Satisfaction with childbirth: theories and methods of measurement

Development and evaluation of a childbirth education programme for Malawian women

AIM

This paper is a report of a study to develop and evaluate a childbirth educational programme for Malawian women.

BACKGROUND

Providing parent education is integral to the midwife's role. Malawian midwives face a challenge in fulfilling this role, with no existing childbirth education programme to facilitate this process.

METHOD

A mixed method approach was used for this three-phase study. In Phase 1, childbirth information needs of Malawian women were determined from literature and interviews with midwives. In Phase 2, a structured childbirth education programme was developed. In Phase 3, a quasi-experimental design using sequential sampling was conducted to evaluate the education programme. Participants were pregnant women who attended antenatal clinics in 2002, with 104 in the control group and 105 in the intervention group. Changes in childbirth knowledge were determined over a 6-week period.

FINDINGS

The childbirth education programme included information, teaching strategies and a schedule for implementation for content relevant to the antenatal, labour and birth and postnatal time periods. Results revealed no significant difference in knowledge in the control group between pretest and post-test scores. For the intervention group, however, an overall significant increase in knowledge across all time periods was demonstrated (P < 0.01).

CONCLUSION

A childbirth education programme, developed for the Malawian context, was associated with important increases in maternal knowledge about antenatal, labour and birth and postnatal topics. The findings have implications for midwives in other developing countries and offer an example of a midwifery-led initiative to provide formal childbirth education to these vulnerable women.

Evaluating multi-dimensional aspects of postnatal hospital care

OBJECTIVES

to investigate women's experiences of postnatal hospital care in relation to four different aspects: (1) interpersonal care; (2) time spent on physical check-ups; (3) time spent on information and support; and (4) time spent on assistance with breast feeding. More specifically, we aimed to establish whether typical clusters of women could be identified, and if so, whether these clusters could be related to specific outcomes of care, to the way in which care is organised, and to the individual's psychological health and socio-demographic background.

DESIGN

longitudinal population-based survey, including three questionnaires completed in early pregnancy, at 2 months and 1 year after birth.

SETTING

all postnatal wards in Sweden.

PARTICIPANTS

women (n=2338) recruited at their first booking visit at 593 antenatal clinics, who responded to questions relating to postnatal hospital care 2 months after birth.

FINDINGS

eight cluster profiles defined by the four aspects of postnatal care were identified. About half of the women were found in clusters that were satisfied with most aspects of care, and half in clusters that were dissatisfied with one aspect or more. Only 32% were very satisfied with all four dimensions. Specific groups of women, such as first-time mothers, migrants, young mothers and those with a short length of stay, were dissatisfied with different assessments of postnatal care. Psychological health in early pregnancy was associated with high ratings of all aspects of care, whereas emergency caesarean section and instrumental vaginal delivery was associated with dissatisfaction with breast feeding support and time spent on health check-ups.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

women's individual appraisal of specific aspects of hospital postnatal care could be grouped into response patterns that were shared by smaller or larger groups. These patterns were related to maternal characteristics, labour outcomes and the way in which care was organised. The multi-faceted approach used in this study provided details about who was dissatisfied with what, and showed that women are not necessarily either satisfied or dissatisfied with care in a general sense. In order to provide individualised care, the carer needs to be aware of these differences.

Women's satisfaction with intrapartum care - a pattern approach

AIM

This paper is a report of a study to investigate women's satisfaction with intrapartum care along three distinct dimensions simultaneously (interpersonal care, information and involvement in decision-making and physical birth environment) and to describe the characteristics of women with different patterns of satisfaction.

BACKGROUND

Patient satisfaction is an important outcome in the evaluation and development of healthcare services. Studies of satisfaction have often used single global ratings but such ratings may not capture the multidimensionality of care during childbirth.

METHOD

A cluster analytic technique was used to establish a finite set of response patterns. Data were obtained from a longitudinal population-based Swedish survey including 2605 women who completed questionnaires in early pregnancy, and 2 months and 1 year after the birth. Data collection commenced in March 1999 and was completed in April 2002.

