Iranian women and care providers’ perceptions of equitable prenatal care

Introduction

Prenatal care which is referred to as the care of pregnant women using evidence-based interventions ¹ is an invaluable resource for obstetric complications’ monitoring ² and offers opportunities for early detection, prevention, and treatment of diseases. ³ Prenatal care can improve women’s and their infants’ health ⁴ and improves pregnancy outcomes ⁵ by preventing adverse outcomes ⁶ such as maternal mortality, ⁷ low birth weight, neonatal mortality, and infant mortality, ^{8 –10} and also it prepares parents for labor, birth, and parenthood. ¹¹ For example, Debiec et al. ¹² in a 10-year retrospective study found that women who had no prenatal care had a nearly eightfold higher risk of preterm birth, compared with those who attended 75%–100% of the recommended visits.

One of the core principles of Primary Healthcare approach which includes prenatal care is the equitable provision of care. Equity as an ethical concept closely related to human rights principles ¹³ received substantial attention in healthcare especially in maternal healthcare and has become a priority concern in health policy-making. ¹⁴ To provide equity in care in general and in prenatal care specifically, it is essential to have appropriate understanding of what equitable care is.

There are different interpretations of the concept of equity ¹⁵ in the context of healthcare. Based on the conducted literature review, major interpretations presented for equity in healthcare included equal access for equal needs; ^{16 –18} equal utilization for equal need; ^17,18 distribution and resource allocation according to the needs; ^16,18 equal distribution of care for all; ¹⁷ absence of unfair and avoidable differences in health among different population groups; ¹⁹ and equal health outcomes. ¹⁸ Pertaining to equitable maternal care, it was defined as all women having access to the same high-quality and high-value care and care differences being based on women’s health needs and values. ²⁰

All of the mentioned definitions mainly emphasized the notion of “need” which is perceived as a personal, subjective, and variable concept. Accordingly, the needs identified by professionals (normative) may differ from those “felt” by the individuals. ²¹ Therefore, the concept of equity, linked with the definition of need, because of its subjective nature is difficult to define and definitions vary depending on whose perspective is taken and within which context it is considered. ^17,22 The existing differences between the views of experts and stakeholders, regarding this concept, make it essential to consider equitable care from the providers’ and users’ perspectives ²³ who are directly engaged in care process.

Clients’ perceptions with equity in healthcare have several consequences; for example, it can affect their satisfactions with the quality of care as equity has been identified as one of the attributes of quality healthcare, ²⁴ subsequently determining their willingness to comply and continue with the services ²⁵ and their utilization of the services provided. ^3,26 Therefore, a better understanding of clients’ and providers’ perceptions of what constitutes equitable prenatal care is substantially important in preventing undesired consequences in prenatal care.

In the conducted literature review, there was a lack of knowledge regarding users’ and providers’ understandings of equitable care in general and equitable prenatal care in particular. Most of the studies conducted in the field of equitable care in general were quantitative focusing on healthcare access, ^{27 –29} utilization, ^19,30,31 and resource allocation. ^32,33 Qualitative studies in the field of equitable care were limited in general, ^15,34,35 and in the prenatal care, most of the qualitative studies reviewed focused on experiences of prenatal care in general ^{1 –3,36,37} or quality of prenatal care. ^{4,25,38 –40} Thus, further knowledge is needed about what is equitable prenatal care in the eyes of pregnant women and their care providers. This knowledge might prove helpful in developing a more equitable system of prenatal healthcare. Consequently, it was decided to fill the knowledge gap by conducting this study. This study is, to our knowledge, the first to explore the providers’ and users’ understandings of equitable prenatal care.

Aim

The aim of this study was to explore pregnant women’s and care providers’ perceptions of equitable prenatal care in an Iranian healthcare context.

Methods

In this study, a qualitative approach with content analysis method was used. Because qualitative approaches have exploratory nature, ⁴¹ believe in multiple realities, and have a special obligation to understand the phenomenon from the perspective of the participants experiencing the phenomenon, they are valuable for studying less well-known areas. ⁴² Content analysis is a useful qualitative research method to answer a research question that explores feelings, perceptions, thoughts, attitudes, or motives related to a concept of interest. ⁴³ Since there is a lack of knowledge in regard to the research topic, using inductive content analysis would be suitable to gain insight into the perceptions of equitable prenatal care. ⁴⁴

Setting and participants

According to Polit and Beck, ⁴⁵ for collecting data in a naturalistic setting where the phenomenon occurred, the study was carried out in six purposively selected public urban health centers located in different geographical areas of Ahvaz city. All the health centers had family health units which provide services including antenatal care, child healthcare, family planning, and immunization. Every center had four to six midwives and health experts to offer such services. Average daily antenatal care attendance in these health centers was 10–15 women. A purposive sampling was used to recruit participants for the study. Being pregnant with ≥ 30 weeks of gestational age and receiving prenatal care from the health centers for pregnant participants, being a full-time employer with at least 6 months of experience in prenatal care for care providers, willingness to participate in the study, and ability to communicate the experiences for both pregnant women and care providers were inclusion criteria. The participants of the study were 10 pregnant women, 6 midwives, and 4 health experts. The participants ranged in age from 18 to 32 years and 23 to 40 years for pregnant women and care providers, respectively. Four of the participated pregnant women were employed, and the rest of them were housewives. The participating care providers had 1–22 years of work experience, and they all had BSc degree in midwifery or health science.

