The Effectiveness of Internet-Based Cognitive Behavioral Therapy for the Treatment of Depression in a Large Real-World Primary Care Practice: A Randomized Trial.

PurposeThe purpose of this study was to compare the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression, to that of treatment as usual (TAU) alone. MethodsIn this study, 302 depressed adult Family Medicine outpatients were randomized to receive either TAU or additional access to Thrive, a fully automated iCBT program with three video-based modules, each containing 10 lessons using behavioral activation, cognitive restructuring, and social skills training. The primary outcome was the change in the score on an online patient health questionnaire (PHQ-9), measured at 0, 8, and 24 weeks. ResultsThe intervention group saw a relative improvement of 2.5 points in PHQ-9 scores at 8 weeks (p = 0.002, d = -0.48), was 6.0 times (p < 0.001) more likely to respond (defined as a ≥ 50% reduction in PHQ-9 score), and was 5.2 times (p = 0.04) more likely to have achieved remission (defined as a PHQ-9 score of < 5) at 8 weeks, but by 24 weeks, the control group had improved to a similar extent as the intervention group (d = -0.14). The intervention group improved in productivity at 8 weeks (p = 0.03), but by 24 weeks, the TAU group had also improved to a similar extent. No significant differences in anxiety, quality of life, or suicidal ideation were found. Patients reported high satisfaction with this iCBT tool, including ease of use, tailoring, and perceived helpfulness. However, only 43% of the intervention group and 58% of the TAU group had outcome measures at every time point. ConclusionsiCBT was associated with greater depression response and remission at 8 weeks, compared with the control group. Depression scores in the intervention group remained similar at 24 weeks, at which time the control group also showed similar rate of response and remission.

Practitioner Education and Feedback to Decrease Ciprofloxacin Prescriptions in Patients with Acute Uncomplicated Cystitis.

CONTEXT: Current guidelines recommend a nonfluoroquinolone agent as first-line treatment of acute uncomplicated cystitis (AUC) because of concerns of antimicrobial resistance and adverse effects. OBJECTIVE: To test whether a multifaceted intervention involving education and feedback reduced primary care practitioners' ciprofloxacin prescriptions for AUC therapy. DESIGN: Primary care practitioners at 3 medical offices participated: 65 in the intervention group and 51 in the control group. Intervention group participants received an educational lecture and emailed summary of antimicrobial guidelines, their AUC prescriptions were audited, and feedback was provided on inappropriate antibiotic choices. Prescriptions at AUC encounters were tracked during baseline, intervention, and postintervention periods. MAIN OUTCOME MEASURES: Proportion of AUC encounters at which ciprofloxacin was prescribed vs recommended first-line antibiotics. RESULTS: Intervention group participants had 5262 eligible AUC encounters, and control group participants had 5473. At baseline, ciprofloxacin was prescribed at 29.7% and 33.7% of eligible AUC encounters in the intervention and control groups, respectively (p = 0.003). After intervention, ciprofloxacin was prescribed at 10.8% of eligible AUC encounters in the intervention group and 34.3% in the control (p < 0.001). Adjusted odds ratios of ciprofloxacin prescription for AUC therapy were significantly lower in the intervention group during postintervention and intervention periods vs baseline (0.29, 95% confidence interval = 0.20-0.44, p < 0.001 and 0.80, 95% confidence interval = 0.66-0.97, p = 0.03). Adjusted odds ratios did not change over time in the controls. CONCLUSION: Educating primary care practitioners and conducting audit and feedback reduced their prescriptions of ciprofloxacin for AUC therapy.

Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study.