RESULTS

Nine different clusters, or patterns of satisfaction/dissatisfaction, were found. Nearly half of the women (47%) were in clusters that were satisfied or very satisfied with at least one dimension of care, 20% in clusters that were fairly satisfied (average), and 33% in less than satisfied clusters. Fifteen per cent were mainly dissatisfied with the physical environment, 8% mainly with interpersonal care, 7% only with information and decision-making and 3% with all dimensions. Women in the different clusters differed statistically significantly in psychological health in early pregnancy, emotional reactions during labour and in labour outcomes, but not in background characteristics.

CONCLUSION

Looking at different dimensions of care instead of a single global measure gave a richer, more diverse, and also a more negative picture of women's experiences of intrapartum care.

Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison

BACKGROUND

The Belgian and Dutch societies present many similarities but differ with regard to the organisation of maternity care. The Dutch way of giving birth is well known for its high percentage of home births and its low medical intervention rate. In contrast, home births in Belgium are uncommon and the medical model is taken for granted. Dutch and Belgian maternity care systems are compared with regard to the influence of being referred to specialist care during pregnancy or intrapartum while planning for a home birth. We expect that a referral will result in lower satisfaction with childbirth, especially in Belgium.

METHODS

Two questionnaires were filled out by 605 women, one at 30 weeks of pregnancy and one within the first two weeks after childbirth, either at home or in a hospital. Of these, 563 questionnaires were usable for analysis. Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Satisfaction with childbirth was measured by the Mackey Satisfaction with Childbirth Rating Scale, which takes into account the multidimensional nature of the concept.

RESULTS

Belgian women are more satisfied than Dutch women and home births are more satisfying than hospital births. Women who are referred to the hospital while planning for a home birth are less satisfied than women who planned to give birth in hospital and did. A referral has a greater negative impact on satisfaction for Dutch women.

CONCLUSION

There is no reason to believe Dutch women receive hospital care of lesser quality than Belgian women in case of a referral. Belgian and Dutch attach different meaning to being referred, resulting in a different evaluation of childbirth. In the Dutch maternity care system home births lead to higher satisfaction, but once a referral to the hospital is necessary satisfaction drops and ends up lower than satisfaction with hospital births that were planned in advance. We need to understand more about referral processes and how women experience them.

Women's expectations of maternity services: a community-based survey

BACKGROUND

Examining women's preferences for maternity care is overdue. Understanding women's preferences and re-orienting services to meet their expectations is critical to improving health outcomes.

METHOD

A self-report survey of a convenience community sample of 63 women visiting a Maternity Coalition/Association for Improvements in Maternity Services stall at a Mother and Baby Expo in 2003.

RESULTS

Over 95% of women ranked birth safety, bonding with the baby, feeling in control during birth, and postnatal care as "very important". Over 85% of women rated educational preparation for birth, the relationship with their caregiver, prenatal care, and breastfeeding successfully as "very important". Avoiding labour pain was considered less important by more women than any other item. Around half the respondents preferred their birth care to be from a chosen midwife with access to medical backup (57.9%, n=37). Some women identified a lack of choice of care options with 45.9% (n=17) reporting "little" or "no" choice in birth care for their previous birth. Poor quality care was also identified with 57.9% (n=22) rating their postnatal care as "mediocre". Given assurance of equal safety and free care, 50% (n=31) of participants would prefer to give birth at a birth centre and 24.2% (15 out of 63) would prefer a homebirth.

CONCLUSION

Factors associated with safety, control, continuity of care and successful mothering are perceived as important for many women. Some women perceived limited birth choices. More needs be done to align the provision of maternity services with women's preferred care options. Given the small self-select, non-representative sample, results should be interpreted with caution.

Satisfaction with cesarean section: qualitative analysis of open-ended questions in a large postal survey

BACKGROUND

Cesarean section rates throughout the developed world continue to rise. Although satisfaction with cesarean section has been widely studied, relatively little is known about the causes of "distress" that may contribute to dissatisfaction. The aim of this study was to explore the factors that women identified as "distressing" so as to understand their responses to standard questions on satisfaction.

METHODS

A questionnaire study of 1,661 women who had delivered their first babies by cesarean section in Aberdeen, Scotland, between 1980 and 1995 elicited a 75 percent response rate and showed that 81 percent of women were satisfied with the experience. Nevertheless, 36 percent rated an aspect as distressing, and 42 percent provided written descriptions of one or more experiences that had distressed them. These responses were coded using content analysis into 5 major categories: before, during, and after the birth, psychological/general, and overall.

