimensions of Satisfaction with System scales comprised the mean score for the Prenatal Care Satisfaction/System (PNCSB). The lower the score the more the pregnant women were satisfied with prenatal care regarding the services and system. The higher the score, the less the pregnant women were satisfied regarding the services and the system delivering her prenatal care. Prenatal Care Payor Source. Payor source was obtained from the demographic information section, question number 97. Choices given to the women were Medicaid, Private Insurance, MICH-Care or None (self-pay). Those included in this study for payor source were Medicaid and Private Insurance. Those who did not have insurance, noted as none or self pay, those insured by MICH-Care, or those who omitted completion of item 97 were excluded. Instrumentation The Patient Satisfaction with Prenatal Care Instrument (PSPC) was developed and revised by Omar and Schiffman (1992) as an instrument to measure patient expectations of and.satisfaction with prenatal care services. The instrument was developed after review of pertinent .1iterature and through three phases. These included focus Hmmum£u0 MO. 00.! 00. 50. 50. N0. 00. m0. 0a.! «hH.! m0.! >Oummc0 uummxm pousmcu muu>wum 0H.! «NH.! 00. «HH.! 0a.! 00.! 00.! 00.! «0H.! 0a.! 000.! mxm 40908 m0.! m0.! 50. HH.! h0.! 0H.! 00.! 00.! im0.! tNH.! no. OHMUOOC HH. 0H. «mm. 00.! #0. N0.! 00. n0.! 00. 00. 00. OumUmuwm GN.I ccON.I uma.! sumH.! ¢¢0N.! ¢c0H.! c:0N.! cgmfl.l «shN.l «inN.! ¢¢0N.! EHOMGH c0. #0.! 00. b0. 50. «05H. «00H. «ed. mo. «Mn. v0. >Hmmumzu0 ch.! «00H.! #0. sNH.! «00H.I ¢¢0H.! ccHN.! «Vn.l su0~.! «00H.! sNH.l >Oummc0 uowmxm wauwflmx 208000 QOHO Hunk 00‘ GENE hh‘fim OHCH UHMU 000H>Omm OHCH GHMU 0‘909 mam 090 «90 «am 44909 uuuum «000m 02909 >000 >000 003 mm macaumHmuuoo m manna 46 satisfaction. Correlations between the two groups revealed similar, moderate correlations and multiple weak correlations between dimensions of expectations with satisfaction (Table 5). Both groups had moderate, yet significant inverse relationships between expectations of information (Inform) and three provider scales: caring relationship (Prov Care), provider information (Prov Info) and total provider satisfaction (Total Provider). In F addition, other satisfaction scales and subscales were also significantly negatively correlated with the expectation of information (Inform) subscales for both groups. Correlational differences were also seen between the two groups in expectations and satisfactions. In the Medicaid group, expectations of one provider (OneProv) had significant weak, negative correlations with all staff and system satisfaction dimensions except system facility (Sys Facl). This pattern was not observed in the private insured group. This would indicate that for the Medicaid group, as expectations of one provider decreased, multiple dimensions of satisfaction increased. Another difference found was in regards to expectations of accessible quality care: expectations of appointments taking a long time, problems getting care, and receiving poor care. Although weak, only the private insured group Zhad.expectations of accessible quality care (AccCare) that were significantly correlated with satisfaction with all 47 dimensions of provider, all dimensions of staff, plus system facility (Sys Facl), system organization (Sys Orga), and total system satisfaction (Total System). Thus, for privately insured women as expectation of having problems with accessible quality care decreased satisfaction with most dimensions of satisfaction increased. Overall, most correlations were at best moderate and were generally negative. There were patterns of similarities between the two groups in expectations of information and satisfaction with provider dimensions and total. There were also patterns of contrast between the two payor source groups with Medicaid women more likely to have expectation of one provider (OneProv) and expectation of other services (OtherServ) correlate with staff satisfaction dimensions and staff total satisfaction, and private insured women more likely to have expectation of accessible quality care (AccCare) correlate with all aspects of satisfaction with care. Relationships for this study did exist between payor source groups for expectations of and satisfaction with prenatal care. Discussion Sample In this retrospective descriptive correlational study, a total of 520 pregnant women were evaluated by payor source. Three hundred and seven women receiving Medicaid and.213 women receiving private insurance were used in the 48 sample. Although the overall sample consisted of mostly white/non-Hispanic women who had a high school education or greater, and had started their care in the first trimester, when the two groups were compared, there were significantly different demographic findings. The Medicaid group was significantly younger than the private insured group. Consistent with the literature, and within this study, pregnant Medicaid populations are frequently younger as well as have different characteristics than the general population (Machala & Miner, 1991; Oberg et al., 1990). Much of the literature regarding prenatal care looked at adequacy of care or outcome by payor source. Sociodemographic characteristics associated with inadequate care were: poverty, unmarried, age less than 20, education less than 12th grade, and higher parity (Curry, 1990). These characteristics, consistent with this study's Medicaid population, have been found to influence the woman's prenatal care. Many of the characteristics of the sample for this study were consistent with the literature. This study, as with the literature (Fingerhut et al., 1987), found that as ‘women's education decreased to under 12 grade in high school, an increase in Medicaid participation was seen. Conversely, the higher the educational level achieved the Inore likely women were to have private insurance to pay for Lirenatal care. In addition, this study, consistent with the 49 literature (Fingerhut et al., 1987), found that lower socioeconomic status women were more likely to have delayed their start of prenatal care. Sixty four percent of the private insured women were having their first baby compared to 36% of Medicaid women. Many of the private insured women in the original collection of data, were participants in childbirth education classes. Although the sampling attempted to obtain parity diversity . . .. 