CONTEXT: The high prevalence and negative implications of resident physicians' burnout is well documented, yet few effective interventions have been identified. OBJECTIVE: To document resident and faculty perspectives on resident burnout, including perceived contributing factors and their recommended strategies for attention and prevention. DESIGN: We conducted 14 focus groups with core faculty and residents in 5 specialties at a large integrated health care system in Southern California. Training programs sampled included family medicine, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry. Discussions were recorded, transcribed, and analyzed using a matrix-based approach to identify common themes. MAIN OUTCOME MEASURES: Resident and faculty perspectives regarding causes of burnout, preventive factors, and potential intervention strategies. RESULTS: Five themes captured the range of factors participants identified as contributing or protective factors for resident burnout: 1) having or lacking a sense of meaning at work; 2) fatigue and exhaustion; 3) cultural norms in medicine; 4) the steep learning curve from medical school to residency; and 5) social relationships at and outside work. Recommended intervention strategies targeted individuals, residents' social networks, and the learning and work environment. CONCLUSION: We engaged residents and core faculty across specialties in the identification of factors contributing to burnout and possible targets for interventions. Our results highlight potential focus areas for future burnout interventions and point to the importance of interventions targeted at the social environments in which residents' work and learn.

Understanding Faculty and Trainee Needs Related to Scholarly Activity in a Large, Nonuniversity Graduate Medical Education Program.

CONTEXT: Graduate medical education (GME) programs must develop curriculum to ensure scholarly activity among trainees and faculty to meet accreditation requirements and to support evidence-based medicine. OBJECTIVE: Test whether research-related needs and interests varied across four groups: primary care trainees, specialty trainees, primary care faculty, and specialty faculty. DESIGN: We surveyed a random sample of trainees and faculty in Kaiser Permanente Southern California's GME programs. We investigated group differences in outcomes using Fisher exact and Kruskal-Wallis tests. MAIN OUTCOME MEASURES: Research experiences, skills, barriers, motivators, and interests in specific research skills development. RESULTS: Participants included 47 trainees and 26 faculty (response rate = 30%). Among primary care faculty, 12 (71%) reported little or no research experience vs 1 (11%) for specialty faculty, 14 (41%) for primary care trainees, and 1 (8%) for specialty trainees (p < 0.001). Submission of research to the institutional review board, an abstract to a conference, or a manuscript for publication in the previous year varied across groups (p = 0.001, p = 0.003, and p < 0.001, respectively). Overall self-reported research skills also differed across groups (p < 0.001). Primary care faculty reported the lowest skill level. Research barriers that differed across groups included other work roles taking priority; desire for work-life balance; and lack of managerial support, research equipment, administrative support, and funding. CONCLUSION: Faculty and trainees in primary care and specialties have differing research-related needs that GME programs should consider when designing curricula to support scholarly activity. Developing research skills of primary care faculty is a priority to support trainees' scholarly activity.

Evaluation of a Community Health Worker Intervention to Reduce HIV/AIDS Stigma and Increase HIV Testing Among Underserved Latinos in the Southwestern U.S.

OBJECTIVES: Latinos are at an elevated risk for HIV infection. Continued HIV/AIDS stigma presents barriers to HIV testing and affects the quality of life of HIV-positive individuals, yet few interventions addressing HIV/AIDS stigma have been developed for Latinos. METHODS: An intervention led by community health workers (promotores de salud, or promotores) targeting underserved Latinos in three southwestern U.S. communities was developed to decrease HIV/AIDS stigma and increase HIV knowledge and perception of risk. The intervention was led by HIV-positive and HIV-affected (i.e., those who have, or have had, a close family member or friend with HIV/AIDS) promotores, who delivered interactive group-based educational sessions to groups of Latinos in Spanish and English. To decrease stigma and motivate behavioral and attitudinal change, the educational sessions emphasized positive Latino cultural values and community assets. The participant pool comprised 579 Latino adults recruited in El Paso, Texas (n=204); San Ysidro, California (n=175); and Los Angeles, California (n=200). RESULTS: From pretest to posttest, HIV/AIDS stigma scores decreased significantly (p<0.001). Significant increases were observed in HIV/AIDS knowledge (p<0.001), willingness to discuss HIV/AIDS with one's sexual partner (p<0.001), and HIV risk perception (p=0.006). Willingness to test for HIV in the three months following the intervention did not increase. Women demonstrated a greater reduction in HIV/AIDS stigma scores when compared with their male counterparts, which may have been related to a greater increase in HIV/AIDS knowledge scores (p=0.016 and p=0.007, respectively). CONCLUSION: Promotores interventions to reduce HIV/AIDS stigma and increase HIV-related knowledge, perception of risk, and willingness to discuss sexual risk with partners show promise in reaching underserved Latino communities.