RESULTS

The most distressing factors were of a psychological or general nature, with 66 percent of distressed women mentioning poor communications, fears, missing out on the birth or the immediate postpartum period, or other emotions. Events happening before, during, and after the birth caused 23, 45, and 44 percent of women to be distressed, respectively. Surgical complications and infections were distressing, but anesthesia was the single factor that caused most distress, leaving 102 women (20%) with unsatisfactory memories of the birth.

CONCLUSIONS

The impact of cesarean birth on women's psychological well-being is highlighted by this study. Enhanced communication during labor and delivery, and preparation or education on issues surrounding cesarean section, can reduce distress and improve women's satisfaction with birth.

Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women

OBJECTIVE

With a prevalence of around 20%, childhood sexual abuse (CSA) is a relevant problem in obstetric care. The aim of our systematic review was to present the current knowledge on the influence of CSA on pregnancy, delivery, and early parenthood.

DATA SOURCES

All English, French, or German primary and secondary literature from the reference lists found after screening the data banks Pubmed, PsycInfo, and Psyndex for publications that include the terms CSA or childhood traumatization and pregnancy, birth, delivery, labor, childbearing, breast feeding, or postpartum, and published after 1970 were reviewed for relevant data.

METHODS OF STUDY SELECTION

Investigations of psychological/medical data banks and cross references revealed 43 relevant studies. Given the paucity of data on this important subject, we opted to review all of these studies.

TABULATION, INTEGRATION, AND RESULTS

Although research projects on this topic are rare and the methodological quality of studies published to date is generally poor, women with a history of CSA seem to present a variety of long-term sequelae referring to pregnancy, delivery, and early parenthood. These sequelae include risk behaviors during pregnancy and disturbance of delivery by sudden memories of sexual abuse situations. Prenatal care is often complicated by the tendency to avoid situations that can trigger memories.

CONCLUSIONS

As effective treatment programs to improve sequelae of CSA are available today, the question of such abuse experiences should be raised as early as possible and adequate interdisciplinary models to care for victimized patients should be established. However, to improve knowledge on the long-term effect of sexual abuse experiences in obstetrical care, methodologically well-designed research projects focusing on the kind and incidence of sequelae, mediating factors as well as prophylactic and therapeutic options are needed.

PTSD, risk factors, and expectations among women having a baby: a two-wave longitudinal study

INTRODUCTION

The aim of the study was to evaluate the incidence of chronic post-traumatic stress disorder (PTSD) after childbirth in relation to pre-partum variables (personality characteristics, anamnestic risk factors) and intra-partum obstetrical and neonatal variables. Since expectations before an event could modify the perceptions, reactions, and satisfaction afterward, the representations of the idealized delivery were carefully analyzed. Moreover, the real and desired help perception from physicians and family members were separately considered during pregnancy and after delivery in relation to PTSD.

METHOD

The study was carried out submitting a questionnaire to pregnant women twice: firstly when women were in their 38 << 42 gestational week (Time 1) and secondly after 3-6 months from childbirth (Time 2). 93 women were recruited at a University City Hospital in Milan, Italy. PTSD subscales, depression, and anxiety levels were also assessed.

RESULTS

2.4% of women had a complete PTSD, while 32.1% of them resulted in having one or two positive subscales of symptoms: 15.5% (N = 13) had a positive intrusion subscale, 25.0% (N = 21) had a positive arousal subscale, while only 3.6% (N = 3) had a positive avoidance subscale. Pre-delivery depression influences PTSD, but only for the intrusion subscale. Pre-delivery physical risk factors are linked to PTSD on the avoidance subscale. At Time 2 depression and PTSD are often present simultaneously. Given the high percentage of healthy newborns, intra-partum obstetrical variables do not seem to influence PTSD. High trait anxiety distinctively coexists with a specific expected delivery and a 'deception' in desired and real support from professionals.

CONCLUSIONS

Childbirth is a risk condition for PTSD, depression during pregnancy influences the intrusion subscale, while having physical problems influences the arousal subscale. Expectations and support are modulated by the anxiety levels and they are not directly related to chronic PTSD.

How do the accounts of the patients on pregnancy and birth process enlighten medical team in terms of narrative ethics?

OBJECTIVE

The aim of this study is to evaluate the relationship between the patient and the physician, midwife and nurse during the process of pregnancy and birth, and to ascertain the importance of communication within this relationship; find out the experiences of patients about the communication process.