Data collection

The data were collected using unstructured interviews from June 2013 to June 2014. The interviews began with general questions such as “What does equitable prenatal care mean to you?” and “When do you feel your care is equitable?” Then, they were asked to explain their own perceptions of equitable care as well as what they (care providers) did to provide an equitable care. Besides, these open-ended questions probing questions such as “Can you give an example which exactly clarifies your feelings about equitable care?” and “Can you explain more?” were used to capture the participants’ experiences. In case of any ambiguity, follow-up interviews were conducted. Totally, 24 one-on-one individual interviews were conducted with 20 participants. Participants were interviewed in private at the selected health centers by their own choice. The interviews lasted an average of 30 min, ranging from 20 to 45 min depending on participants’ tolerance and interest in sharing their own experiences. All interviews were recorded by using a digital voice recorder with the informants’ consent and then transcribed verbatim immediately after interviewing. Data collection continued until data saturation was achieved; that is, sampling continued to the point at which no new information is obtained and redundancy is achieved. ⁴⁵

Data analysis

A content analysis approach was employed for data analysis which took place concurrently with data collection. For analyzing the data, Elo and Kyngas’s ⁴⁴ qualitative content analysis approach was applied. First, in the preparation stage, the whole interview was chosen as the most suitable unit of analysis. In order to obtain the sense of the whole, each interview was read several times. In the organizing stage, open coding was conducted by rereading the interviews and writing notes and headings on the text margins. Then, the headings were grouped based on comparisons regarding their similarities and differences. This process was repeated for each interview. Finally and through abstraction, seven main themes were formulated.

Trustworthiness

In accordance with Streubert and Carpenter, ⁴² credibility of the data was established through prolonged engagement in the field from June 2013 to June 2014. Member checking was also used during the data analysis process to make sure whether the findings reveal the participants experiences, and whenever needed changes were made. To cover a wide range of viewpoints and experiences, maximum variation sampling was used according to health centers location, work experience of care providers, the age of the participants, and so on. Dependability and confirmability of the data were confirmed via auditing the interviews and analysis process by some qualitative research experts.

Ethical considerations

We received ethics approval for this study from the Ethics Committee affiliated to Ahvaz Jundishapur University of Medical Sciences (Ethics Code: ajums.REC.1392, 166). We also received permission for conducting the study from Ahvaz Health Network. All participants were informed about the aim of the study and interview recording. The participants were assured regarding voluntary participation, confidentiality of their provided data, and their anonymity. For participants’ convenience, interviews were scheduled with their own choice. Phone number and work address of the first author were also given to the participants.

Findings

At the end of the data analysis, the following seven themes from the data were obtained through interviews, explaining what Iranian pregnant women and care providers thought of equitable prenatal care: guideline-based care, time-saving care, nondiscriminatory care, privacy-respecting care, affordable comprehensive care, effective client–provider relationships, and caregivers’ competency.

Discussion

The findings of the study offer some information about equity’s major components in prenatal care based on the described perceptions of women and care providers. Based on these findings, equitable care must be guideline-centered, time-saving, nondiscriminatory, privacy-respecting, comprehensive and affordable, provided by competent care providers, and establishing effective clients–care providers’ relationships. Based on the findings of this study, women’s and care providers’ perception about equity in prenatal care is related to determining factors of care quality. Maybe it is because the care quality and equitable care are directly related to each other ^46,47 and that primary healthcare can contribute to the equitable care only when the care quality is optimized. ⁴⁸ In fact, women’s and care providers’ perception concerning equity in prenatal care is centered on the care process especially on how to establish relationships. In a study conducted by Silva et al., ⁴⁹ the patients also concentrated on process aspects of providing care—interpersonal aspect of care—in the perception of health services quality.

Pregnancy creates for women a very special condition which makes them emotionally more sensitive and need to get attention from others, especially care providers. Therefore, caregivers have responsibility to be compassionate with and supportive to pregnant women. ⁵⁰ From the viewpoint of participating women in this study, this factor is of high importance and is dominated over the other elements of care including technical aspect of care. These findings are consistent with the findings of a study conducted by Oladapo et al. ⁵¹

Participants in our study focused on issues such as respecting, compassion, sympathy, being affable, paying attention, and intimacy. Shahriari et al. ⁵² also considered human relationships between clients and care providers as one of the important values related to care and emphasized that traits like compassion, patience, and tolerance contribute to high-quality care. Several studies have also emphasized the importance of good and respectful relationship from the perspective of clients. ^5,6,11,38,53 In a review study on women’s prenatal experiences, Novick ⁵⁴ has also emphasized the central role of relationships in quality care. Generally speaking, an interpersonal aspect of care bears the highest importance among care receivers ⁵⁵ and affects women’s viewpoint about care and their perception about care quality. ³⁸ The more the care is provided in a more respectful atmosphere and more efficient relationship is established, the more satisfaction the clients will feel, and the more they are willing to go to health centers and use the services. ^54,56

