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Choosing a hospital for obstetric, gynecologic, or reproductive healthcare: what matters most to patients?
Original Research Choosing a hospital for obstetric, gynecologic, or reproductive healthcare: what matters most to patients? Luciana E. Hebert, PhD; Lori Freedman, PhD; Debra B. Stulberg, MD
BACKGROUND: Despite millions of U.S. women receiving obstetric/
gynecologic or reproductive care in a hospital each year, little is known about which factors matter most to women in choosing a hospital for this care. OBJECTIVE(S): To describe women’s reasons for choosing their hospital for obstetric/gynecologic or reproductive care, and to examine characteristics associated with reporting specific factors as important in hospital choice. MATERIALS AND METHODS: We conducted a nationally representative, cross-sectional survey of women aged 18e45 years. The 2016 survey recruited women from AmeriSpeak, a probability-based research panel. A total of 1430 women completed the survey. All data analysis used weighting and accounted for the complex survey design. We conducted bivariate and multinomial logistic regression modeling to assess associations. RESULTS: Three-fourths of women cited a hospital’s overall reputation/ quality as a reason, and one-third named this as the most important
H
alf of all reproductive-aged women in the United States expect to have a child in the future, regardless of how many children they already have; among nulliparous women aged 15e24 years, 86% anticipate giving birth at some point in their lives.1 With nearly 4 million births in the United States each year,2 for many women, obstetric or reproductive care represents their most frequent and common hospital experience. Despite the commonality of this experience, how women choose a hospital for their care is not well studied. Previous studies of hospital choice have used hospital discharge or Medicare or Medicaid data rather than asking users directly about their choices and preferences for hospital care. These studies often rely on conditional models to examine hospital use and hospital bypass patterns as proxy measures
Cite this article as: Hebert LE, Freedman L, Stulberg DB. Choosing a hospital for obstetric, gynecologic, or reproductive healthcare: what matters most to patients? Am J Obstet Gynecol MFM 2019;XX:x.ex-x.ex. 2589-9333/$36.00 ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajogmf.2019.100067
reason for choosing a hospital. A total of 14% reported hospital religious affiliation as a reason. Compared to those with no prior deliveries, women who had delivered an infant were more likely to report that their top reason was specialty services/provider (relative risk ratio, 2.97; 95% confidence interval, 1.96e4.52) and were also more likely to report overall hospital quality/reputation as their top reason (relative risk ratio, 1.52; 95% confidence interval, 1.06e2.17), compared to logistical reasons. Metropolitan versus non-metropolitan residence was also a significant factor in hospital choice. CONCLUSION: Women endorse many factors when choosing a hospital for reproductive care, but perceived quality and reputation outweigh logistical concerns such as location and insurance. Key words: hospitals, maternal and perinatal care and outcomes,
obstetrics/gynecology, quality of care, patient safety, patient assessment, patient satisfaction
instead of using hospital choice itself. Findings from these studies indicate that proximity to a hospital is a consistent factor in hospital use .3e6 In addition to proximity, hospital characteristics, including teaching status,7 hospital ownership (publicly or privately held),4,8 range of services offered,9,10 and market share,11 among others, are documented factors related to hospital choice. On the patient side, patient age,7,12 sex, race/ ethnicity,13 and insurance status are each associated with hospital choice.12 Choice of hospital can be particularly important in reproductive healthcare. Among those studies that have focused on choice of hospital specifically for reproductive, maternal or obstetric/gynecologic (ObGyn) care, patient income,14 high birth volume ,14 obstetric risk status,15 and patient’s insurance status,15 have each contributed to women’s choice of hospital in which to deliver. Fewer studies have asked women themselves what they look for when selecting a hospital for such care. Hospitals with a religious affiliation represent a large and growing proportion of the healthcare landscape. One in 6 patients receive their care in Catholic hospitals annually.16 Catholic and nonCatholic hospitals primarily differ in
whether their providers are expected to follow religious policies restricting sterilization, abortion, contraception, and some treatment for obstetric complications and miscarriage. Receiving reproductive care at a Catholic hospital can affect a patient’s experience and range of options,17e20 and prior research indicates that patients may not anticipate these differences before seeking care.21 In light of these considerations, this study had the following aims: 1) to estimate reproductive-aged women’s reasons for choosing a hospital for their reproductive care, and 2) to examine women’s characteristics associated with the importance of given factors in hospital choice. As a sub-aim, this study also sought to examine how religious affiliation factors into women’s decision making around where to seek hospital care.
Materials and Methods Respondents were drawn from the AmeriSpeak Panel, a nationally representative panel recruited and maintained by NORC at the University of Chicago. The study team e-mailed a survey invitation to 2857 English-speaking women aged 18e45 years registered with the Panel, a probability-based sample of MONTH 2019 AJOG MFM
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Original Research AJOG MFM at a Glance Why was this study conducted? To estimate reproductive-age women’s reasons for choosing a hospital for their obstetric/gynecologic or reproductive care, and to examine characteristics associated with the importance of given factors in hospital choice. Key findings Three-fourths of the women cited a hospital’s overall reputation/quality as a reason, and one-third of the women as the most important reason for choosing a hospital. Previous experiences with reproductive care were associated with prioritizing specialty services or reputation compared to logistical concerns. What does this add to what is known? Women’s decision making regarding where to seek reproductive care is multifaceted, and prioritizes perceived quality and providers in addition to logistical concerns such as insurance and distance. Women’s previous reproductive experiences are associated with their priorities in choosing a hospital for reproductive care. Improving women’s health experiences may help facilitate their decisions regarding future care.
civilian, noninstitutionalized adults selected and recruited from the NORC National Frame. This sample frame provides 97% sample coverage and is recruited via mail, telephone, and inperson contact. Respondents could complete the survey through the online portal or by telephone as they preferred. We conducted 3 waves of recruitment between June and November 2016, with multiple e-mail and telephone reminders sent to encourage survey participation following the initial survey invitation. Participants received $4 cash equivalent for completing the survey via phone or $2 cash equivalent for completing the survey online; these incentives were later increased to $10 cash equivalent to encourage survey completion in the second and third waves of recruitment. A thorough description of the AmeriSpeak Panel and the methods for this study have been previously reported.22 This study was granted exempt status by the Institutional Review Boards at both the University of California San Francisco and the University of Chicago.
Panel measures Measures obtained from the AmeriSpeak Panel data include the following: age, race, Hispanic ethnicity, highest educational attainment, religious 2 AJOG MFM MONTH 2019
identification, frequency of religious service attendance, geographic region of country, residence in a metropolitan area (area with a population of at least 100,000), political party identification, and whether the panel member has health insurance and type of health insurance held (ie, private or bought on an exchange, public or other).
Survey measures To measure respondents’ maternal and reproductive healthcare history, the survey asked respondents if they had ever received care for any of the following services: prenatal care during pregnancy, delivery of a child, pelvic examination and/or Papanicolaou (Pap) smear, tubal ligation/sterilization, birth control given or prescribed by a healthcare provider, care for a pregnancy complication, miscarriage or loss, or fertility treatment of any kind. To assess respondents’ reasons for choosing a hospital for obstetric/gynecologic or reproductive care, the survey first asked respondents to provide the name and location of their preferred hospital for obstetric/gynecologic or reproductive healthcare and then asked them to identify reasons for choosing that hospital. Based on qualitative interviews with patients and providers about reproductive care, we categorized
commonly cited reasons for hospital choice according to the following schema: location, specialty (this hospital is best for obstetric/gynecologic or reproductive care), overall reputation (hospital is known as high quality in general), insurance, hospital religious affiliation, or based on their doctor/ healthcare provider (this is where your doctor or other provider works). The survey provided participants with this list and asked them to mark whether each was or was not a reason for choosing that hospital; the survey then asked participants to select, among these reasons, which was the most important reason for which they go to that hospital. The survey also asked respondents 3 questions to measure their prioritization of religious affiliation when choosing a hospital: 1) whether they had ever chosen a hospital specifically because it was Catholic; 2) whether they had ever chosen a hospital specifically because it was not Catholic; and 3) whether they had ever chosen a hospital specifically because it was affiliated with some other religion. These questions were not specific to reproductive or obstetric/gynecologic care, but did follow a number of questions that specifically asked about hospital choice in regard to obstetric/ gynecologic and reproductive care. To identify the religious affiliation of respondents’ preferred hospitals, we verified each hospital name against a known list of Catholic-affiliated hospitals and supplemented this list with our own Internet search. A more extensive description of the methods and results of this subanalysis are reported elsewhere.23 For bivariate analyses, we combined the following reasons based on theoretical similarity for ease of interpretation: location and insurance were collapsed to form a measure of logistics, and specialty and doctor/healthcare provider were collapsed together to reflect clinical services.