1-. A-A- by including women who were attending "refresher" childbirth classes, this sample may not be representative of the private insured population. Thus, some of the differences seen in parity may be explained by the sampling itself. However, if someone has never experienced prenatal care services, one might suggest that expectations would be different than those of a woman with a repeat pregnancy. Perhaps, had the data been matched by age and parity, different or stronger relationships might have been noted. Expectations of Prenatal Care by Payor Source Both Medicaid and privately insured women overall had a moderate level of expectation of their prenatal care. However, higher mean scores were found for accessible quality care; both groups generally agreed they expected to Shave problems getting prenatal care and expected visits to ‘take long. Consistent with the findings of this study, (nonceptually all women develop a certain expectation of Irrenatal care as consumers of other health care (Greeneich, 50 1993), even those who had not yet had a child. This unique conceptualization is integrated from multiple aspects of women's socialization (Greeneich, 1993). Many factors influence expectations of prenatal care but both groups were noted to have some expectation of that care. This study found Medicaid women had higher expectation in receiving other services (nutritionist, social worker and public health nurse). In this Medicaid group however, over 63% were not having their first pregnancy. Perhaps previous pregnancy experiences had influenced their expectation of the present prenatal care. As well, with increasing public announcements of public services to low income women, these women may have felt receiving other services was an anticipated component of services normally expected in obtaining prenatal care. In addition, the Medicaid group was significantly younger when compared to the privately insured group, thus, more likely to expect and relate to ongoing education. The private insured group did not have high expectations of being referred to other services. Perhaps this group anticipated that the information that they would need would be included and offered with regular prenatal care and a referral to public health was not necessary. In (addition, they may have felt that services through the puflolic health department were specific to low income women. 51 Although not of significant level, it is of interest that women receiving Medicaid had higher expectations of having one provider, even though low socioeconomic status women are more likely to receive prenatal care at a clinic setting (Fingerhut et al., 1987) where multiple providers are more likely to be offering care. This may be influenced by the lack of primary care providers for many low income individuals who have no routine health care insurance. The expectation that when an individual does have insurance, one [ provider will then deliver the care may be had by Medicaid - women. Women in the privately insured group had higher expectation of receiving personalized care. To receive individualized attention, to have the provider care both mentally and physically, and to have a referral for problems were not as significantly expected by Medicaid women. This goes along with the concept of developing a relationship with an individual obstetrician or private physician as a primary provider of prenatal care. Again, lower socioeconomic women receiving Medicaid are often not accepted at a private practice (Fingerhut, et al., 1987; Young, McMahon, Bowman, & Thompson, 1990) and thus seek care at public clinics where one provider may not be available. In addition, without prior health care insurance or .irregular coverage, perhaps many low income women had never (developed the same level of relationships as privately 52 insured women. Therefore, perhaps Medicaid recipients do not expect to have personalized care as often. The Medicaid group had significantly higher total expectations of their prenatal care than the private group. In this study, the Medicaid group was more likely to be having a second pregnancy. Thus, many women may have been previously educated as to what to expect and to the services available. For the primiparas, word of mouth, community or state public service announcements may have increased the awareness of services available to low income women and the importance of prenatal care. Perhaps as a result, Medicaid women have come to expect more be offered during prenatal care, when compared to privately insured women. Another factor may be that low income are often uninsured and unable to participate in non-pregnant preventative health care services. Increased insurance (Medicaid) coverage of pregnant women has afforded low income women insurance coverage that they are perhaps not accustomed to receiving. Low income women may therefore have overall higher expectations of prenatal care services once insurance coverage is secured. Privately insured women are less apt to have disruption in coverage and perhaps, assume once ;pregnant, they will receive a certain level of prenatal care jprevdously experienced, thus, no significant increase in expectations may exist. An additional point is that the :mirvey was administered in the third trimester. The timing I " o I Midi-ital; . o 53 of the survey administration by itself, may be a concern. Women retrospectively reported on their prenatal care expectations; thus, expectations may have been influenced by past experiences, by the present care and services received, or both. As seen in this study, overall both groups had moderate levels of expectations of prenatal care. The privately insured women did not have expectation of overall services as