Reviewer's report
Title:Expectations and satisfaction with antenatal care among pregnant women
with a focus on vulnerable groups: a descriptive study in Ghent.
Version:1Date:13 August 2015
Reviewer: Helen Haines
Reviewer's report:
Thank- you for the opportunity to review this descriptive study exploring the
expectations and satisfaction with antenatal care among pregnant women in
Ghent, Belgium. The study focused on women from vulnerable groups.
Abstract
Introduction
1. Please include the work of Larsson (1, 2) who has recognised the
shortcomings of measuring satisfaction based on fulfilling expectations.
2. Line 93 – A more thorough critique of how expectations are shaped would
inform the next section on vulnerable women. Satisfaction with the health-care
system may depend more on factors external to the health system than on the
experience of care as a patient, hence measuring the latter may be of limited use
as a basis for quality improvement or system reform see: Thompson AGH, Sunol
R. Expectations as Determinants of Patient Satisfaction: Concepts, Theory and
Evidence. International Journal of Quality in Health Care 1995; 7: 127-41.
Socioeconomic status and healthcare satisfaction :
1. This section begins with: ‘Special care should be paid to the satisfaction with
antenatal care of vulnerable women’ but then states that poor attendance/ late
attendance at antenatal care is associated with several vulnerable groups of
women. By virtue of belonging to these groups barriers to accessing antenatal
care abound (eg cost, transport, information, family support, language barriers,
child care etc ) - satisfaction with care may play only a small part. The reference
to Handler A, Kennelly J, Peacock N: Reducing racial/ethnic disparities in
reproductive and perinatal outcomes: the evidence from population-based
interventions was not useful in supporting this contention as the reader is not
directed to a chapter or page number that clearly gives any evidence in support
of low satisfaction with care being the de-motivating factor for attendance
amongst vulnerable women.
Please also take a look at: Kilbourne, A. M., Switzer, G., Hyman, K.,
Crowley-Matoka, M., & Fine, M. J. (2006). Advancing Health Disparities
Research Within the Health Care System: A Conceptual Framework. American
Journal of Public Health, 96(12), 2113–2121. doi:10.2105/AJPH.2005.077628
2. Line 99: The term ’literature’ is not very convincing when making an argument.
Please tell the reader more about the studies to which you are referring.
3. Line 107 -110 is out of sync – please move to the methods section under
setting.
Methods
4. How did you estimate the recruitment number (100)? Was this the number of
women expected to attend the clinic during the recruitment period? Or did you
calculate how many vulnerable women may attend during this period (given you
tell us later that a particular program and Ob/GYN attract vulnerable women at
certain clinic times). This section is not clear.
5. Line 147 – omit repeated phrase ‘waiting room’.
6. Line 159- replace’ assure’ with ‘ensure’
7. Line 163: please tell us the participation rate as well as the response rate.
Figure one tells us that 155 women were invited but we don’t’ know how many
could have been invited during the recruitment period
8. Line 171: The readers do not need to be told why you collect demographic
data in a study such as this.
9. Line 198: Please give a more comprehensive explanation of Prudencio’s factor
analysis and test/retest analysis – ‘satisfying results’ is highly inadequate. It is
less than convincing that testing an instrument in a Portuguese population will
hold true for a population in Belgium with so little critical reflection in this section.
Apart from deleting one item which was not appropriate in the Belgium setting,
did the authors undertake their own factor analysis of the PESPC for this
population?
10. Line 204 – a reference should be included for back translation
11. Line 212- what do the authors mean by ‘our scale’. Much more information
should be given here in regard to how the scoring works ie low scores equal high
expectation, high satisfaction; if any items are reversed (it appears they are not).
12. Line 218- Data Analysis. ‘To analyse differences groups, the ANOVA- test ...’’
I guess this is a typo and the authors are intending to determine differenced
between groups and within groups. Please clarify.
Results
13. Line 227: please give the range and SD when quoting a mean
14. Table 1 should include all demographic data.
15. Line 254 – what is meant by ‘possible intervals’? Are these part of the
recommended scoring procedure to be used in PESPC? Please explain your
rationale for doing this.