Data analysis We estimated descriptive statistics to describe characteristics of the survey sample. We conducted bivariate analyses
Original Research to evaluate associations between participant characteristics and their most important reasons for choosing a hospital for reproductive care. We used c2 tests to evaluate significance of associations. We then performed multinomial logistic regression modeling to examine the association between participant characteristics and their reasons for choosing a hospital; logistical reasons (location and insurance) as the most important reason was selected as a baseline value. There was substantial overlap and high correlation in respondents’ receipt of prenatal care, delivery of an infant, and treatment for pregnancy complications. We thus included only delivery of an infant in the final regression model. Bivariate analyses and theoretical understanding informed by the literature guided multinomial model development and fitting. We compared models using information criteria to arrive at the final model as presented. All data analysis used weighting and accounted for the complex survey design; a was set at 0.05. All analyses were performed using Stata statistical software, version 14 (StataCorp, College Station, TX).
Results Of the 2857 women invited to participate in the survey, 1430 completed surveys, for a response rate of 50.1%. Descriptive statistics of the survey respondents are provided in Table 1. Twothirds of women had at least some college education (66.3%). Participants were racially, ethnically, and religiously diverse, and the majority (88.7%) resided in a metropolitan area. Nearly 9 in 10 women (86.9%) had ever received a pelvic examination or Pap smear, and 79.5% had received birth control from a healthcare provider. More than 6 in 10 respondents reported that they had received prenatal care (62.9%), and the same percentage had delivered an infant (62.3%). Slightly less than one-third of all women reported they had ever received care for pregnancy complications (31.3%). Participants’ reasons for choosing a hospital for reproductive care, and their
TABLE 1
Demographic characteristics of study sample and history of services received Characteristic
n
%
Age, y 18e26 years
450
31.5
2735 years
484
33.9
36e45 years
496
34.7
Non-Hispanic white
800
56
Non-Hispanic black
197
13.8
Hispanic
289
20.2
Other
144
10.1
Less than high school
146
10.2
High school graduate
336
23.5
Some college
482
33.7
College graduate
467
32.6
Protestant, noneBorn Again
139
11.8
Catholic
201
17.0
Other/just Christian
125
10.6
Race/ethnicity
Education
Religion
Other (non-Christian)
130
11
Nothing/atheist/agnostic
298
25.3
Born-Again Protestant
287
24.3
Never
146
23.3
Less than monthly
466
39.5
Monthly
154
13
Weekly
287
24.3
1268
88.7
162
11.3
Northeast
248
17.3
Midwest
292
20.4
South
542
37.9
West
349
24.4
Strong democrat
164
13.8
Moderate/lean Democrat
565
47.7
Independent/none
113
9.6
Moderate/lean Republican
275
23.2
Religious attendance
Metropolitan Non-metropolitan Region
Party identification
Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
(continued)
MONTH 2019 AJOG MFM
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Original Research TABLE 1
Demographic characteristics of study sample and history of services received (continued) Characteristic Strong republican
n
% 67
5.7
Private/employer/exchange
589
53.5
Public
240
21.8
Other
130
11.8
None
142
12.9
Health insurance
Services ever received (% responding yes) Prenatal care during pregnancy
62.9
Delivery of an infant
62.3
Pelvic examination and/or Pap smear
86.9
Tubal ligation/sterilization
15.5
Birth control from a healthcare provider
79.5
Care for pregnancy complication
31.3
Fertility treatment of any kind
7.5
Pap, Papanicoloau. Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
most important reason, are shown in Figure 1. More than three-fourths of women cited a hospital’s overall reputation or quality as their reason for choosing a hospital; one-third reported that this was the most important reason. More than 7 in 10 women reported location as a reason, but only 13% cited this as the most important reason. Although more than two-thirds endorsed insurance (67.6%) and doctor/healthcare provider (69.3%) as reasons to choose a hospital, one-fifth apiece cited these as the most important reasons. A total of 14% reported a hospital’s religious affiliation as a reason for choosing a hospital, and <1% reported that this was the most important reason. Among those who reported religious affiliation was a reason, nearly one-half (46.0%; 95% confidence interval [CI], 36.8e55.5) identified a religious hospital when asked to report their own primary hospital. Just over 3% (3.3%; 95% CI, 2.3e4.7) of women reported choosing a hospital because it was Catholic, whereas nearly 6% (5.6%; 95% CI, 4.4e7.0) reported 4 AJOG MFM MONTH 2019
that they had chosen a hospital because it was not Catholic. Just over 1% (1.6%; 95% CI: 1.0-2.5) reported choosing a hospital because it was affiliated with another religion. Having received prenatal care, delivery of an infant, receipt of a pelvic examination or Pap smear, and having received care for pregnancy complications were each associated with women’s top reasons for choosing a hospital (Table 2). Age, race/ethnicity, and region of residence were also significantly associated with top reasons for selecting a hospital. In the multinomial model (Table 3), women in metropolitan areas (relative risk ratio [RRR], 1.74; 95% CI, 1.01e3.00) and women who had delivered an infant (RRR, 2.97; 95% CI, 1.96e4.52) were more likely to cite specialty services/provider issues as their top reason relative to logistical reasons, compared to women in nonmetropolitan areas and women who had not delivered, respectively. Similarly, metropolitan residence (RRR, 2.07; 95% CI, 1.21e3.52) and delivery of an infant (RRR, 1.52; 95% CI,
1.06e2.17) were also associated with choosing a hospital because of its reputation or quality, compared to reasons related to location or insurance.
Comment Principal findings In choosing a hospital for reproductive, maternal, or obstetric care, women of reproductive age endorse a number of factors as reasons to choose a particular hospital, with hospital quality or reputation the most commonly endorsed and the most important reason. Metropolitan residence and prior reproductive experiences were consistently associated with choosing a hospital based on specialty/staff or quality/ reputation over more logistical concerns such as insurance or location. Women located in metropolitan areas may simply have more choices in selecting a hospital for reproductive care compared to women located in non-metropolitan areas. The salience of prior experiences and services used, including prenatal care, prior delivery, and treatment for pregnancy complications may also suggest that women’s own experiences are instructive in how they view and select hospitals, rather than convenience alone.
Results Findings from this study add to the growing literature surrounding hospital choice for reproductive care.20,21,23 These data suggest that both quality and provider/specialty services are important factors in hospital choice, in addition to location and insurance acceptance. An app-based study of pregnant women found that women were more likely to choose a hospital for obstetric care based on their specific healthcare provider, not the hospital itself.24 Women first chose a provider, deeming the provider more important (56% more important) than the hospital (7% more important). This study also indicated that women do not use quantitative measures of quality (metrics) but, rather, use anecdotal evidence or their own experience to form an opinion about the quality of care.