high as Medicaid recipients. Little variability was found in the expectation dimensions of prenatal care with both groups. It is curious that women in both payor source groups expressed such little variance in expectations regarding a major life event of having a baby. But perhaps, the uniqueness of these women being asked and the retrospective nature of the study may offer an explanation. Further research is certainly indicated regarding expectations of prenatal care. Satisfaction of Prenatal Care by Payor Source Overall both groups were satisfied with their prenatal care. Neither group was dissatisfied with any dimension of satisfaction with their prenatal care. Perhaps the anticipated birth of a child, or what some studies refer to .as the halo effect (Oberst, 1984; Seguin et al., 1989) was OCKNJrring. Women may have felt somehow obligated to express a certain level of satisfaction for fear of impact somehow cn1 the remainder of their care, although informed consent Ii‘f‘iFfi-n- 54 indicated otherwise. Personal interactions with the provider or staff, or the wording of the instrument itself may also have made it difficult to be strongly dissatisfied with many questions. All women were in the last trimester of their pregnancy. Many may have been uncomfortable and/or have been anxious regarding the impending labor and wished to complete the 108 item survey quickly and leave the office/clinic. Thus, many women may have answered in the i§u~—-I-w’ ‘~ 3 1 middle range and perhaps not truly thought each and every question through thoroughly. Women receiving Medicaid were significantly more satisfied with information from the provider and the total provider subscale, when compared to the private insured group. This finding is consistent with the report by Hall and Dornan (1990) that satisfaction was related to the manner and information given by the provider. Curry (1990) reports that when provider services are depersonalized, prenatal care can be negatively impacted, and thus satisfaction decreased. Further, the Medicaid group was younger than the private insured group, therefore, perhaps more in need of this information, and more influenced by the authority of the health care professional. A portion of the sample for this study was from childbirth classes. Low socioeconomic vumnen frequently do not attend outside childbirth education (:lasses. Knowing this, perhaps the prenatal care providers 55 have established teaching standards for lower income women during their appointment times. Perhaps many prenatal care providers have also come to assume higher income women will participate in childbirth education classes and obtain information at that time rather than providers offering information during regular prenatal care visits. By targeting the younger or lower income client for educational information, it may not be realized that many higher income women as well, expect information and are dissatisfied with the provider if information is not offered. Further, private insured women may not have their concerns addressed. Even though the private insured group were more educated, they also were more likely to be having their first baby. These women may have felt they were in need of prenatal care information to assist with this new experience. Perhaps the providers felt that higher educated women would be more motivated to seek information on their own. However, the private insured women were not as satisfied when information was not offered. Dissatisfaction with provider has been contributed to inadequate teaching (Curry, 1990). As well, a decrease in time spent discussing the pregnant woman's concerns has been related to decrease in satisfaction (Sullivan et al., 1982). Private insured pregnant women may need to be addressed more directly as to their concerns and educational needs, and then have these integrated in their care. 56 Looking at the staff satisfaction dimensions, it was found that the Medicaid group was significantly more satisfied with the information given by staff when compared to the private insured group. ,Again, the Medicaid group was younger, had lower educational level and were low income. Assumptions may have been made by the staff, based on age, that increased information needed to be given. This may also be linked to the fact that with low socioeconomic women having poorer outcomes, increased education is marketed towards them. The private insured group was satisfied, but significantly less satisfied than the Medicaid group. There was no significant difference in the caring relationship by staff or the total staff satisfaction subscale, overall interactions were felt as comparable in satisfaction by the two groups. However, it may be that prenatal care education in the office/clinic is offered by staff who interact with Medicaid women differently than staff in office/clinics of the private insured group. Perhaps, again, staff make the assumption that older, highly educated, married women do not need to be given information, and information is not offered to all women equally. The women in the private insured group were significantly more satisfied with the amount of time they waited to be seen and time spent in the office, the facility's waiting room, exam rooms, and parking, the organization's consistency in providers and choice of 57 providers, as well as the total system satisfaction. Again, this increased satisfaction with the material aspects of the services may reflect the fact that these women were more likely to receive their care at a private provider versus a public clinic setting. These facilities may have had better staffing to maintain the office and grounds as well as located in more affluent areas of the community. Private insured women in this study were more likely to be married, having their first pregnancy and more likely did not have to deal with barriers associated with poverty. In addition, as suggested within the literature (Inglis, 1991), Medicaid women have other factors, poorer health, substance abuse, and more irregular utilization of prenatal care, that make them