Deaf women's experiences and satisfaction with prenatal care: a comparative study.
ABSTRACT The quality of communication between physician and patient is a major contributor to patient satisfaction and treatment adherence. Deaf patients who use American Sign Language experience significant communication barriers in most medical settings. This study investigated factors impacting deaf patients' satisfaction with prenatal care and prenatal care disparities between deaf and hearing women.
Questionnaires modified from Omar and Schiffman's prenatal satisfaction measure were administered to 23 deaf and 32 hearing women.
Deaf women were less satisfied than hearing women with physician communication and less satisfied with overall care. Deaf women's expectations about provision of interpreter services being met or exceeded was significantly associated with overall satisfaction. Hearing women had more prenatal care appointments and reported receiving more information from their doctors.
Maximizing communication effectiveness with deaf patients results in better prenatal care and improved patient satisfaction. Good communication includes conveying concern and making efforts to ensure that whatever communication methods used are effective.
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ABSTRACT: Background:Deaf mothers who use American Sign Language (ASL) consider themselves a linguistic minority group, with specific cultural practices. Rarely has this group been engaged in infant-feeding research.Objectives:To understand how Deaf mothers who use ASL learn about infant feeding and to identify their breastfeeding challenges.Methods:Using a community-based participatory research approach, we conducted 4 focus groups with Deaf mothers who had at least 1 child 0-5 years old. A script was developed using a social ecological model (SEM) to capture multiple levels of influence. All groups were conducted in ASL, filmed, and transcribed into English. Deaf and hearing researchers analyzed data by coding themes within each SEM level.Results:Fifteen mothers participated. All had initiated breastfeeding with their most recent child. Breastfeeding duration for 8 of the mothers was 3 weeks to 12 months. Seven of the mothers were still breastfeeding, the longest for 19 months. Those mothers who breastfed longer described a supportive social environment and the ability to surmount challenges. Participants described characteristics of Deaf culture such as direct communication, sharing information, use of technology, language access through interpreters and ASL-using providers, and strong self-advocacy skills. Finally, mothers used the sign for "struggle" to describe their breastfeeding experience. The sign implies a sustained effort over time that leads to success.Conclusion:In a setting with a large population of Deaf women and ASL-using providers, we identified several aspects of Deaf culture and language that support breastfeeding mothers across institutional, community, and interpersonal levels of the SEM.Journal of Human Lactation 03/2013; · 1.98 Impact Factor
November-December 2006Family Medicine
Poor communication between clinicians and patients
leads to low patient satisfaction and treatment adher-
ence rates and, thus, contributes to poorer health care
outcomes.1-3 Language barriers also lead to negative
health outcomes and patient ratings of care.1 Deaf pa-
tients, for whom communication can be difficult, are at
risk for low health care satisfaction and adherence.
Approximately 20 million Americans have some
hearing loss.4 Of this group, 4.8 million report being
unable to hear or understand any speech.4 Communica-
tion methods among deaf individuals vary from oral
approaches to manual approaches, including American
Sign Language (ASL).5
Deaf individuals use medical services more often,
take more sick days from work, and report poorer health
than hearing people.6,7 Deaf persons visit physicians
more frequently, have more difficulties communicating
with physicians, and feel less comfortable with them.6
Data from the National Health Interview Surveys
(1990–1991) suggest that the deaf population’s health
care utilization pattern is complex.8 Prelingually deaf-
ened adults, who are more likely to use sign language,
use fewer health care services than average, similar to
other language minorities, while postlingually deafened
adults used health care services more than average,
similar to people with chronic illness.8
Deafness negatively affects the communication
relationship between practitioner and patient.6,9-11 One
third of what hospital staff try to communicate to deaf
patients may be misunderstood.11 Even among highly
educated deaf people, communication difficulties are
cited as the primary cause for dissatisfaction with
A focus group study of 45 deaf women found that
their lack of knowledge regarding health issues was
common, including little understanding of the value
of cancer screening, Pap smears, mammography, and
the purposes of prescribed medications. Deaf women
also reported avoidance of health services due to
communication barriers.14 Deaf persons are less likely
than hearing counterparts to obtain illness prevention
information from their physician, television, radio, or
books and are more likely to obtain this information
from deaf clubs.15
Deaf Women’s Experiences and Satisfaction
With Prenatal Care: A Comparative Study
Amanda O’Hearn, PhD
From the University of Rochester Medical Center.