Original Research FIGURE 1
Reasons and most important reason for choosing a hospital for reproductive care 100 90 76.4
80
72.2
69.3
67.6
70
57.5
60 50 40
33.3
30 20.4
20.1
20
13.6
13.4
10
7.3
4.8 0.7
0 Overall reputaon/quality
Insurance
Doctor/Healthcare provider
Locaon
Is a Reason
Most important reason
Specialty
Hospital religious affiliaon
Other
Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
TABLE 2
Percentage of respondents reporting each factor as their top reason for choosing a hospital, by respondent characteristics Logistics (location/ insurance)
Services (specialty/ provider)
Overall reputation (quality)
Religious affiliation
30.2
32.6
36.8
0.4
30.2
33.2
36.1
0.5
34.4
28.5
36.8
0.4
26.3
30.7
42.8
0.3
35.8
28.2
35.7
0.4
31.4
33.6
34.2
0.8
26.4
38.8
34.3
0.5
18e26
38.9
18.4
40.9
1.9
27e35
35.4
26.3
38.0
0.3
36e45
33.7
33.9
32.1
0.3
Non-Hispanic white
35.9
30.9
32.6
0.6
Non-Hispanic black
27.8
23.6
46.8
1.8
Hispanic
39.5
20.2
39.3
1
Characteristic Services ever received Prenatal care during pregnancya Delivery of an infant
a
Pelvic examination and/or Pap smeara Tubal ligation/sterilization Birth control from a healthcare provider Care for pregnancy complication Fertility treatment of any kind
c
b
Other characteristics Age, ya
Race/ethnicityc
Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
(continued)
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Original Research TABLE 2
Percentage of respondents reporting each factor as their top reason for choosing a hospital, by respondent characteristics (continued) Characteristic
Logistics (location/ insurance)
Services (specialty/ provider)
Overall reputation (quality)
Religious affiliation
Other
38.3
19.4
42.4
0
Less than high school
38.9
24.8
34.5
1.7
High school graduate
34.9
22.0
42.0
1.2
Some college
33.4
28.7
37.1
0.9
College graduate
38.1
27.8
33.9
0.2
Protestant, noneBorn Again
37.8
27.6
34.6
0
Catholic
35.7
25.7
36.8
1.8
Other/just Christian
27.0
30.3
42.7
0
Other (non-Christian)
37.6
24.2
38.2
0
Nothing/atheist/agnostic
45.3
22.6
32.1
0
Born-Again Protestant
35.4
24.3
39.0
1.3
Never
42.3
19.5
37.6
0.6
Less than monthly
37.9
27.2
34.3
0.6
Monthly
33.3
27.7
39.0
0
Weekly
35.5
25.4
37.9
1.1
Metropolitan
35.1
26.4
37.9
0.7
Non-metropolitan
42.5
27.3
28.5
1.8
Northeast
40.0
23.9
34.8
1.3
Midwest
31.3
31.3
36.7
0.7
South
28.1
29.9
41.2
0.9
West
48.2
19.4
32.1
0.4
Private/employer/exchange
35.5
29.7
34.5
0.3
Public
34.2
24.0
40.2
1.6
Other
46.7
17.8
36.0
0.6
None
32.1
22.9
45.0
0
Education
Religion
Religious attendance
Region
b
Health insurance
Party identification Strong Democrat
35.9
21.3
41.9
0.9
Moderate/lean Democrat
38.2
22.6
39.0
0.3
Independent/none
31.2
33.7
32.9
2.3
Moderate/lean Republican
38.9
30.0
30.8
0.3
Strong Republican
21.4
31.9
46.8
0
Pap, Papanicolaou. P < .001; b P < .01; c P < .05. Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019. a
6 AJOG MFM MONTH 2019
Original Research Although patients cite quality as important, previous studies suggest that they rarely report consulting actual quality metrics.25 Information from a mixed-methods study found that women interpret quality of a hospital based on interactions with clinical staff, and in terms of patient-centered care, communication, and medical team coordination.26 Less than 1 in 3 pregnant women (28%) in this study reported having used comparative quality information about hospitals in choosing a hospital for delivery. Patients’ primacy of the provider over the hospital itself was also reported in this study. Anecdotal or narrative information from an individual’s trusted network may be more important in healthcare decision making,27e30 in which patients rely on a “lay referral network” to inform their choice for hospital care.4 In a prior survey of pregnant women,26 a hospital that “accepts your insurance” was rated as “very important” by 98% of respondents, followed by “is one where you had a good experience in the past” (77%) and “was recommended by your doctor or midwife” (64%). More formalized metrics of quality (“ratings on a website that compares hospitals” and “rating from patients on website that compares hospitals”) ranked lower in terms of importance. The importance of women’s previous reproductive health service use in their reasons for selecting a hospital is also of note. One previous study has found that after controlling for hospital and market characteristics, patients’ satisfaction with a previous hospital experience is associated with loyalty/repeat use.31 One’s own experience, or that of a close or trusted friend or relative, may therefore contribute to women’s sense of the quality and/or reputation of a hospital. Although it is not studied here, learning more about how women define quality and reputation in the realm of reproductive care may be valuable. A previous study that looked at patients who had received care at a religiously affiliated hospital found that only 1 of 200 former patients cited hospital religious affiliation as a determinant in their choice for care.32 Rather,
TABLE 3
Relative risk ratios (95% confidence intervals) from multinomial logistic regression analysis assessing top reason for choosing a hospital for obstetric/gynecologic or reproductive care RRR (95% CI) Services (specialty/provider) vs logistics (location/insurance)
Overall reputation (quality) vs logistics (location/insurance)
18e26
Ref
Ref
27e35
1.05 (0.64e1.73)
0.88 (0.58e1.33)
36e45
1.33 (0.80e2.22)
0.75 (0.47e1.19)
Northeast
Ref
Ref
Midwest
1.79 (1.00e3.21)
Age, y
Region
South
1.62 (0.91e2.87)
West
0.63 (0.34e1.15)
1.43 (0.85e2.43) a
1.60 (0.96e2.68)a 0.70 (0.40e1.22)
Residence Non-metropolitan
Ref
Ref
Metropolitan
1.74 (1.01e3.00)
b
2.07 (1.21e3.52)b
Delivery of an infant
2.97 (1.96e4.52)c
1.52 (1.06e2.17)c
CI, confidence interval; Ref, reference; RRR, relative risk ratio. P < .10; b P < 0.01; c P < .05. Hebert et al. Choosing a hospital for reproductive care. AJOG MEM 2019.
a
physicians’ practices (50.0%), previous experience at the hospital (28.5%), and proximity (11.5%) each rated higher in terms of patients’ priority in hospital selection. As Catholic-affiliated hospitals increase their market share of care,18 it is important to understand whether women proactively seek out this care or whether they end up at Catholic hospitals because of other factors. In line with previous studies that have examined religious affiliation in hospital selection, few women reported a hospital’s religious affiliation as salient in their decision regarding where to seek care. This is despite the fact that 8 in 10 women consider it important to know about a hospital’s religious restrictions on care when deciding where to get care.22 In addition, analysis using these same data found that more than one-third of women who report a Catholic hospital as their primary facility for reproductive care are unaware of its Catholic affiliation, suggesting that other factors motivate choice of hospital.23 Together, these
findings indicate that although women consider this knowledge important, religious affiliation is either undesirable or outweighed by other considerations when selecting a hospital for reproductive care.
Clinical implications Findings from this study indicate the importance of women’s previous clinical experiences in how they make decisions about hospital care; given this importance, supporting women during their use of hospital-based reproductive healthcare and ensuring a quality experience should be prioritized. Furthermore, encouraging increased hospitalbased reproductive health infrastructure in non-metropolitan areas, so that women in those areas can also choose quality over proximity, may help foster more equity for women in these areas. Finally, the primacy of quality/reputation in hospital care decisions among non-Hispanic black women may reflect the alarming maternal health disparities MONTH 2019 AJOG MFM
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Original Research faced by women of color.33 More efforts to reduce maternal mortality among these women and to ensure equal treatment in medical care should be prioritized.
important in hospital choice, the dataset did not capture or include any verified metrics of hospital capacity or quality, nor did it explore how women define quality or reputation, relying solely on women’s perceptions of this.
Research implications Because quality and reputation are important factors in women’s choices for reproductive care, additional research should explore further what components women consider as part of a highquality hospital experience. In addition, comparison of women’s experiences with outside metrics of hospital quality would help providers understand how to best meet patients’ needs and balance competing demands.