high risk. In the process of delivering good medical care, these appointments are more likely to take longer. Evaluation, plan and implementation for high risk pregnancies take longer, yet with a lower level of education, perhaps many of the Medicaid women did not fully understand the reason and the importance of the longer office/clinic visit. Although the Medicaid group was satisfied with all of these system dimensions, they were significantly less satisfied when compared to the private insured group. The Medicaid group may have had more barriers trying to utilize prenatal care. Public transportation with set schedules, child care for other children who are not always welcome in the waiting room, and 58 available providers for Medicaid obstetric services (Curry, 1990) all can have a tremendous impact on satisfaction. Thus, women may need to wait longer because of lack of flexibility in transportation. As well, many agencies trying to address these barriers experienced by low income women, are attempting to do "one stop shopping" (Machala & Miner, 1991) where the woman has multiple appointments following each other (provider, staff educator, nutritionist) at one agency. This will then decrease the number of times transportation is needed, but increase the amount of time spent at the clinic and further, may confuse women as to the consistency of the provider of care. Further, the subjects in this study were all paid volunteers. Perhaps women were not truly interested in the research, and did not pay attention to the questions on the survey. In addition, perhaps those who were less satisfied with their care were also less likely to attend regular prenatal care services and did not participate in the original study at all, or just didn't bother to complete a questionnaire. An additional factor is that it is unknown how many women were not included in the study because of (preterm delivery, because they left care altogether or switched providers because of dissatisfaction. Women, also, were not queried as to whether their primary source of insurance changed during the course of the pregnancy. Thus, 59 other factors may also have influenced satisfaction with prenatal care and were not evaluated in this study. All women perceived a certain level of satisfaction with their prenatal care. However, satisfaction with prenatal care services was perceived differently by women who were receiving Medicaid when compared to women who received private insurance. Similarities existed between the payor source groups in satisfaction with three dimensions and one total subscale. However, differences in satisfaction were found in five dimensions and two total subscales. Relationship between Expectation of and Satisfaction with Prenatal Care by Payor Source Although this study did find significant differences in expectation in and satisfaction with prenatal care by payor source, no strong relationships were noted. However, one moderate and multiple weak correlations were found that were significant. In addition, a majority of the correlations were negative, indicating an inverse relationship. There was little variability in the scores by payor source. With little overall variability, generally low correlation values are found. Perhaps the convenience sample was too homogenous. A more likely contributing factor is that expectations were evaluated retrospectively. Pregnant women experience many changes during a pregnancy. From confirmation of a pregnancy to late in the third 6O trimester, a myriad of experiences occur. Expectations of prenatal care may lack significance for the women as they approach the end of the pregnancy, or they may have forgotten what was really expected with prenatal care months before. When asked to remember back, perhaps many of the women took a more non committal response, resulting in only moderate levels of expectations reported by their responses. In addition, satisfaction scores also lacked variability. Women were generally satisfied with prenatal care in both groups. Again, without a broad range of values, scores were clustered. These scores again, may be influenced by the timing of the survey. Women who are regularly attending prenatal care generally are more likely to be satisfied with the service they are receiving. Although high risk pregnancy status was not known, many of the sample were obtained at pregnancy support programs, which may be loosely inferred with the pregnancy progressing without severe complications. If the pregnancy was felt to be developing favorably, women may be more likely to feel satisfied with other aspects of their care. Since both groups had similar levels of expectations, and levels of satisfaction, a lack of variability is most likely contributory to no strong significant correlations. An additional point may be that other significant factor correlations were not included in this study. If the questions regarding expectation did not significantly 61 correlate to levels of satisfaction by pregnant women, this too, would result in low variability in scores, and thus potentially in low correlations. Significant correlations that were found, were generally negative. With moderate levels of expectations it does not take much positive intervention to raise satisfaction scores. Perhaps with only a moderate level of expectation expressed by both groups of women, many dimensions of satisfaction were inversely related and increased, as a result. Low levels of expectations correlated with higher levels of satisfaction. Very little was found in the literature regarding correlations between expectation of and satisfaction with prenatal care by payor source. Perhaps no specific factors have peaked interest regarding expectation elements that specifically correlate with prenatal care satisfaction elements. One finding of this study was that Medicaid women's expectation of one provider (Prov) negatively correlated with generally all dimensions of satisfaction. These were mostly significant correlations. As these women decreased their expectation of having one provider, satisfaction with