Cultural measures associated with sexual risk behaviors among Latino youth in Southern California: a longitudinal study.

CONTEXT: Cultural variables have been associated with sexual risk behaviors among Latino youth, but findings across studies are inconsistent. METHODS: A longitudinal study of acculturation patterns followed Latino youth in Southern California from 2005 to 2012. Data from 995 participants were used in logistic and ordered regression analyses to test whether cultural variables measured in high school were associated with sexual risk behaviors in emerging adulthood, and whether gender moderated these associations. RESULTS: The cultural value of respect for parents was negatively associated with participants' odds of reporting an earlier age at sexual debut (odds ratio, 0.8) and condom nonuse at most recent sexual intercourse (0.8). A measure of acculturation reflecting U.S. cultural practices was positively associated with the likelihood of being sexually experienced (1.2), having concurrent sexual partners (1.5) and, among males only, having a greater number of sexual partners (1.3). Second- and later-generation immigrant youth had lower odds of not using a condom at most recent sexual intercourse than first-generation youth (0.6 and 0.5, respectively). Strength of endorsement of Latino cultural practices was negatively associated with females' lifetime number of partners (0.8), but positively associated with males' (1.4). CONCLUSIONS: The cultural measures associated with Latino youths' sexual behaviors differed across outcomes and by gender. Further understanding of these associations and their underlying mechanisms may help inform the development of culturally sensitive sexual health interventions.

Women's reports on postabortion family-planning services provided by the public-sector legal abortion program in Mexico City.

OBJECTIVE: To investigate patients' views of family-planning services provided in Mexico City during abortion care at public facilities and their acceptance of postabortion contraception. METHODS: In total, 402 women seeking first-trimester abortion care in Mexico City were surveyed. Logistic regression was used to test whether postabortion contraception varied according to abortion visit characteristics or patient sociodemographics. RESULTS: Most participants (328 [81.6%]) reported being offered contraception at their visit and 359/401 (89.5%) selected a contraceptive method for postabortion use, with 236/401 (58.9%) selecting an intrauterine device. Women who underwent surgical abortion were more likely than those who underwent medical abortion to report being offered contraception (P<0.001); women attended by a female physician were more likely than those attended by a male physician to report being offered contraception (P<0.05). Women who attended the general hospital were less likely to report being offered contraception (P<0.001). CONCLUSION: Public-sector facilities in Mexico City provide a high level of postabortion family-planning care, and uptake of postabortion contraception is high.

Decriminalization of abortion in Mexico City: the effects on women's reproductive rights.

In April 2007, the Mexico City, Mexico, legislature passed landmark legislation decriminalizing elective abortion in the first 12 weeks of pregnancy. In Mexico City, safe abortion services are now available to women through the Mexico City Ministry of Health's free public sector legal abortion program and in the private sector, and more than 89 000 legal abortions have been performed. By contrast, abortion has continued to be restricted across the Mexican states (each state makes its own abortion laws), and there has been an antichoice backlash against the legislation in 16 states. Mexico City's abortion legislation is an important first step in improving reproductive rights, but unsafe abortions will only be eliminated if similar abortion legislation is adopted across the entire country.

Women's experiences of and perspectives on abortion at public facilities in Mexico City three years following decriminalization.

OBJECTIVE: To understand the experiences of women undergoing legal first-trimester abortion through Mexico City's Ministry of Health (MOH) services. Aims included comparing satisfaction with medical and surgical abortion services; drawing evidence-based recommendations for program improvement; and measuring contraceptive uptake following abortion. METHODS: A total of 350 women completed a 65-item survey questionnaire at 2 main MOH abortion facilities. Moreover, a subset of 20 participated in an in-depth interview. Multivariate analysis was performed to investigate satisfaction with abortion care and in-depth interview (IDI) data were analyzed. RESULTS: The participants overwhelmingly reported satisfaction with the care they received, with no significant differences between the medical and surgical abortion groups. However, qualitative data revealed a need for a more sympathetic staff, reduced waiting times, more comprehensive information on surgical abortion, and counseling that includes psychosocial issues. Postabortion contraception uptake was high, with most women opting for the intrauterine device. CONCLUSION: The quantitative analysis suggests that although most women were satisfied with the services, some areas were identified as requiring improvement. The IDI data suggest that women wanted counseling to better address psychosocial needs and allow for discussion on a wider range of contraceptive methods.