Strengths and limitations Our study used a nationally representative sample of women of reproductive age to examine an important and common, but understudied, issue. Unlike other studies related to decision making around hospital care, we asked women which factors were most important to them in choosing a hospital for care, which represents a strength of this study. There are a number of limitations associated with this study that should be noted. First, unlike other studies of hospital choice, our dataset lacked a number of measures relating to hospital characteristics, such as network affiliation, variety of services offered, and sole provider status in a community. The dataset also lacked any measure describing of the hospital’s market competition or saturation in a specific setting. The response rate of 50% was somewhat low, but is consistent with previously published studies using the AmeriSpeak panel34 and is adjusted to be representative of the United States nationally. Compared to those who responded to the survey, nonrespondents were more likely to be Hispanic or non-Hispanic black, slightly younger, of lower income, and less educated. These differences, however, have been accounted for in the weighting of the data, which adjusted for nonresponse by race/ethnicity, age, education, and census division. Finally, although many individuals cited quality as highly 8 AJOG MFM MONTH 2019
Conclusions Women’s decision making regarding where to seek reproductive care is multi-faceted, and prioritizes perceived quality and providers in addition to logistical concerns such as insurance and distance. Women’s previous reproductive experiences are associated with their priorities in choosing a hospital for reproductive care. Improving women’s health experiences may help facilitate their decisions regarding future care. n References 1. Daugherty J, Martinez G. Birth expectations of U.S. women aged 15-44. NCHS Data Brief 2016;260:1–8. 2. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. Natl Vital Stat Rep 2018;67:155. 3. Porell FW, Adams EK. Hospital choice models: a review and assessment of their utility for policy impact analysis. Med Care Res Rev 1995;52:158–95. 4. Luft HS, Garnick DW, Mark DH. Does quality influence choice of hospital? JAMA 1990;263: 2899–906. 5. Cohen MA, Lee HL. The determinants of spatial distribution of hospital utilization in a region. Med Care 1985;23:27–38. 6. McGuirk MA, Porell FW. Spatial patterns of hospital utilization: the impact of distance and time. Inquiry 1984;21:84–95. 7. Adams EK, Houchens R, Wright GE, Robbins J. Predicting hospital choice for rural Medicare beneficiaries: the role of severity of illness. Health Serv Res 1991;26:583–612. 8. Roh CY, Moon MJ. Nearby, but not wanted? The bypassing of rural hospitals and policy implications for rural healthcare systems. Policy Stud J 2005;33:377–94. https://doi.org/10. 1111/j.1541-0072.2005.00121.x. 9. Buczko W. What affects rural beneficiaries use of urban and rural hospitals? Healthcare Financ Rev 1992;14:107. 10. Tai W-TC, Porell FW, Adams EK. Hospital choice of rural medicare beneficiaries: patient, hospital attributes, and the patient-physician relationship. Health Serv Res 2004;39:1903–22. 11. Luft HS, Hunt SS. Evaluating individual hospital quality through outcome statistics. JAMA 1986;255:2780–4. 12. Goldsteen RL, Falcone DJ, Broyles RW, Goldsteen K, Reilly BJ. Local factors affecting the tendency to bypass local hospitals for
inpatient mental healthcare: an exploratory analysis. J Rural Health 1994;10:89–97. 13. Keating NL, Kouri EM, He Y, Freedman RA, Volya R, Zaslavsky AM. Location isn’t everything: proximity, hospital characteristics, choice of hospital, and disparities for breast cancer surgery patients. Health Serv Res 2016;51:1561–83. 14. Bronstein JM, Morrisey MA. Bypassing rural hospitals for obstetrics care. J Heal Polit Policy Law 1991;16:87–118. 15. Phibbs CS, Mark DH, Luft HS, et al. Choice of hospital for delivery: a comparison of high-risk and low-risk women. Health Serv Res 1993;28: 201–22. 16. Catholic Health Association of the United States. U.S. Catholic Healthcare 2018. Available at: https://www.chausa.org/docs/default-source/ default-document-library/cha_2018_miniprofile7aa 087f4dff26ff58685ff00005b1bf3.pdf?sfvrsn¼2. Accessed December 1, 2019. 17. Kaye J, Amiri B, Melling L, Dalven J, Hasbrouck P. Health Care Denied. New York, NY: American Civil Liberties Union; 2016. 18. Uttley L, Khaikin C, HasBrouck P. Growth of Catholic hospitals and health systems: 2016 update of the Miscarriage of Medicine Report. New York; 2016. Available at: http://static1.1. sqspcdn.com/static/f/816571/27061007/146522 4862580/MW_Update-2016-MiscarrOfMedicinereport.pdf?token¼uc78iJBtZPh%2Fk2lj. Accessed December 1, 2019. 19. Stulberg DB, Hoffman Y, Dahlquist IH, Freedman LR. Tubal ligation in Catholic hospitals: a qualitative study of ob-gyns’ experiences. Contraception 2014;90:422–8. Accessed December 1, 2019. 20. Freedman LR, Stulberg DB. Conflicts in care for obstetric complications in Catholic hospitals. Am J Bioeth Prim Res 2013;4:1–10. 21. Guiahi M, Sheeder J, Teal S. Are women aware of religious restrictions on reproductive health at Catholic hospitals? A survey of women’s expectations and preferences for family planning care. Contraception 2014;90: 429–34. 22. Freedman LR, Hebert LE, Battistelli MF, Stulberg DB. Religious hospital policies on reproductive care: what do patients want to know? Am J Obstet Gynecol 2018;218:251. 23. Wascher JM, Hebert LE, Freedman LR, Stulberg DB. Do women know whether their hospital is Catholic? Results from a national survey. Contraception 2018;98:498–503. 24. Gourevitch RA, Mehrotra A, Galvin G, Karp M, Plough A, Shah NT. How do pregnant women use quality measures when choosing their obstetric provider? Birth 2017;44:120–7. 25. Huppertz JW, Carlson JP. Consumers’ use of HCAHPS ratings and word-of-mouth in hospital choice. Health Serv Res 2010;45(6 Part 1): 1602–13. 26. Maurer M, Firminger K, Dardess P, Ikeler K, Sofaer S, Carman KL. Understanding consumer perceptions and awareness of hospital-based maternity care quality measures. Health Serv Res 2016;51:1188–211.
Original Research 27. Lupton D, Donaldson C, Lloyd P. Caveat emptor or blissful ignorance? Patients and the consumerist ethos. Soc Sci Med 1991;33: 559–68. 28. Dolan P. Patients rarely use online ratings to pick physicians. Am Med News 2008;51:1. 29. Peters E, Dieckman N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers. Med Care Res Rev 2007;64:169–90. 30. Hibbard JH, Peters E. Supporting informed consumer healthcare decisions: data presentation approaches that facilitate the use of information in choice. Annu Rev Public Health 2003;24:413–33. 31. Kessler DP, Mylod D. Does patient satisfaction affect patient loyalty? Int J Healthcare Qual Assur 2011;24:266–73.
32. Nix TW, Gibson JG. Does a hospital's religious affiliation affect choice of hospital and patient satisfaction? J Health Care Mark 1989;9: 40e1. 33. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancyrelated deathseUnited States, 2007e2016. MMWR Morb Mortal Wkly Rep 2019;68: 762–5. 34. Gupta RS, Warren CM, Smith BM, Jiang J, Blumenstock JA, Davis MM. Prevalence and severity of food allergies among US adults. JAMA Open Netw 2019;2:1–14.