Background and Objectives: The quality of communication between physician and patient is a major
contributor to patient satisfaction and treatment adherence. Deaf patients who use American Sign Lan-
guage experience significant communication barriers in most medical settings. This study investigated
factors impacting deaf patients’ satisfaction with prenatal care and prenatal care disparities between
deaf and hearing women. Methods: Questionnaires modified from Omar and Schiffman’s prenatal
satisfaction measure were administered to 23 deaf and 32 hearing women. Results: Deaf women were
less satisfied than hearing women with physician communication and less satisfied with overall care.
Deaf women’s expectations about provision of interpreter services being met or exceeded was sig-
nificantly associated with overall satisfaction. Hearing women had more prenatal care appointments
and reported receiving more information from their doctors. Conclusions: Maximizing communication
effectiveness with deaf patients results in better prenatal care and improved patient satisfaction. Good
communication includes conveying concern and making efforts to ensure that whatever communica-
tion methods used are effective.
(Fam Med 2006;38(10):712-6.)
Clinical Research and Methods
713Vol. 38, No. 10
Clinical Research and Methods
Most clinicians do not know sign language and are
not educated about deafness.16 Even providers who
recognize deaf patients’ preferences for sign language
fail to use interpreter services regularly.17 Although
clinicians often believe that writing and lip reading
provide effective communication,17,18 the average deaf
high school graduate reads at a third- or fourth-grade
level.19 Speechreading is not sufficient either, with the
best lip-readers understanding only 20% of spoken
Deaf patients report increased access and positive
experiences in health care when practitioners use
qualified interpreters.21 Providers who demonstrate
sensitivity to communication, using even minimal sign
language skills, or show a willingness to use pen and
paper are appreciated.14 Deaf patients who were enrolled
in an experimental primary care program where ASL
interpreters were provided were more satisfied with
physician communications and had improved preven-
tive care outcomes.22 They also were more likely to
report receiving Pap tests, mammography, and rectal
examinations than deaf patients who were not enrolled
in the interpreter access program.
Prenatal care has been shown to decrease infant
mortality and improve quality of life for newborns,23,24
yet many pregnant women do not fully utilize prena-
tal care.25 One of the motivating factors for pregnant
women to receive prenatal care is satisfaction.19,26 Some
of the factors related to patient satisfaction include per-
ceived quality of communication with their physician,
continuity of care, attendance at childbirth classes,
and perceived physician concern.27 Women who do not
feel that they received adequate prenatal information
feel less prepared for delivery and are less satisfied
with the experience.28 Omar and Schiffman29 found
that women whose expectations of prenatal care were
met were more satisfied than those whose expectations
were not met.
There have been no reported studies on prenatal
care and deaf women. The present study compares
deaf and hearing women’s experiences in prenatal care,
in particular as related to communication and patient
A survey questionnaire was adapted from Omar and
Schiffman’s29 prenatal satisfaction measure. This modi-
fied questionnaire was composed of 37 items related
to several facets of patient satisfaction, expectations
about communication and care, and health outcomes
of both baby and mother. Perceived quality of com-
munication, perceived physician concern, continuity
of care (number of different doctors seen), and overall
satisfaction were assessed through Likert-scale items.
Several open-ended questions were included to generate
ideas about deaf women’s experiences and guide future
studies. Number of prenatal care visits was compared
to the visit schedule suggested by the Expert Panel on
the Content of Prenatal Care,30 which recommends nine
visits for low-risk women. Demographic information
also was collected, and questions were included that
assessed deafness-related communication factors. The
study was reviewed and approved by the Institutional
Review Board at Gallaudet University.
Hearing and deaf participants were recruited via
e-mail and posted advertisements on the university
campus, as well as through the Internet, friendship
networks, and deaf organizations. Twenty-three deaf
women and 32 hearing women who had a baby within
the past 3 years completed the questionnaire. Most deaf
women (91%) reported using sign language as their
primary mode of communication although one third
of this group also endorsed using some mode of oral
communication (lipreading, talking) at least some of the
time. Additional information regarding the participant
sample is presented in Tables 1 and 2.
We used descriptive statistics (means, standard de-
viation, percentages) to describe subjects’ demograph-
ics and the proportion of women in the hearing versus
deaf groups who responded differently to survey items.
Analysis of variance was used to determine if differ-
ences between the groups were significant.