METHODS

Three hundred eighty-eight people were interviewed about the pregnancy and birth process. Chi square (chi(2)) and t-tests were used for the statistical evaluation of the data. Forty-nine pregnant women, who were participating in any pregnancy training program, were asked to write down their experiences related to the pregnancy and birth process in a notebook. Thirty-two (65.3%) of these notebooks were taken back 3 months after the delivery, and these notebooks were evaluated within the framework of "narrative ethics" and common themes were found out in order to be discussed in this paper.

RESULTS

It is found out that communication skills of doctors and midwives/nurses were of primary importance for all the participants.

CONCLUSION

Pregnancy and birth are special processes and being informed is of great importance in this process. Every woman has a story to tell about her pregnancy and birth processes.

PRACTICE IMPLICATION

These findings may contribute to the development of new hypotheses. Hence, similar research projects should be conducted, and the findings should be compared.

Swedish women's satisfaction with medical and emotional aspects of antenatal care

AIM

This paper reports a study to investigate how satisfied Swedish women are with their antenatal care.

BACKGROUND

Medical care is of high priority, but other aspects, such as psychosocial support are also important for women during pregnancy. Identifying women who are dissatisfied with their antenatal care could help us to improve this. Methods. A national cohort of 2746 Swedish-speaking women completed a questionnaire in early pregnancy and at 2 months postpartum. The data were collected in 1999-2000.

RESULTS

The majority of participants were satisfied with their antenatal care, but 23% were dissatisfied with the emotional aspects and 18% with the medical aspects. The strongest predictors of dissatisfaction were women's opinions that midwives had not been supportive and had not paid attention to their partners' needs. If the women believed that there were not enough antenatal visits or had met three or more midwives during their antenatal visits, they were more likely to be dissatisfied with the care received. Those with low levels of education were more likely to be dissatisfied with both medical and emotional aspects of antenatal care.

CONCLUSIONS

Midwives working in antenatal care should support pregnant women and their partners in a professional and friendly way in order to increase satisfaction with care. Organizing teamwork with no more than two midwives taking care of a woman during a normal pregnancy could make women feel more supported by their midwives.

A randomised controlled trial to evaluate the effect of self-administered analgesia on women's experience of outpatient treatment at colposcopy

OBJECTIVE

To evaluate the effect of self-administered isoflurane and desflurane on women's experience of outpatient treatment at colposcopy.

DESIGN

A prospective double-blinded randomised controlled trial.

SETTING

A colposcopy clinic serving a regional population.

POPULATION

Three hundred and ninety-six women scheduled for treatment of cervical intraepithelial neoplasia (CIN) by large loop excision of the transformation zone (LLETZ).

METHODS

Self-administration of trial gas during a LLETZ procedure. One hundred and ninety-eight women were randomised to use isoflurane and desflurane and 198 to use placebo.

MAIN OUTCOME MEASURES

Patient satisfaction, pain and anxiety.

RESULTS

The mean pain score for cervical surgery was significantly lower for women using isoflurane and desflurane (22.4) than the placebo arm (29.6) (P= 0.003). There was no significant difference between arms in anxiety levels before or after treatment. More women using isoflurane and desflurane (78%) reported 'total helpfulness' of the trial gas than those using placebo (67%) (P= 0.012). A subgroup analysis of trial participants classified as anxious by Hospital Anxiety and Depression Scale (HADS) score at recruitment showed that using isoflurane and desflurane significantly increased total treatment acceptability, helpfulness of the gas and willingness to undergo a similar procedure at six-month follow up.

CONCLUSION

Satisfaction with outpatient treatment at colposcopy is generally high. The main effect of isoflurane and desflurane evaluated in this trial was to reduce pain. It appeared to be effective for women with clinically significant anxiety and could be offered as an alternative to general anaesthesia.

What is it about antenatal continuity of caregiver that matters to women?

BACKGROUND

Continuity of care and of caregiver are thought to be important influences on women's experience of maternity care. The aim of this study was to analyze the influence of two aspects of continuity of caregiver in the antenatal period on women's overall rating of antenatal care: the extent to which women saw the same caregiver throughout pregnancy, and the extent to which women thought that their caregiver knew and remembered them and their progress from one visit to the next.