Author and article information From the Department of Obstetrics & Gynecology (Dr Hebert), University of Chicago, Chicago, IL; Department of
Obstetrics, Gynecology & Reproductive Sciences (Dr Freedman), University of California San Francisco, Oakland, CA; Department of Family Medicine (Dr Stulberg), University of Chicago, Chicago, IL. Received Oct. 23, 2019; accepted Nov. 6, 2019. The authors report no conflict of interest. This study was supported by the Society of Family Planning Research Fund (SFPRF9-11). Dr Freedman’s time was also Supported was also provided by the Greenwall Foundation (0062905 2014- 2017) (L.E.H.). The funders had no role in design, conduct, or analysis of the content of this paper. L.E.H. is currently affiliated with the Institute for Research and Education Advancing Community Health (IREACH), and Elson S. Floyd College of Medicine, Washington State University, Seattle. Corresponding author: Luciana E. Hebert, PhD. [email protected]
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BACKGROUND: Despite millions of U.S. women receiving obstetric/
gynecologic or reproductive care in a hospital each year, little is known about which factors matter most to women in choosing a hospital for this care. OBJECTIVE(S): To describe women’s reasons for choosing their hospital for obstetric/gynecologic or reproductive care, and to examine characteristics associated with reporting specific factors as important in hospital choice. MATERIALS AND METHODS: We conducted a nationally representative, cross-sectional survey of women aged 18e45 years. The 2016 survey recruited women from AmeriSpeak, a probability-based research panel. A total of 1430 women completed the survey. All data analysis used weighting and accounted for the complex survey design. We conducted bivariate and multinomial logistic regression modeling to assess associations. RESULTS: Three-fourths of women cited a hospital’s overall reputation/ quality as a reason, and one-third named this as the most important
H
alf of all reproductive-aged women in the United States expect to have a child in the future, regardless of how many children they already have; among nulliparous women aged 15e24 years, 86% anticipate giving birth at some point in their lives.1 With nearly 4 million births in the United States each year,2 for many women, obstetric or reproductive care represents their most frequent and common hospital experience. Despite the commonality of this experience, how women choose a hospital for their care is not well studied. Previous studies of hospital choice have used hospital discharge or Medicare or Medicaid data rather than asking users directly about their choices and preferences for hospital care. These studies often rely on conditional models to examine hospital use and hospital bypass patterns as proxy measures
Cite this article as: Hebert LE, Freedman L, Stulberg DB. Choosing a hospital for obstetric, gynecologic, or reproductive healthcare: what matters most to patients? Am J Obstet Gynecol MFM 2019;XX:x.ex-x.ex. 2589-9333/$36.00 ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajogmf.2019.100067
reason for choosing a hospital. A total of 14% reported hospital religious affiliation as a reason. Compared to those with no prior deliveries, women who had delivered an infant were more likely to report that their top reason was specialty services/provider (relative risk ratio, 2.97; 95% confidence interval, 1.96e4.52) and were also more likely to report overall hospital quality/reputation as their top reason (relative risk ratio, 1.52; 95% confidence interval, 1.06e2.17), compared to logistical reasons. Metropolitan versus non-metropolitan residence was also a significant factor in hospital choice. CONCLUSION: Women endorse many factors when choosing a hospital for reproductive care, but perceived quality and reputation outweigh logistical concerns such as location and insurance. Key words: hospitals, maternal and perinatal care and outcomes,
obstetrics/gynecology, quality of care, patient safety, patient assessment, patient satisfaction
instead of using hospital choice itself. Findings from these studies indicate that proximity to a hospital is a consistent factor in hospital use .3e6 In addition to proximity, hospital characteristics, including teaching status,7 hospital ownership (publicly or privately held),4,8 range of services offered,9,10 and market share,11 among others, are documented factors related to hospital choice. On the patient side, patient age,7,12 sex, race/ ethnicity,13 and insurance status are each associated with hospital choice.12 Choice of hospital can be particularly important in reproductive healthcare. Among those studies that have focused on choice of hospital specifically for reproductive, maternal or obstetric/gynecologic (ObGyn) care, patient income,14 high birth volume ,14 obstetric risk status,15 and patient’s insurance status,15 have each contributed to women’s choice of hospital in which to deliver. Fewer studies have asked women themselves what they look for when selecting a hospital for such care. Hospitals with a religious affiliation represent a large and growing proportion of the healthcare landscape. One in 6 patients receive their care in Catholic hospitals annually.16 Catholic and nonCatholic hospitals primarily differ in
whether their providers are expected to follow religious policies restricting sterilization, abortion, contraception, and some treatment for obstetric complications and miscarriage. Receiving reproductive care at a Catholic hospital can affect a patient’s experience and range of options,17e20 and prior research indicates that patients may not anticipate these differences before seeking care.21 In light of these considerations, this study had the following aims: 1) to estimate reproductive-aged women’s reasons for choosing a hospital for their reproductive care, and 2) to examine women’s characteristics associated with the importance of given factors in hospital choice. As a sub-aim, this study also sought to examine how religious affiliation factors into women’s decision making around where to seek hospital care.
Materials and Methods Respondents were drawn from the AmeriSpeak Panel, a nationally representative panel recruited and maintained by NORC at the University of Chicago. The study team e-mailed a survey invitation to 2857 English-speaking women aged 18e45 years registered with the Panel, a probability-based sample of MONTH 2019 AJOG MFM
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Original Research AJOG MFM at a Glance Why was this study conducted? To estimate reproductive-age women’s reasons for choosing a hospital for their obstetric/gynecologic or reproductive care, and to examine characteristics associated with the importance of given factors in hospital choice. Key findings Three-fourths of the women cited a hospital’s overall reputation/quality as a reason, and one-third of the women as the most important reason for choosing a hospital. Previous experiences with reproductive care were associated with prioritizing specialty services or reputation compared to logistical concerns. What does this add to what is known? Women’s decision making regarding where to seek reproductive care is multifaceted, and prioritizes perceived quality and providers in addition to logistical concerns such as insurance and distance. Women’s previous reproductive experiences are associated with their priorities in choosing a hospital for reproductive care. Improving women’s health experiences may help facilitate their decisions regarding future care.
civilian, noninstitutionalized adults selected and recruited from the NORC National Frame. This sample frame provides 97% sample coverage and is recruited via mail, telephone, and inperson contact. Respondents could complete the survey through the online portal or by telephone as they preferred. We conducted 3 waves of recruitment between June and November 2016, with multiple e-mail and telephone reminders sent to encourage survey participation following the initial survey invitation. Participants received $4 cash equivalent for completing the survey via phone or $2 cash equivalent for completing the survey online; these incentives were later increased to $10 cash equivalent to encourage survey completion in the second and third waves of recruitment. A thorough description of the AmeriSpeak Panel and the methods for this study have been previously reported.22 This study was granted exempt status by the Institutional Review Boards at both the University of California San Francisco and the University of Chicago.
Panel measures Measures obtained from the AmeriSpeak Panel data include the following: age, race, Hispanic ethnicity, highest educational attainment, religious 2 AJOG MFM MONTH 2019
identification, frequency of religious service attendance, geographic region of country, residence in a metropolitan area (area with a population of at least 100,000), political party identification, and whether the panel member has health insurance and type of health insurance held (ie, private or bought on an exchange, public or other).
Survey measures To measure respondents’ maternal and reproductive healthcare history, the survey asked respondents if they had ever received care for any of the following services: prenatal care during pregnancy, delivery of a child, pelvic examination and/or Papanicolaou (Pap) smear, tubal ligation/sterilization, birth control given or prescribed by a healthcare provider, care for a pregnancy complication, miscarriage or loss, or fertility treatment of any kind. To assess respondents’ reasons for choosing a hospital for obstetric/gynecologic or reproductive care, the survey first asked respondents to provide the name and location of their preferred hospital for obstetric/gynecologic or reproductive healthcare and then asked them to identify reasons for choosing that hospital. Based on qualitative interviews with patients and providers about reproductive care, we categorized
commonly cited reasons for hospital choice according to the following schema: location, specialty (this hospital is best for obstetric/gynecologic or reproductive care), overall reputation (hospital is known as high quality in general), insurance, hospital religious affiliation, or based on their doctor/ healthcare provider (this is where your doctor or other provider works). The survey provided participants with this list and asked them to mark whether each was or was not a reason for choosing that hospital; the survey then asked participants to select, among these reasons, which was the most important reason for which they go to that hospital. The survey also asked respondents 3 questions to measure their prioritization of religious affiliation when choosing a hospital: 1) whether they had ever chosen a hospital specifically because it was Catholic; 2) whether they had ever chosen a hospital specifically because it was not Catholic; and 3) whether they had ever chosen a hospital specifically because it was affiliated with some other religion. These questions were not specific to reproductive or obstetric/gynecologic care, but did follow a number of questions that specifically asked about hospital choice in regard to obstetric/ gynecologic and reproductive care. To identify the religious affiliation of respondents’ preferred hospitals, we verified each hospital name against a known list of Catholic-affiliated hospitals and supplemented this list with our own Internet search. A more extensive description of the methods and results of this subanalysis are reported elsewhere.23 For bivariate analyses, we combined the following reasons based on theoretical similarity for ease of interpretation: location and insurance were collapsed to form a measure of logistics, and specialty and doctor/healthcare provider were collapsed together to reflect clinical services.