16. Table 4 – what is the % column referring to?
17. Table 5 – I am rather confused by this table. The author’s state that they
have used ANOVA however the table gives the appearance that they have
analysed the continuous dependent variables of expectations and satisfaction by
two groups for each independent variable in which case a T Test would have
been the appropriate choice. Either way, asterix have been used erroneously.
Currently it looks like both dichotomous variables are significant where the * are
placed. Please report the actual P value and the effect size for each variable
tested if in fact an ANOVA has been used. Also what is ‘confrontation’ supposed
to mean here – there has been no definition of this.
18. Line 281 – (see Table 8). There is no table 8 in this document, nor table
seven for that matter even though it is not referred to!
19. Annexe 1 – Is this Abuse Assessment Screen a validated tool? It is not
discussed in the method section other than having been used in BIDENS. In its
current form it needs English editing.
20. There is no clear result linking poor or late attendance at Antenatal care with
belonging to vulnerable group - this was proposed in the introduction as a central
problem.
21. The next lot of results which are linking various factors with IPV while
interesting, are not clearly connected to the key research aim. We were not told
previously that the authors intended to examine this in such detail. Again rather
confusing given the main aim was expectations and satisfaction with antenatal
care.
Discussion
22. Line 295 – ‘literature’ – see previous comment
23. Line 311 – typo’ ...pregnancy care in may result...
24. Line 315 – incorrect use of past tense
25. Line 329 – this is the crux of the argument however there is little discussion
about the fact that vulnerable women did have the lowest expectations except to
say that it was in line with previous work.
26. The next section on satisfaction could have been greatly strengthened by the
authors discussing the proposal that the issue for vulnerable groups of women
attending antenatal care is more related to the social determinants of health than
satisfaction with the care when and if they attend. This study has shown that the
hypothesis of improving satisfaction is flawed if it is predicated upon matching
expectations.
27. Associations between risk factors for inadequate antenatal care;
I am really not sure why this section became such as focus in the discussion as it
seems to be restating what we already know and that is factors that make a
person vulnerable – financial stress, IPV, immigrant status and being of a young
age.
Conclusion
28. ‘The association between several risk factors (e.g. smoking & unplanned
pregnancy, non-Belgian nationality & financial distress, IPV & low SES), that are
known to contribute to poor pregnancy outcomes, was demonstrated in our
study- This study did not measure poor pregnancy outcomes.
29. References: Please check the accuracy of the referencing eg ref 9 and 16
are incomplete
References
1. Larsson BW, Larsson G. Development of a short form of the Quality from the
Patient's Perspective (QPP) questionnaire. Journal of Clinical Nursing.
2002;11(5):681-7.
2. Larsson G, Larsson BW. Quality improvement measures based on patient
data: Some psychometric issues. International Journal of Nursing Practice.
2003;9(5):294.
1. Is the question posed by the authors well defined? Yes Line 120: Aim and
research question: he general objective of this study was to assess satisfaction
and expectations with antenatal care, with a focus on vulnerable women Specific
aims were to identify risk factors for low expectations and to explore which
aspects of antenatal care could be improved in a hospital setting.
2. Are the methods appropriate and well described?
No – see comments
3. Are the data sound?
Some of the tables are poorly constructed so it is difficult to make a clear
assessment
4. Do the figures appear to be genuine, i.e. without evidence of manipulation?
Hard to determine.
5. Does the manuscript adhere to the relevant standards for reporting and data
deposition?
Generally yes.
6. Are the discussion and conclusions well balanced and adequately supported
by the data?
Not entirely – see detailed comments
7. Are limitations of the work clearly stated? yes fairly well
8. Do the authors clearly acknowledge any work upon which they are building,
both published and unpublished?
Yes however some reference is inaccurate
9. Do the title and abstract accurately convey what has been found?
Yes
10. Is the writing acceptable?
Needs some English editing
Level of interest: An article of limited interest
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
'I declare that I have no competing interests'