Patient characteristics and service trends following abortion legalization in Mexico City, 2007-10.

Legal abortion services have been available in public and private health facilities in Mexico City since April 2007 for pregnancies of up to 12 weeks gestation. As of January 2011, more than 50,000 procedures have been performed by Ministry of Health hospitals and clinics. We researched trends in service users' characteristics, types of procedures performed, post-procedure complications, repeat abortions, and postabortion uptake of contraception in 15 designated hospitals from April 2007 to March 2010. The trend in procedures has been toward more medication and manual vacuum aspiration abortions and fewer done through dilation and curettage. Percentages of post-procedure complications and repeat abortions remain low (2.3 and 0.9 percent, respectively). Uptake of postabortion contraception has increased over time; 85 percent of women selected a method in 2009-10, compared with 73 percent in 2007-08. Our findings indicate that the Ministry of Health's program provides safe services that contribute to the prevention of repeat unintended pregnancies.

Sociodemographic factors associated with obstacles to abortion care: findings from a survey of abortion patients in Mexico City.

BACKGROUND: First-trimester abortion was legalized in Mexico City in 2007, and services are now provided at public and private sites throughout the city. However, little is known about the obstacles women face when seeking abortion care. METHODS: We surveyed women who obtained abortion services (n = 398) at three public sector facilities in Mexico City to identify the obstacles women faced when obtaining abortions. We used logistic regression to test whether obstacles varied by sociodemographic characteristics. RESULTS: Women with low education were more likely than high school-educated women to report difficulty getting appointments. Unmarried women and women with low education were more likely than married women or high school educated women to report difficulty getting time off work for appointments and arranging for transportation to the facility. Separated or divorced women were more likely than married women to report partner or other family member opposition to the abortion. Women who lived outside of Mexico City were more likely than Mexico City residents to report difficulty with transportation. CONCLUSION: Education, marital status, and place of residence were associated with the obstacles women reported. Strategies to improve access to care should be targeted to the groups at highest risk of experiencing obstacles: Women with primary education or lower, single women, separated/divorced women, and those residing outside of Mexico City.

Conducting collaborative abortion research in international settings.

Nearly 20% of the 208 million pregnancies that occur annually are aborted. More than half of these (21.6 million) are unsafe, resulting in 47,000 abortion-related deaths each year. Accurate reports on the prevalence of abortion, the conditions under which it occurs, and the experiences women have in obtaining abortions are essential to addressing unsafe abortion globally. It is difficult, however, to obtain accurate and reliable reports of attitudes and practices given that abortion is often controversial and stigmatized, even in settings where it is legal. To improve the understanding and measurement of abortion, specific considerations are needed throughout all stages of the planning, design, and implementation of research on abortion: Establishment of strong local partnerships, knowledge of local culture, integration of innovative methodologies, and approaches that may facilitate better reporting. This paper draws on the authors' collaborative research experiences conducting abortion-related studies using clinic- and community-based samples in five diverse settings (Poland, Zanzibar, Mexico City, the Philippines, and Bangladesh). The purpose of this paper is to share insights and lessons learned with new and established researchers to inform the development and implementation of abortion-related research. The paper discusses the unique challenges of conducting abortion-related research and key considerations for the design and implementation of abortion research, both to maximize data quality and to frame inferences from this research appropriately.

Abortion stigma: a reconceptualization of constituents, causes, and consequences.

Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups--and differences between the groups--help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects.

Does the outcome of a first pregnancy predict depression, suicidal ideation, or lower self-esteem? Data from the National Comorbidity Survey.