METHODS

An anonymous, population-based postal survey was conducted of 1,616 women who gave birth in a 14-day period in September 1999 in Victoria, Australia. Multivariate methods were used to analyze the data.

RESULTS

Most women saw the same caregiver at each antenatal visit (77%), and thought that caregivers got to know them (65%). This finding varied widely among different models of maternity care. Before adjustment, women were much more likely to describe their antenatal care as very good if they always or mostly thought the caregiver got to know them (OR 5.86, 95% CI 4.3, 7.9), and if they always or mostly saw the same caregiver at each visit (OR 2.91, 95% CI 2.0, 4.3). Adjusting for sociodemographic factors, parity, risk status of the pregnancy, and several specific aspects of antenatal care revealed that seeing the same caregiver was no longer associated with rating of care (adjusted OR 0.65, 95% CI 0.3,1.2), but women who thought that caregivers got to know and remember them remained much more likely to rate their care highly (adjusted OR 3.18, 95% CI 2.0, 5.1).

CONCLUSIONS

These findings suggest that changing the delivery of antenatal care to increase women's chances of seeing the same caregiver at each visit is not by itself likely to improve the overall experience of care, but time spent personalizing each encounter in antenatal care would be well received. The analysis also confirmed the importance that women place on quality interactions with their doctors and midwives.

Maternity care with the women's business service at the Mildura Aboriginal Health Service

OBJECTIVE

To assess and contrast views and experiences of women attending the Women's Business Service at the Mildura Aboriginal Health Service with those of rural women attending public maternity services who participated in a Victorian statewide survey conducted in 2000.

METHODS

Face-to-face interviews were conducted with clients of the Women's Business Service (n=25) using a structured interview schedule based on the Victorian Survey of Recent Mothers 2000. Comparisons were made with rural women who had participated in the 2000 survey and had received public care for their pregnancy (n=333).

RESULTS

Compared with rural participants in the 2000 survey, women who attended the Women's Business Service were significantly more likely to say care providers kept them informed (OR 20.63, 95% CI 3.27-853.75), midwives were never rushed during check-ups (OR 22.24, 95% CI 3.50-921.47), and to say they were happy with medical care (OR 5.79, 95% CI 1.68-30.67). Eighty per cent of interview participants described their antenatal care as 'very good'. Fewer women rated intrapartum care (64%) or postnatal hospital care (43%) as 'very good'. Compared with rural participants in the statewide survey, women attending the Women's Business Service were significantly more confident about looking after their baby in the first week at home (OR 9.08, 95% CI 2.95-37.01), and less likely to want additional help or advice (OR 0.21, 95% CI 0.04-0.73).

CONCLUSIONS

Women using the Women's Business Service were significantly more positive about many aspects of their care than women attending other rural public maternity services. The study lends support to the view that Aboriginal community-controlled health services are well placed to provide appropriate and accessible care to Indigenous women.

Childbearing in U.S. military hospitals: dimensions of care affecting women's perceptions of quality and satisfaction

BACKGROUND

The U.S. Department of Defense provides medical services for approximately 9.1 million beneficiaries, one-half of whom are women. Information is lacking about how well the military health system has adopted patient-centered approaches for promoting individual choice and preference in a bureaucratically structured military hospital. The purpose of this study was to examine women's evaluations of maternity care with respect to decision-making, confidence, trust in health care providers, and treatment within the military hospital.

METHODS

The Department of Defense Inpatient Childbirth Survey was mailed to a simple stratified random sample of beneficiaries who received maternity care at a military hospital between July 1 and September 30, 2001. Data for 11 dimensions of women's care and experiences were examined from self-reported assessments of 2,124 respondents who gave birth at one of 44 military hospitals. A multiple logistic regression model was estimated to determine which dimensions of care predicted beneficiaries' likelihood to recommend the military hospital to family and friends.

RESULT

Less than 50 percent of respondents would recommend the military hospital to family and friends. Significantly associated with women's willingness to recommend their specific military hospital to others were courtesy and availability of staff, confidence and trust in provider, treatment with respect and dignity, information and education, physical comfort, involvement of friends and family, continuity and transition, and involvement in decision-making.