There was a trend for hearing women to have
more prenatal appointments than deaf women, (F
[1,54]=3.88, P=.054). Thirty-one hearing women (97%)
reported having nine or more prenatal appointments;
for deaf women, only 17 (74%) had nine or more ap-
Hearing women reported getting significantly more
information from their doctors than did deaf women.
Ninety-one percent of hearing women reported they got
“a lot” of information from their doctor, while 61% of
deaf women endorsed the same (F [1,54]=7.95, P< .01).
More of the hearing women reported that their doctors
counseled them about abstinence from alcohol than did
the deaf women (91% versus 61%) (F [1,54]=7.95, P<
.01). There were no significant differences between the
groups in length of hospital stay for mother or child,
total number of doctors seen, premature deliveries,
baby’s birth weight, participation in prenatal classes,
or presence of delivery complications. Both groups
endorsed being equally informed by their doctors on
the use of vitamins, weight gain during pregnancy, and
November-December 2006 Family Medicine
Significant differences were noted between deaf and
hearing women for overall satisfaction with prenatal
care; hearing women had higher satisfaction scores
than deaf women. Likewise, hearing women also re-
ported greater satisfaction with communication and
with perceived physician concern than did deaf women
No differences in satisfaction score were found in
relation to use of a doctor versus a midwife, number
of doctors seen, premature delivery, or the baby’s birth
weight. The 16 deaf women who used oral means of
communication did not differ in overall satisfaction
from the six who did not (F [1,21]=.43, P=.52). Deaf
women became less satisfied overall as the number of
prenatal appointments increased (r =-.49, P<.05).
The same was not found for hearing women (r (29)=
Ninety-five percent of deaf respondents preferred
their doctor to communicate with them by signing or
through an interpreter, while only half reported being
provided with a professional interpreter at least some
of the time. Deaf respondents were asked to compare
expectations they had about interpreter services (eg, “I
expected my doctor to provide me with an interpreter
for appointments,” “I expected I would bring my own
interpreter for appointments.”) versus what actually
happened in prenatal visits and at delivery. As inter-
preter expectations were met and exceeded, satisfaction
increased ([r (22)=.43, P<.05]).
When asked “Should your doctor be responsible for
good communication?” 100% of hearing women an-
swered affirmatively, while only 82% of deaf women
did. Open-ended questions revealed a common theme
of deaf patients wanting doctors to use several ways
to communicate to increase the clarity of the message,
such as writing if communication was not understood
through lipreading. “She took time to talk with me and
she explained things clearly. When I wasn’t sure if I
understood, she wrote information down.” Frequently,
deaf women said that the provision of interpreter ser-
vices would demonstrate the physician’s concern for
them as well as improve communication. “Provide
interpreters so I won’t have to rely on family, so com-
munication will be faster, clearer.”
Participants’ Sample Characteristics
Characteristics %n % n
Under 25 years
40 and over
13 months–2 years
25 months and over
Seen most for care
Midwife or other
Deafness-related Characteristics of Deaf Participants
Decibel loss, in better ear
Profound, 90 and above
Onset of deafness
Etiology of deafness
Communication used in general
Communication with doctor
Frequency of interpreted appointments
6 or more
Who interpreted (multiple answers permitted)
715Vol. 38, No. 10
Clinical Research and Methods
The importance of clear communication was the sub-
ject of many deaf respondents’ open-ended comments.
“[The doctor should be] putting more interest in writing
and adding information to my questions.” None of the
deaf women stated that their doctors called them to
check on them, whereas several hearing women did.
Despite the communication and prenatal care sat-
isfaction differences between the deaf and hearing
participants in this study, the measures associated with
pregnancy outcomes (birth weight, length of hospital
stay, premature deliveries, or delivery complications)
did not show significant differences between the groups.
This participant sample was particularly well educated,
which may have been a mitigating factor decreasing
pregnancy risks, and the sample was not large enough
to identify differences between groups in events that
occur infrequently. Nevertheless, we did find that deaf
women were less satisfied overall with their prenatal
care, less satisfied with physician concern and quality of
communication, had fewer prenatal care appointments,
and received less information from their physicians than
did hearing women.
It is notable that the deaf respondents who were pro-
ficient in oral communication (ie, speaking, lipreading)
were no more satisfied with their prenatal care than the
deaf women who communicated exclusively through
sign language. Regardless of variations in their com-
munication abilities, the deaf women were consistently
less satisfied then the hearing women. This finding
suggests that oral proficiencies among deaf individuals
do not by themselves yield effective communication or
patient satisfaction. Specific efforts are still necessary
to ensure that communication is effective with deaf
patients with speech and speech reading proficiencies.