Data analysis We estimated descriptive statistics to describe characteristics of the survey sample. We conducted bivariate analyses
Original Research to evaluate associations between participant characteristics and their most important reasons for choosing a hospital for reproductive care. We used c2 tests to evaluate significance of associations. We then performed multinomial logistic regression modeling to examine the association between participant characteristics and their reasons for choosing a hospital; logistical reasons (location and insurance) as the most important reason was selected as a baseline value. There was substantial overlap and high correlation in respondents’ receipt of prenatal care, delivery of an infant, and treatment for pregnancy complications. We thus included only delivery of an infant in the final regression model. Bivariate analyses and theoretical understanding informed by the literature guided multinomial model development and fitting. We compared models using information criteria to arrive at the final model as presented. All data analysis used weighting and accounted for the complex survey design; a was set at 0.05. All analyses were performed using Stata statistical software, version 14 (StataCorp, College Station, TX).
Results Of the 2857 women invited to participate in the survey, 1430 completed surveys, for a response rate of 50.1%. Descriptive statistics of the survey respondents are provided in Table 1. Twothirds of women had at least some college education (66.3%). Participants were racially, ethnically, and religiously diverse, and the majority (88.7%) resided in a metropolitan area. Nearly 9 in 10 women (86.9%) had ever received a pelvic examination or Pap smear, and 79.5% had received birth control from a healthcare provider. More than 6 in 10 respondents reported that they had received prenatal care (62.9%), and the same percentage had delivered an infant (62.3%). Slightly less than one-third of all women reported they had ever received care for pregnancy complications (31.3%). Participants’ reasons for choosing a hospital for reproductive care, and their
TABLE 1
Demographic characteristics of study sample and history of services received Characteristic
n
%
Age, y 18e26 years
450
31.5
2735 years
484
33.9
36e45 years
496
34.7
Non-Hispanic white
800
56
Non-Hispanic black
197
13.8
Hispanic
289
20.2
Other
144
10.1
Less than high school
146
10.2
High school graduate
336
23.5
Some college
482
33.7
College graduate
467
32.6
Protestant, noneBorn Again
139
11.8
Catholic
201
17.0
Other/just Christian
125
10.6
Race/ethnicity
Education
Religion
Other (non-Christian)
130
11
Nothing/atheist/agnostic
298
25.3
Born-Again Protestant
287
24.3
Never
146
23.3
Less than monthly
466
39.5
Monthly
154
13
Weekly
287
24.3
1268
88.7
162
11.3
Northeast
248
17.3
Midwest
292
20.4
South
542
37.9
West
349
24.4
Strong democrat
164
13.8
Moderate/lean Democrat
565
47.7
Independent/none
113
9.6
Moderate/lean Republican
275
23.2
Religious attendance
Metropolitan Non-metropolitan Region
Party identification
Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
(continued)
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Original Research TABLE 1
Demographic characteristics of study sample and history of services received (continued) Characteristic Strong republican
n
% 67
5.7
Private/employer/exchange
589
53.5
Public
240
21.8
Other
130
11.8
None
142
12.9
Health insurance
Services ever received (% responding yes) Prenatal care during pregnancy
62.9
Delivery of an infant
62.3
Pelvic examination and/or Pap smear
86.9
Tubal ligation/sterilization
15.5
Birth control from a healthcare provider
79.5
Care for pregnancy complication
31.3
Fertility treatment of any kind
7.5
Pap, Papanicoloau. Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
most important reason, are shown in Figure 1. More than three-fourths of women cited a hospital’s overall reputation or quality as their reason for choosing a hospital; one-third reported that this was the most important reason. More than 7 in 10 women reported location as a reason, but only 13% cited this as the most important reason. Although more than two-thirds endorsed insurance (67.6%) and doctor/healthcare provider (69.3%) as reasons to choose a hospital, one-fifth apiece cited these as the most important reasons. A total of 14% reported a hospital’s religious affiliation as a reason for choosing a hospital, and <1% reported that this was the most important reason. Among those who reported religious affiliation was a reason, nearly one-half (46.0%; 95% confidence interval [CI], 36.8e55.5) identified a religious hospital when asked to report their own primary hospital. Just over 3% (3.3%; 95% CI, 2.3e4.7) of women reported choosing a hospital because it was Catholic, whereas nearly 6% (5.6%; 95% CI, 4.4e7.0) reported 4 AJOG MFM MONTH 2019
that they had chosen a hospital because it was not Catholic. Just over 1% (1.6%; 95% CI: 1.0-2.5) reported choosing a hospital because it was affiliated with another religion. Having received prenatal care, delivery of an infant, receipt of a pelvic examination or Pap smear, and having received care for pregnancy complications were each associated with women’s top reasons for choosing a hospital (Table 2). Age, race/ethnicity, and region of residence were also significantly associated with top reasons for selecting a hospital. In the multinomial model (Table 3), women in metropolitan areas (relative risk ratio [RRR], 1.74; 95% CI, 1.01e3.00) and women who had delivered an infant (RRR, 2.97; 95% CI, 1.96e4.52) were more likely to cite specialty services/provider issues as their top reason relative to logistical reasons, compared to women in nonmetropolitan areas and women who had not delivered, respectively. Similarly, metropolitan residence (RRR, 2.07; 95% CI, 1.21e3.52) and delivery of an infant (RRR, 1.52; 95% CI,
1.06e2.17) were also associated with choosing a hospital because of its reputation or quality, compared to reasons related to location or insurance.
Comment Principal findings In choosing a hospital for reproductive, maternal, or obstetric care, women of reproductive age endorse a number of factors as reasons to choose a particular hospital, with hospital quality or reputation the most commonly endorsed and the most important reason. Metropolitan residence and prior reproductive experiences were consistently associated with choosing a hospital based on specialty/staff or quality/ reputation over more logistical concerns such as insurance or location. Women located in metropolitan areas may simply have more choices in selecting a hospital for reproductive care compared to women located in non-metropolitan areas. The salience of prior experiences and services used, including prenatal care, prior delivery, and treatment for pregnancy complications may also suggest that women’s own experiences are instructive in how they view and select hospitals, rather than convenience alone.
Results Findings from this study add to the growing literature surrounding hospital choice for reproductive care.20,21,23 These data suggest that both quality and provider/specialty services are important factors in hospital choice, in addition to location and insurance acceptance. An app-based study of pregnant women found that women were more likely to choose a hospital for obstetric care based on their specific healthcare provider, not the hospital itself.24 Women first chose a provider, deeming the provider more important (56% more important) than the hospital (7% more important). This study also indicated that women do not use quantitative measures of quality (metrics) but, rather, use anecdotal evidence or their own experience to form an opinion about the quality of care.
