A Cross-sectional Survey of Women’s Provider Gender Preferences for Gynecology and Obstetrics Care at King Abdulaziz University Hospital

Objective: This study investigated women’s gender preferences for their obstetrician-gynecologist. Methods: A cross-sectional survey was conducted of participants (aged >14 years) visiting the obstetrics and gynecology clinics of King Abdulaziz University Hospital, Jeddah in March 2015. The main outcome measures included respondents’ gender preferences regarding their obstetrician-gynecologists and their ratings of the quality of care provided by male and female obstetrician-gynecologists. Results: Of the 500 women invited, 418 accepted and participated in this survey (response rate, 83.6%). Approximately 52.6% of the respondents reported selecting their physicians. Most respondents preferred a female provider for pelvic examinations (77.1%), for new-born care (64.5%), for having primary health screening (61.2%), and for major gynecological surgery (47.0%). The most common factors that affected a woman’s decision when choosing a physician were comfort with a female practitioner (20.2%), husband's preference for a female doctor (11.7%), and the physician's knowledge (11.7%). The most important physician attribute that highly impacts women’s decisions is the experience of the physician (54.5%). Across all income levels, women were likely to consult a female obstetrician/gynecologist more often and for longer periods (p=0.010). Conclusion: Women visiting the gynecology and obstetrics clinics of King Abdulaziz University Hospital prefer a female gynecologist-obstetrician.


Introduction
Patients' preferences in choosing their physicians have been a subject of interest in previous studies [1][2][3]. Some studies specifically focused on women's preferences in choosing their obstetrician/ gynecologist, especially the gender-related criterion [4,5]. An increase in the number of female obstetricians/gynecologists was reported to correlate with changes in women's preferences for female obstetricians/ gynecologists [6,7], with the most commonly reported reasons for women's choices being religious beliefs, cultural traditions and enhanced feelings of privacy [4,8].
In an ultraconservative country such as Saudi Arabia, one of the most important Islamic rules is modesty. The most conspicuous indication of modesty among Saudi women is their dress, which involves veiling and wearing an abaya, a black ankle-length cloth. In addition, women have to abstain from physical contact with nonrelated men. Islamic scholars advise that it is inappropriate for Muslim women to be examined by a doctor of the opposite gender, especially when consultation would involve examination of the genital organs [9]. Consequently, in the healthcare setting, gender issues are expected to influence patients' choices of physician.
The last decade has witnessed an increase in demand for women's health care in Saudi Arabia [10]. Several authors have reported gender differences in obstetrician-gynecologists and female medical students' interest in this specialty practice field [11][12][13][14][15]. However, there is a paucity of research addressing whether one isolated factor-namely, physician gender-bears any correlation with patient selection. To date, only two hospital-based studies, one conducted in AlKhobar and the other in Riyadh, found that patients in obstetrics and gynecology preferred a female physician [16]. This study aims to investigate women's gender preferences for their obstetrician-gynecologist at a tertiary hospital in Jeddah.

Study design and setting
In March 2015, a cross-sectional survey was conducted on women in the obstetrics and gynecology waiting rooms of King Abdulaziz University Hospital, Jeddah, Saudi Arabia. During scheduled visit days, participants who were >14 years old were offered entry into the study.

Ethical considerations
Informed consent was sought from all the participants prior to recruitment. Participants were assured that the survey would be conducted anonymously and data would be solely used for research purposes. The Biomedical Ethics Committee at King Abdulaziz University approved all aspects of this study.

Survey instrument and data collection
The survey instrument was a self-administered 21-item questionnaire modified from a validated questionnaire [4]. Questionnaires were consistently distributed by medical students. Surveys were written in Arabic and English to allow for differences in preferred language, and each questionnaire took about 10 minutes to complete while women waited for their respective appointments.
The questionnaire gathered demographic data, including age, level of education, marital status, monthly income, occupation, and religion. Other items that the questionnaires addressed included the length of each respondent's visits to the clinics (either in months or years), the gender of the physician that they often visited, the gender of the physician at their last visit, and whether each respondent had the opportunity to choose the obstetrician-gynecologist who treated herand, if not, would they have liked to have the opportunity to choose their physician.
In addressing women's gender preferences regarding their obstetrician-gynecologists, we focused on several specific aspects of obstetric and gynecologic care, including pelvic examinations, obstetric care, and gynecologic surgery. Respondents were also asked to choose and rank physician attributes that they consider when choosing an obstetrician and gynecologist. They were asked to rate the quality of care provided by their physician at their most recent visit. Ratings were based on a scale whereby 1 indicated 'poor' service and 10 indicated 'excellent service' .