Care providers participating in this study considered guideline-centered care as an indication of equitable care. It seems because the care providers are legally responsive to the clients’ outcomes and their performance evaluation is conducted by superior authorities based on their evaluable objective performance, this aspect is more emphasized. Some features such as interactions are not generally taken into consideration for evaluation. This feature was specifically presented by caregivers, and pregnant women never mentioned it which shows that maybe caregivers concentrate on technical aspects of care, while clients pay more attention to communicational aspect of care rather than technical aspects of care. In a study by Sword et al., ³⁸ following the instructions, based on the viewpoint of the participants, ensures better outcomes. Other studies also consider such care as an improving care quality, ⁵⁷ and improving care quality is one of the signs of equity in care.

We also found out that the time-saving care or spending short time to receive services is one of the characteristics of equity in care. Some of the participating women in the study spent much time receiving the required services. In various studies, long time waiting has been identified as a major problem and obstacle in prenatal care services. ^3,26,56 In some studies, long time of waiting has been reported. For example, the average waiting time reported by woman in a study by Ekott et al. ³ was 6 h. The studies have also shown that long time waiting for receiving services was a key factor affecting decision-making about utilizing prenatal services, first visit for receiving services, choosing care provider, ⁵⁸ and predicting satisfaction. ²⁰

Another feature of the equitable care mentioned by both pregnant women and care providers in this study was a care based on equality and free from discrimination. Equality and nondiscrimination are the foundations of equity concept. That is why equality as a central concept in healthcare is emphasized in the Declaration of Alma Ata (1978). ⁵⁹ The women participating in this study also said that care providers never discriminated among clients and provided similar services to all of them.

Respecting privacy while providing services or counseling was another important feature which both women and care providers emphasized. Privacy is a basic human need ⁶⁰ which is related to one’s existence ⁶¹ and being respected ⁶² and cannot be violated by anybody. ⁶¹ When the clients share their information with care providers, they expect to share such information privately, ⁶¹ and unauthorized persons have no access to it because it is part of their privacy. Various studies highlighted the importance of respecting privacy. ^38,60,63 In a study by Shahriari et al., ⁵² respecting privacy was introduced as one of the moral values related to care. Based on the findings of various studies, paying attention to clients’ privacy has a direct relationship with their satisfaction from service ^39,62,63 and utilizing services. ⁶⁴ However, clients in various studies complained about violating their privacy and their private information being heard by others. ^39,56,62,63 These findings are consistent with the findings of this study.

In this study, it was clear that all the required services for pregnant women are not provided in health centers, and clients had to go to private centers to receive services such as ultrasound, laboratory services, and providing supplements. In addition, in cases the clients need to receive counseling from gynecologist or other specialists, they have to go to private offices. However, most of the women visiting health centers belong to lower classes of the society and such expenses can impose high pressure on these low-income people. ⁶⁵ Consistent with our findings, other studies demonstrated that health services expenses—direct and indirect—and being unable to pay are among major obstacles to use prenatal services. ^19,58 In a systematic review, Simkhada et al. ⁶⁶ showed that socioeconomic factors are identified as an important factor affecting use of antenatal care services. The lack of a comprehensive coverage of the required services and failure to meet needs may lead users to suspect healthcare system as unfair because women prefer those health centers which can supply their favorite services such as comprehensive and concordant care. ⁶³ Although the Iranian healthcare system has been characterized by a strong public sector component, it is time to improve and broaden the public health sector to include more services which meet the needs of pregnant women, particularly vulnerable women, in the current era.

Participants in our study emphasized the care provider’s scientific competence as an element of equity in care. Both midwives and health experts believed that prenatal care must be allocated to midwives who received more specialized knowledge during their studies. However, health experts who did not receive adequate education in this area are also expected to provide such care in health centers. They considered this issue as violating the equitable care. In other studies, the importance of professional competency was emphasized, too, ^36,37 and considered the clinical knowledge as an important judging factor about prenatal services quality. ³⁸ It is evident that clients’ positive perception of care providers’ skills and competency can increase their willingness to attend, ⁵⁶ to utilize services, ⁶⁷ and to improve baby’s and mother’s health. ⁶⁸ Therefore, it is necessary for health system authorities to pay close attention to personnel’s preparations and to allocating roles based on specialties.

Conclusion

The findings of our study suggest that, concerning equitable care, participants’ perception is very broad and covers a wide range of dimensions, that may receive little attention by health planners and policy-makers. Therefore, in order to develop equitable care, it is essential not confining ourselves to the limited dimensions of equity and noticing other dimensions with higher importance for clients and care providers. Improving equitable care regardless of attitude of stakeholders and care providers is impossible as it is possible what matters most for officials and planners never matters for them. At the end, although attaining an equitable prenatal care is challenging, it is worthy in improving maternal health.