Original Research FIGURE 1
Reasons and most important reason for choosing a hospital for reproductive care 100 90 76.4
80
72.2
69.3
67.6
70
57.5
60 50 40
33.3
30 20.4
20.1
20
13.6
13.4
10
7.3
4.8 0.7
0 Overall reputaon/quality
Insurance
Doctor/Healthcare provider
Locaon
Is a Reason
Most important reason
Specialty
Hospital religious affiliaon
Other
Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
TABLE 2
Percentage of respondents reporting each factor as their top reason for choosing a hospital, by respondent characteristics Logistics (location/ insurance)
Services (specialty/ provider)
Overall reputation (quality)
Religious affiliation
30.2
32.6
36.8
0.4
30.2
33.2
36.1
0.5
34.4
28.5
36.8
0.4
26.3
30.7
42.8
0.3
35.8
28.2
35.7
0.4
31.4
33.6
34.2
0.8
26.4
38.8
34.3
0.5
18e26
38.9
18.4
40.9
1.9
27e35
35.4
26.3
38.0
0.3
36e45
33.7
33.9
32.1
0.3
Non-Hispanic white
35.9
30.9
32.6
0.6
Non-Hispanic black
27.8
23.6
46.8
1.8
Hispanic
39.5
20.2
39.3
1
Characteristic Services ever received Prenatal care during pregnancya Delivery of an infant
a
Pelvic examination and/or Pap smeara Tubal ligation/sterilization Birth control from a healthcare provider Care for pregnancy complication Fertility treatment of any kind
c
b
Other characteristics Age, ya
Race/ethnicityc
Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019.
(continued)
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Original Research TABLE 2
Percentage of respondents reporting each factor as their top reason for choosing a hospital, by respondent characteristics (continued) Characteristic
Logistics (location/ insurance)
Services (specialty/ provider)
Overall reputation (quality)
Religious affiliation
Other
38.3
19.4
42.4
0
Less than high school
38.9
24.8
34.5
1.7
High school graduate
34.9
22.0
42.0
1.2
Some college
33.4
28.7
37.1
0.9
College graduate
38.1
27.8
33.9
0.2
Protestant, noneBorn Again
37.8
27.6
34.6
0
Catholic
35.7
25.7
36.8
1.8
Other/just Christian
27.0
30.3
42.7
0
Other (non-Christian)
37.6
24.2
38.2
0
Nothing/atheist/agnostic
45.3
22.6
32.1
0
Born-Again Protestant
35.4
24.3
39.0
1.3
Never
42.3
19.5
37.6
0.6
Less than monthly
37.9
27.2
34.3
0.6
Monthly
33.3
27.7
39.0
0
Weekly
35.5
25.4
37.9
1.1
Metropolitan
35.1
26.4
37.9
0.7
Non-metropolitan
42.5
27.3
28.5
1.8
Northeast
40.0
23.9
34.8
1.3
Midwest
31.3
31.3
36.7
0.7
South
28.1
29.9
41.2
0.9
West
48.2
19.4
32.1
0.4
Private/employer/exchange
35.5
29.7
34.5
0.3
Public
34.2
24.0
40.2
1.6
Other
46.7
17.8
36.0
0.6
None
32.1
22.9
45.0
0
Education
Religion
Religious attendance
Region
b
Health insurance
Party identification Strong Democrat
35.9
21.3
41.9
0.9
Moderate/lean Democrat
38.2
22.6
39.0
0.3
Independent/none
31.2
33.7
32.9
2.3
Moderate/lean Republican
38.9
30.0
30.8
0.3
Strong Republican
21.4
31.9
46.8
0
Pap, Papanicolaou. P < .001; b P < .01; c P < .05. Hebert et al. Choosing a hospital for reproductive care. AJOG MFM 2019. a
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Original Research Although patients cite quality as important, previous studies suggest that they rarely report consulting actual quality metrics.25 Information from a mixed-methods study found that women interpret quality of a hospital based on interactions with clinical staff, and in terms of patient-centered care, communication, and medical team coordination.26 Less than 1 in 3 pregnant women (28%) in this study reported having used comparative quality information about hospitals in choosing a hospital for delivery. Patients’ primacy of the provider over the hospital itself was also reported in this study. Anecdotal or narrative information from an individual’s trusted network may be more important in healthcare decision making,27e30 in which patients rely on a “lay referral network” to inform their choice for hospital care.4 In a prior survey of pregnant women,26 a hospital that “accepts your insurance” was rated as “very important” by 98% of respondents, followed by “is one where you had a good experience in the past” (77%) and “was recommended by your doctor or midwife” (64%). More formalized metrics of quality (“ratings on a website that compares hospitals” and “rating from patients on website that compares hospitals”) ranked lower in terms of importance. The importance of women’s previous reproductive health service use in their reasons for selecting a hospital is also of note. One previous study has found that after controlling for hospital and market characteristics, patients’ satisfaction with a previous hospital experience is associated with loyalty/repeat use.31 One’s own experience, or that of a close or trusted friend or relative, may therefore contribute to women’s sense of the quality and/or reputation of a hospital. Although it is not studied here, learning more about how women define quality and reputation in the realm of reproductive care may be valuable. A previous study that looked at patients who had received care at a religiously affiliated hospital found that only 1 of 200 former patients cited hospital religious affiliation as a determinant in their choice for care.32 Rather,
TABLE 3
Relative risk ratios (95% confidence intervals) from multinomial logistic regression analysis assessing top reason for choosing a hospital for obstetric/gynecologic or reproductive care RRR (95% CI) Services (specialty/provider) vs logistics (location/insurance)
Overall reputation (quality) vs logistics (location/insurance)
18e26
Ref
Ref
27e35
1.05 (0.64e1.73)
0.88 (0.58e1.33)
36e45
1.33 (0.80e2.22)
0.75 (0.47e1.19)
Northeast
Ref
Ref
Midwest
1.79 (1.00e3.21)
Age, y
Region
South
1.62 (0.91e2.87)
West
0.63 (0.34e1.15)
1.43 (0.85e2.43) a
1.60 (0.96e2.68)a 0.70 (0.40e1.22)
Residence Non-metropolitan
Ref
Ref
Metropolitan
1.74 (1.01e3.00)
b
2.07 (1.21e3.52)b
Delivery of an infant
2.97 (1.96e4.52)c
1.52 (1.06e2.17)c
CI, confidence interval; Ref, reference; RRR, relative risk ratio. P < .10; b P < 0.01; c P < .05. Hebert et al. Choosing a hospital for reproductive care. AJOG MEM 2019.
a
physicians’ practices (50.0%), previous experience at the hospital (28.5%), and proximity (11.5%) each rated higher in terms of patients’ priority in hospital selection. As Catholic-affiliated hospitals increase their market share of care,18 it is important to understand whether women proactively seek out this care or whether they end up at Catholic hospitals because of other factors. In line with previous studies that have examined religious affiliation in hospital selection, few women reported a hospital’s religious affiliation as salient in their decision regarding where to seek care. This is despite the fact that 8 in 10 women consider it important to know about a hospital’s religious restrictions on care when deciding where to get care.22 In addition, analysis using these same data found that more than one-third of women who report a Catholic hospital as their primary facility for reproductive care are unaware of its Catholic affiliation, suggesting that other factors motivate choice of hospital.23 Together, these
findings indicate that although women consider this knowledge important, religious affiliation is either undesirable or outweighed by other considerations when selecting a hospital for reproductive care.
Clinical implications Findings from this study indicate the importance of women’s previous clinical experiences in how they make decisions about hospital care; given this importance, supporting women during their use of hospital-based reproductive healthcare and ensuring a quality experience should be prioritized. Furthermore, encouraging increased hospitalbased reproductive health infrastructure in non-metropolitan areas, so that women in those areas can also choose quality over proximity, may help foster more equity for women in these areas. Finally, the primacy of quality/reputation in hospital care decisions among non-Hispanic black women may reflect the alarming maternal health disparities MONTH 2019 AJOG MFM
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Original Research faced by women of color.33 More efforts to reduce maternal mortality among these women and to ensure equal treatment in medical care should be prioritized.
important in hospital choice, the dataset did not capture or include any verified metrics of hospital capacity or quality, nor did it explore how women define quality or reputation, relying solely on women’s perceptions of this.
Research implications Because quality and reputation are important factors in women’s choices for reproductive care, additional research should explore further what components women consider as part of a highquality hospital experience. In addition, comparison of women’s experiences with outside metrics of hospital quality would help providers understand how to best meet patients’ needs and balance competing demands.