Sample size determination
A power analysis was performed to determine statistical significance for gender preference among physician attributes in selecting an obstetrics and gynecology provider. The power analysis determined that we needed 50 patients to participate in the survey. Based on this figure, the confidence interval for gender preference was on the order of 0.03. We decided to sample over 200 women to improve the statistical power and reliability of our analyses.

Statistical analysis
Analyses were done using the Statistical Package for the Social Sciences (SPSS IBM, New York, US), version 22. Results are described in absolute values and percentages for categorical and nominal variables, while continuous variables are presented as means and standard deviations. To establish relationships between categorical variables, we used the chi-square test, while an independent t-test was used to compare group means. These tests were undertaken with the assumption of normal distribution. Welch's T was employed for group means.
Finally, a conventional p-value<0.05 was used to reject the null hypothesis.

Results
A total of 500 women were invited to participate in this crosssectional survey. Of these, 418 chose to participate, yielding a response rate of 83.6%.
The age of the respondents ranged from 16-70 years. Approximately 41.4% of the respondents had completed college; however, 70.7% were unemployed (Table 1).   Table 2: Respondents' behaviors regarding obstetrics and gynecology visits at the clinics (*the total is <418 due to missing values).
The majority of respondents (n=314; 77.1%) preferred a female provider for pelvic examinations; 14.5% had no preference. Similarly, in most cases, women preferred a female provider for new-born care (n=264; 64.5%), for a primary health screening (n=251; 61.2%), and for a major gynecological surgery (n=189; 47.0%). One hundred eighty-nine respondents (46.7%) considered women to have more sympathy; however, approximately equal proportions of the respondents thought that either of the genders had more respect for their patients. In general, most respondents believed female providers were better obstetricians/gynecologists than their male counterparts (Table 3).

Variables
Frequency (  More than half of the respondents admitted they were embarrassed to consult a male obstetrician (Table 4). In most cases, women preferred a physician who was older than them. The most frequently reported factor that affected women's decisions to choose a male or female physician was comfort with a female practitioner (20.2%), husband's preference for a female doctor (11.7%), and the physician's knowledge (11.7%). When selecting a physician, approximately onethird of the respondents thought it was important for the physician to give the patient his/her full attention during consultation. Other important factors included the opportunity for involvement in the treatment plan (27.1%), accessibility of the physician for appointment and questions (12.6%), and the sympathetic behavior of the physician (10.1%). When asked about physician attributes that would highly impact their decision to choose a physician, more than half of the participants (54.5%) selected the physician's experience; boardcertification was the second important physician attribute, followed by reputation (recommendation by a relative or friend) (  Further analysis showed that across all income levels, women were likely to consult a female obstetrician/gynecologist more often and for longer periods (p=0.010) ( Table 5). In addition, at higher income levels women tended to consult female doctors. Respondents did not differ in their gender preferences based on their level of education (p=0.308), marital status (p=0.590), health insurance status (p=0.308), religion (p=0.764), occupation (p=0.167), or employment type (p=0.174).
We also did not find significant differences between women's ratings of care provided by male or female physicians (8.4(2.1) for male physicians compared to 8.2(2.1) for female physicians; p=0.402)).
Similarly, we did not find significant differences in women's ratings of care provided by either gender based on whether they selected their physician or not (8.23(2.2) for women who chose their physicians compared to 8.37(2.0) for those who did not select their physician; p=0.482) (  Table 5: Association between demographics and frequency of visits to the obstetrician by gender (*data are presented as frequency (percentage) unless otherwise specified. The total is<418 due to missing values in some cases).