This study examines the risk of depression, suicidal ideation, and lower self-esteem following an abortion versus a delivery, with and without adjusting for important correlates. Using the National Comorbidity Survey, we tested how first pregnancy outcome (abortion vs. delivery) related to subsequent major depression, suicidal ideation, and self-esteem. Models controlling for risk factors, such as background and economic factors, prepregnancy violence experience, and prepregnancy mental health, as well as a model with all risk factors, were examined. When no risk factors were entered in the model, women who had abortions were more likely to have subsequent depression, OR=1.53, 95% CI [1.05-2.22], and suicidal ideation, OR=2.02, 95% CI [1.40-2.92], but they were not more likely to have lower self-esteem, B=-.02. When all risk factors were entered, pregnancy outcome was not significantly related to later depression, OR=0.87, 95% CI [0.54-1.37], and suicidal ideation, OR=1.19, 95% CI [0.70-2.02]. Predictors of mental health following abortion and delivery included prepregnancy depression, suicidal ideation, and sexual violence. Policies and practices implemented in response to the claim that abortion hurts women are not supported by our findings. Efforts to support women's mental health should focus on known risk factors, such as gender-based violence and prior mental health problems, rather than abortion history.

Clients' perceptions of the quality of care in Mexico city's public-sector legal abortion program.

CONTEXT: In 2007, first-trimester abortion was legalized in Mexico City. Limited research has been conducted to understand clients' perceptions of the abortion services available in public-sector facilities. METHODS: Perceptions of quality of care were measured among 402 women aged 18 or older who had obtained abortions at any of three public-sector sites in Mexico City in 2009. Six domains of quality of care (client-staff interaction, information provision, technical competence, postabortion contraceptive services, accessibility and the facility environment) were assessed, and ordinal logistic regression analysis was conducted to identify the domains that were important in women's overall evaluation of care. RESULTS: Clients gave overall services a high rating, with a mean of 8.8 out of 10. In multivariate analysis, overall ratings were higher among women who said the doctor made them feel comfortable (odds ratio, 3.3), the receptionist was respectful (1.7), the staff was very careful to protect their privacy (2.5), they had received sufficient information on self-care at home following the abortion and on postabortion emotions (1.9 and 2.0, respectively) and they felt confident in the doctor's technical skill (2.5). Rating site hours as very convenient (2.4), waiting time as acceptable (2.8) and the facility as very clean (1.9) were all associated with higher overall scores. Compared with women who had given birth, those who had not rated the services lower overall (0.6). CONCLUSION: Efforts to improve patient experiences with abortion services should focus on client-staff interaction, information provision, service accessibility, technical competence and the facility environment. The most highly significant factor appears to be whether a doctor makes a woman feel comfortable during her visit.

Abstinence and teenagers: prevention counseling practices of health care providers serving high-risk patients in the United States.

CONTEXT: Abstinence-only education has had little demonstrable impact on teenagers' sexual behaviors, despite significant policy and funding efforts. Given the struggle over resources to improve teenagers' reproductive health outcomes, the views of clinicians serving teenagers at high risk for unintended pregnancy and STDs merit particular attention. METHODS: In 2005, a qualitative study with 31 clinicians serving low-income, at-risk patients was conducted. A semistructured interview guide was used to ask clinicians about adolescent pregnancy, HIV and STD prevention counseling, and when they include abstinence. Thematic content analysis was used to examine the content of the counseling and the techniques used in different situations. RESULTS: Providers reported offering comprehensive counseling, presenting abstinence as a choice for teenagers, along with information about contraceptives and condoms. Several providers mentioned that with young, sexually inexperienced teenagers, they discuss delaying sexual activity and suggest other ways to be affectionate, while giving information on condoms. Providers explained how they assess whether teenagers feel ready to be sexually active and try to impart skills for healthy relationships. Some described abstinence as giving teenagers a way to opt out of unwanted sexual activity. Many support abstinence if that is the patient's desire, but routinely dispense condoms and contraceptives. CONCLUSIONS: Overall, providers did not give abstinence counseling as a rigid categorical concept in their preventive practices, but as a health tool to give agency to teenagers within a harm reduction framework. Their approach may be informative for adolescent policies and programs in the future.

Women's perspectives on family planning service quality: an exploration of differences by race, ethnicity and language.