Strengths and limitations Our study used a nationally representative sample of women of reproductive age to examine an important and common, but understudied, issue. Unlike other studies related to decision making around hospital care, we asked women which factors were most important to them in choosing a hospital for care, which represents a strength of this study. There are a number of limitations associated with this study that should be noted. First, unlike other studies of hospital choice, our dataset lacked a number of measures relating to hospital characteristics, such as network affiliation, variety of services offered, and sole provider status in a community. The dataset also lacked any measure describing of the hospital’s market competition or saturation in a specific setting. The response rate of 50% was somewhat low, but is consistent with previously published studies using the AmeriSpeak panel34 and is adjusted to be representative of the United States nationally. Compared to those who responded to the survey, nonrespondents were more likely to be Hispanic or non-Hispanic black, slightly younger, of lower income, and less educated. These differences, however, have been accounted for in the weighting of the data, which adjusted for nonresponse by race/ethnicity, age, education, and census division. Finally, although many individuals cited quality as highly 8 AJOG MFM MONTH 2019
Conclusions Women’s decision making regarding where to seek reproductive care is multi-faceted, and prioritizes perceived quality and providers in addition to logistical concerns such as insurance and distance. Women’s previous reproductive experiences are associated with their priorities in choosing a hospital for reproductive care. Improving women’s health experiences may help facilitate their decisions regarding future care. n References 1. Daugherty J, Martinez G. Birth expectations of U.S. women aged 15-44. NCHS Data Brief 2016;260:1–8. 2. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. Natl Vital Stat Rep 2018;67:155. 3. Porell FW, Adams EK. Hospital choice models: a review and assessment of their utility for policy impact analysis. Med Care Res Rev 1995;52:158–95. 4. Luft HS, Garnick DW, Mark DH. Does quality influence choice of hospital? JAMA 1990;263: 2899–906. 5. Cohen MA, Lee HL. The determinants of spatial distribution of hospital utilization in a region. Med Care 1985;23:27–38. 6. McGuirk MA, Porell FW. Spatial patterns of hospital utilization: the impact of distance and time. Inquiry 1984;21:84–95. 7. Adams EK, Houchens R, Wright GE, Robbins J. Predicting hospital choice for rural Medicare beneficiaries: the role of severity of illness. Health Serv Res 1991;26:583–612. 8. Roh CY, Moon MJ. Nearby, but not wanted? The bypassing of rural hospitals and policy implications for rural healthcare systems. Policy Stud J 2005;33:377–94. https://doi.org/10. 1111/j.1541-0072.2005.00121.x. 9. Buczko W. What affects rural beneficiaries use of urban and rural hospitals? Healthcare Financ Rev 1992;14:107. 10. Tai W-TC, Porell FW, Adams EK. Hospital choice of rural medicare beneficiaries: patient, hospital attributes, and the patient-physician relationship. Health Serv Res 2004;39:1903–22. 11. Luft HS, Hunt SS. Evaluating individual hospital quality through outcome statistics. JAMA 1986;255:2780–4. 12. Goldsteen RL, Falcone DJ, Broyles RW, Goldsteen K, Reilly BJ. Local factors affecting the tendency to bypass local hospitals for
inpatient mental healthcare: an exploratory analysis. J Rural Health 1994;10:89–97. 13. Keating NL, Kouri EM, He Y, Freedman RA, Volya R, Zaslavsky AM. Location isn’t everything: proximity, hospital characteristics, choice of hospital, and disparities for breast cancer surgery patients. Health Serv Res 2016;51:1561–83. 14. Bronstein JM, Morrisey MA. Bypassing rural hospitals for obstetrics care. J Heal Polit Policy Law 1991;16:87–118. 15. Phibbs CS, Mark DH, Luft HS, et al. Choice of hospital for delivery: a comparison of high-risk and low-risk women. Health Serv Res 1993;28: 201–22. 16. Catholic Health Association of the United States. U.S. Catholic Healthcare 2018. Available at: https://www.chausa.org/docs/default-source/ default-document-library/cha_2018_miniprofile7aa 087f4dff26ff58685ff00005b1bf3.pdf?sfvrsn¼2. Accessed December 1, 2019. 17. Kaye J, Amiri B, Melling L, Dalven J, Hasbrouck P. Health Care Denied. New York, NY: American Civil Liberties Union; 2016. 18. Uttley L, Khaikin C, HasBrouck P. Growth of Catholic hospitals and health systems: 2016 update of the Miscarriage of Medicine Report. New York; 2016. Available at: http://static1.1. sqspcdn.com/static/f/816571/27061007/146522 4862580/MW_Update-2016-MiscarrOfMedicinereport.pdf?token¼uc78iJBtZPh%2Fk2lj. Accessed December 1, 2019. 19. Stulberg DB, Hoffman Y, Dahlquist IH, Freedman LR. Tubal ligation in Catholic hospitals: a qualitative study of ob-gyns’ experiences. Contraception 2014;90:422–8. Accessed December 1, 2019. 20. Freedman LR, Stulberg DB. Conflicts in care for obstetric complications in Catholic hospitals. Am J Bioeth Prim Res 2013;4:1–10. 21. Guiahi M, Sheeder J, Teal S. Are women aware of religious restrictions on reproductive health at Catholic hospitals? A survey of women’s expectations and preferences for family planning care. Contraception 2014;90: 429–34. 22. Freedman LR, Hebert LE, Battistelli MF, Stulberg DB. Religious hospital policies on reproductive care: what do patients want to know? Am J Obstet Gynecol 2018;218:251. 23. Wascher JM, Hebert LE, Freedman LR, Stulberg DB. Do women know whether their hospital is Catholic? Results from a national survey. Contraception 2018;98:498–503. 24. Gourevitch RA, Mehrotra A, Galvin G, Karp M, Plough A, Shah NT. How do pregnant women use quality measures when choosing their obstetric provider? Birth 2017;44:120–7. 25. Huppertz JW, Carlson JP. Consumers’ use of HCAHPS ratings and word-of-mouth in hospital choice. Health Serv Res 2010;45(6 Part 1): 1602–13. 26. Maurer M, Firminger K, Dardess P, Ikeler K, Sofaer S, Carman KL. Understanding consumer perceptions and awareness of hospital-based maternity care quality measures. Health Serv Res 2016;51:1188–211.
Original Research 27. Lupton D, Donaldson C, Lloyd P. Caveat emptor or blissful ignorance? Patients and the consumerist ethos. Soc Sci Med 1991;33: 559–68. 28. Dolan P. Patients rarely use online ratings to pick physicians. Am Med News 2008;51:1. 29. Peters E, Dieckman N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers. Med Care Res Rev 2007;64:169–90. 30. Hibbard JH, Peters E. Supporting informed consumer healthcare decisions: data presentation approaches that facilitate the use of information in choice. Annu Rev Public Health 2003;24:413–33. 31. Kessler DP, Mylod D. Does patient satisfaction affect patient loyalty? Int J Healthcare Qual Assur 2011;24:266–73.
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Author and article information From the Department of Obstetrics & Gynecology (Dr Hebert), University of Chicago, Chicago, IL; Department of
Obstetrics, Gynecology & Reproductive Sciences (Dr Freedman), University of California San Francisco, Oakland, CA; Department of Family Medicine (Dr Stulberg), University of Chicago, Chicago, IL. Received Oct. 23, 2019; accepted Nov. 6, 2019. The authors report no conflict of interest. This study was supported by the Society of Family Planning Research Fund (SFPRF9-11). Dr Freedman’s time was also Supported was also provided by the Greenwall Foundation (0062905 2014- 2017) (L.E.H.). The funders had no role in design, conduct, or analysis of the content of this paper. L.E.H. is currently affiliated with the Institute for Research and Education Advancing Community Health (IREACH), and Elson S. Floyd College of Medicine, Washington State University, Seattle. Corresponding author: Luciana E. Hebert, PhD. [email protected]
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