Discussion
Our analysis indicates that more than half of patients seeking obstetric and gynecologic care, regardless of their financial status, preferred to have women as their caregivers. Preference for a female provider has also been reported in both Muslim and non-Muslim women [5][6][7]17,18], with Muslim patients' choices usually being driven by religious beliefs [6,17]. In a cross-sectional survey of 218 Emirati women, McLean et al. [17] found that a female physician was almost exclusively preferred for the gynecological scenario (96.8%). According to previous reports [19,20], Muslim women almost always request a female health provider for medical conditions involving areas of the body required by Islam to be covered, which they (Muslim women) generally felt uncomfortable exposing to a man. Contrary to our findings, other authors [4] reported that more than half of the women (56.6%) who chose their own healthcare providers selected a male gynecologist-obstetrician. Nevertheless, this disparity might be due to a difference in culture between our conservative society and the liberal Western world.
The results of the present survey demonstrate that approximately 52.6% of the respondents reported choosing their physicians. In most cases, women reported comfort, spouse's preference for a female doctor, and physician's knowledge as frequent factors that affected their decision between choosing a male or female physician. Although one might suggest that patients who choose their obstetriciangynecologists tended to be more satisfied than those who did not, the fact that there was no difference between the two groups in terms of their rating of care vis-à-vis physician gender refutes this hypothesis. When asked about physician attributes that would highly impact their decision to choose a physician, more than half of the women surveyed (54.5%) selected the physician's experience. In their survey, Johnson et al. [4] found that physician attributes, such as experience, knowledge, and ability, were reported as qualities that patients considered when choosing obstetrician-gynecologists. They also found that physician gender was a minor factor to patients selecting obstetriciangynecologists when their perceptions of important physician qualities where combined with their responses regarding gender. Furthermore, the authors suggested that patient demand for obstetriciangynecologists can easily be satisfied with an equal distribution between genders, because the qualities important to patients can be identified in both men and women. While physician qualities were important aspects that had a high impact on our respondents' decision, within our study, gender bias still appeared to be the most important factor in physician selection.
According to a prior report, women aged ≤ 25 years preferred to have a female doctor for gynecological examination [21]. In another study, Amer-Alshiek et al. [22] found that respondents' preferred female obstetricians/gynecologists because they felt more comfortable and less embarrassed; respondents also reported that female obstetricians/gynecologists were gentler during intimate procedures. Results from other studies conducted among Arab traditional and religious women demonstrated that one of the major reasons for preference of same sex obstetricians/gynecologists was feeling more comfortable and less embarrassed when care was provided by a female [7,23]; same sex obstetricians/gynecologists were found to be particularly important for intimate procedures [23]. In the current report, more than half of the respondents preferred a female provider for pelvic examinations and for major gynecological surgery. Similarly, most women preferred a female provider for newborn care and for primary health screenings, which may be because most of the women believed that female providers were better obstetricians/gynecologists than their male counterparts. experiences with their regular obstetricians-gynecologists and therefore could not determine whether these influenced their choice of physician. Second, we did not investigate the role of care managers, who can potentially influence patients' perceptions of health care providers as well as their perceptions of the quality of care at the obstetrics and gynecology clinics of our institution. A model that incorporated care managers (specially trained nurses) demonstrated that patients were more satisfied with the level of care due to the strong partnership between care managers and patients and the effective collaboration between physicians and care managers [24]. Third, because this study is hospital-based, the findings cannot be extrapolated to the population of Jeddah. However, these findings can serve as a preliminary step toward identifying demand for female providers in obstetrics and gynecology at King Abdulaziz University Hospital.

Conclusions
We have presented data that strongly suggest women visiting the gynecology and obstetrics clinics of King Abdulaziz University Hospital prefer a female gynecologist-obstetrician. Furthermore, obstetrician-gynecologists who are qualified, sympathetic, reputable, and viewed by their patients as knowledgeable and experienced are in demand. In our setting, where religious and cultural norms play a pivotal role in social interactions, women's preferences for same gender obstetricians/gynecologists have implications for health care services.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial, or non-profit sector.