For a deaf patient who prefers sign language, effective
communication is dependent on the provision of inter-
preter services, regardless of any
oral communication proficiencies
that deaf person may have.
When deaf women’s expecta-
tions about interpreters were
met or exceeded, satisfaction in-
creased. This finding is supported
by prior research indicating that
the negative consequences that
can ensue when physicians know
that interpreters should be used,
yet do not use them.17 With hear-
ing loss being the sixth most
common chronic condition in the
United States,31 there is compel-
ling reason for medical education
curricula to include information
regarding optimal communica-
tion with deaf and hard of hearing patients or family
Deaf women reported fewer prenatal appointments
than hearing women. Whether this reflects a difference
in the number of appointments scheduled versus the
number attended (or both) cannot be determined from
the available data. As the number of prenatal appoint-
ments increased for deaf women, their satisfaction
decreased. It may be that deaf women find diminishing
value in additional appointments as they contend with
ongoing communication barriers with their doctors.
Hearing women reported receiving more information
from their doctors and were more often counseled about
abstinence from alcohol. This also is likely due to com-
munication barriers that prompted deaf women to seek
information in other ways. This may have implications
for health outcomes, especially in higher risk medical
situations or with women whose education level is lower
than that of the women in our sample.
When asked “Should your doctor be responsible for
good communication?” 100% of hearing women an-
swered affirmatively, while only 82% of deaf women
did. This may partially explain why deaf women report
satisfaction with their doctors, even when communica-
tion is difficult; they may perceive that they bear some
of the responsibility for effective communication (or
lack thereof). Alternatively, deaf women’s expectations
may be significantly lower, such that a lesser quality
of communication exceeds their attenuated expecta-
The fact that deaf women were not satisfied with
several aspects of communication, yet reported being
satisfied overall, merits further consideration. The in-
fluence of stigma on self-esteem and satisfaction may
provide some answers. In general, stigmatized indi-
viduals are not dissatisfied with their lives.33 Members
of marginalized groups compare themselves not to the
majority but to members of their own group.34 Deaf
Means, Standard Deviations (SDs), and One-way Analyses of Variance
(ANOVA) for Deaf and Hearing Respondents on Satisfaction Variables
SD MeanSD F Test P Value
November-December 2006Family Medicine
women may perceive small attempts by their doctors
as impressive in a context relative to their reference
group’s past experiences.
As in other studies, when doctors made efforts to
be sensitive to communication, positive outcomes
resulted.14 Our results suggest that physician efforts
to make communication effective cannot be readily
distinguished from physician concern. Adopting more
concern, especially where communication is involved
with deaf patients, may well increase overall patient
The major limitation of this study was the small, edu-
cated sample, which limits generalizability. Research
conducted in ASL rather than through questionnaires
would yield greater numbers of participants who are
not fluent in English. Comparison of deaf and hearing
women’s experiences receiving care from the same
doctor, or the same group practice, would further en-
hance the results. Additionally, recall bias may have
influenced the results, as this study was assessing
satisfaction from a period of time up to 3 years prior to
the survey, and satisfaction may have been influenced
by subsequent physician interactions.
Future studies should examine what types of training
can be most effective with physicians to result in both
physician and patient satisfaction. Including informa-
tion about hearing loss in resident training curricula
on patient-doctor communication may be one avenue.
Barnett32 provides detailed recommendations in this
Acknowledgments: This work was supported in part by a grant from the
National Institute on Disability and Rehabilitation Research in the US
Department of Education’s Office of Special Education and Rehabilitative
Services. However, the contents of this article do not necessarily represent
the policy of the US Department of Education, and you should not assume
endorsement by the federal government. The work also was supported in part
by Cooperative Agreement Number I-U48-DP-000031 from the Centers for
Disease Control and Prevention. Its contents are solely the responsibility of
the author and do not necessarily represent the official views of the Centers
for Disease Control and Prevention.
This study was presented at the American Public Health Association’s
Annual Conference, November 2004, Washington, DC.
Correspondence: Address correspondence to Dr O’Hearn, University of
Rochester Medical Center, 300 Crittenden Boulevard, Rochester, NY 14642.
585-275-2285. Fax: 585-273-1117. firstname.lastname@example.org.
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