CONTEXT: Despite calls to make family planning services more responsive to the values, needs and preferences of clients, few studies have asked clients about their experiences or values, and most have used surveys framed by researchers', rather than clients', perspectives. METHODS: Forty in-depth interviews exploring lifetime experiences with and values regarding services were conducted with 18-36-year-old women who visited family planning clinics in the San Francisco Bay Area in 2007. Women were categorized as black, white, English- or Spanish-speaking Latina, or of mixed ethnicity to allow examination of differences by racial, ethnic and language group. Interviews were audiotaped, transcribed and coded thematically; matrices were then used to compare the themes that emerged across the subgroups. RESULTS: Eight themes emerged as important to women's views of services: service accessibility, information provision, attention to client comfort, providers' personalization of care, service organization, providers' empathy, technical quality of care and providers' respect for women's autonomy. Women reported that it was important to feel comfortable during visits, to feel that their decision-making autonomy was respected, to have providers show empathy and be nonjudgmental, and to see the same provider across visits. The only notable difference among racial, ethnic and language groups was that Spanish-speaking Latinas wanted to receive language-appropriate care and contraceptive information. CONCLUSIONS: Future surveys of family planning service quality should include measures of the factors that women value in such care, and efforts to improve providers' communication and counseling skills should emphasize the personalization of services and respect for clients' autonomy.

Reproductive health service preferences and perceptions of quality among low-income women: racial, ethnic and language group differences.

CONTEXT: Eliminating racial and ethnic disparities in health care is an important national priority. Despite substantial research documenting such disparities, this topic has received limited attention in the reproductive health field. METHODS: Logistic regression was used to test for group differences in three service delivery preferences and five service quality perceptions among a nationally representative sample of 1,741 low-income black, Latina and white women aged 18-34; the data were collected in 1995 and represent the most recent data available for looking at these issues. RESULTS: English-speaking Latinas and Spanish-speaking Latinas were more likely than whites to prefer a female clinician at their visits (odds ratios, 1.8 and 3.6, respectively) and to highly value clinician continuity (1.7 and 2.2). English-speaking Latinas and blacks were more likely than whites to prefer receiving reproductive health care at a site delivering general health care (1.5 and 1.6). Both groups of Latinas were less likely than whites to give the facility environment or the patient-centeredness at their most recent reproductive health visit the highest rating (0.3-0.5). Blacks were more likely than whites to report ever having been pressured by a clinician to use contraceptives (2.3). CONCLUSIONS: Efforts to reduce racial, ethnic and language group differences in clients' perceptions of reproductive health service quality should focus on improving client-clinician communication, the service environment and contraceptive counseling. Future research should continue to assess group differences and try to determine their underlying causes.

Knowledge and opinions of emergency contraceptive pills among female factory workers in Tijuana, Mexico.

Workers in Mexico's maquiladoras (assembly plants) are mainly young, single women, many of whom could benefit from emergency contraceptive pills (ECPs). Because ECPs are readily available in Mexico, women who know about the therapy can obtain it easily. Do maquiladora workers know about the method? Could worksite programs help increase awareness? To investigate these questions, we conducted a five-month intervention during which workers in three maquiladoras along the Mexico-United States border could attend educational talks on ECPs, receive pamphlets, and obtain kits containing EC supplies. Among the workers exposed to our intervention, knowledge of ECPs increased. Reported ECP use also increased. Although our intervention apparently increased workers' knowledge and use, the factory proved to be a difficult intervention setting. Problems we experienced included a factory closure and management/staff opposition to certain project elements. Future studies should continue to investigate work-site interventions and other strategies to reach workers.

Factors affecting Latina immigrants' perceptions of maternal health care: findings from a qualitative study.

Due to the influx of Latino immigration in the United States, health care services are faced with the challenge of meeting the needs of this growing population. In this qualitative study, we explored Latina immigrants' experiences with maternal health care services. We found that despite enduring language barriers and problems, Spanish-speaking women expressed satisfaction with their care. Factors influencing women's perceptions of care included sociocultural norms (respeto, personalismo, and familismo), previous experiences with care in their countries of origin, having healthy babies, and knowledge about entitlement to interpreter services. We offer recommendations for public health practice and research.