CONCLUSIONS

In a military population, obstetric patients who are treated with respect, courtesy, and dignity, are involved in decisions about their care, and have established trusting relationships with their practitioners are significantly more likely to recommend the military hospital to others. It is important for military health care leaders to establish a proactive program of patient-centered maternity care. Continuous care, education, support services, and a multidisciplinary approach should be integrated to retain and recapture obstetric patients who are served in military hospitals in the United States.

A midwifery model of care for childbearing women at high risk: genuine caring in caring for the genuine

According to this paper's synthesis of research, three constituents of ideal midwifery care emerge. First, a dignity-protective action takes place in a midwife's caring relationship with a childbearing woman at high risk and includes mutuality, trust, ongoing dialogue, enduring presence, and shared responsibility. Secondly, the midwife's embodied knowledge is based on genuineness to oneself and consists of theoretical, practical, intuitive, and reflective knowledge. Finally, nurse-midwives have a special responsibility to balance the natural and medical perspectives in the care of childbearing women at high risk, especially by promoting the woman's inborn capacity to be a mother and to give birth in a natural manner. This midwifery model of care is labeled "Genuine Caring in Caring for the Genuine." Here, the word genuine expresses the nature of midwifery care, as well as the nature of each pregnant woman being cared for as a unique individual.

Mothers' involvement in decision making during the birthing process: a quantitative analysis of women's online birth stories

This article reports on a study of 551 women's birth stories that were posted on a birth stories Web site. These online stories were analyzed for the communication and decision making that takes place between patients and clinicians during the birthing process. In more than half of the stories, the women wrote about at least 1 decision that was made. Further analyses were performed on the 285 stories in which decisions were made. According to this analysis, overall, women were involved in decision making about 57% of the time. The most frequent decision was about painkillers. Making decisions about painkillers and having a midwife as a primary clinician predicted a woman's increased involvement in decision making. Women's involvement in decision making correlated positively with the use of positive emotion words and negatively with the use of negative emotion words in the online birth stories.

Social capital, the miniaturization of community and assessment of patient satisfaction in primary healthcare: a population-based study

AIMS

A study was undertaken to assess the impact of social participation, trust and the miniaturization of community, i.e. high social participation/low trust, on two measures of patient dissatisfaction in primary healthcare.

METHODS

The Scania 2000 public-health survey is a cross-sectional, postal questionnaire study. A total of 3,456 persons aged 18-80 years who had a regular doctor within the primary healthcare system were included. A logistic regression model was used to investigate the association between the social capital variables and dissatisfaction. Multivariate analysis analysed the importance of confounders on the differences in lack of general openness and lack of information concerning treatment in accordance with social capital variables.

RESULTS

Lack of openness is positively associated with low trust, the miniaturization of community and low social capital, while lack of information is not significantly associated with the miniaturization of community, but to a lesser extent with low trust and low social capital.

CONCLUSIONS

Low levels of trust and the miniaturization of community may enhance non-specific patient dissatisfaction such as experience of lack of openness by the patient. In contrast, the miniaturization of community was not significantly associated with the more specific "lack of information". The results have implications for the evaluation of patient dissatisfaction.

Factors related to childbirth satisfaction

BACKGROUND

A woman's satisfaction with the childbirth experience may have immediate and long-term effects on her health and her relationship with her infant, but there is a lack of current research in this area.

AIM

This paper reports a study to examine multiple factors for their association with components of childbirth satisfaction and with the total childbirth experience.

METHOD

A correlational descriptive study was conducted with 60 low-risk postpartum women, aged 18-46 years, with uneventful vaginal deliveries of healthy full-term infants at two medical centres in the south-eastern United States. The Labor Agentry Scale, McGill Pain Questionnaire and Mackey Childbirth Satisfaction Rating Scale and a background questionnaire were completed by women. Obstetrical data were collected from the medical record.

FINDINGS

Personal control was a statistically significant predictor of total childbirth satisfaction (P = 0.0045) and with the subscale components of satisfaction (self, partner, baby, nurse, physician and overall). In addition, having expectations for labour and delivery met was a significant predictor of satisfaction with own performance during childbirth.

CONCLUSIONS

Personal control during childbirth was an important factor related to the women's satisfaction with the childbirth experience. Helping women to increase their personal control during labour and birth may increase the women's childbirth satisfaction.

Obstetric patient satisfaction: asking patients what they like

OBJECTIVE

This study was undertaken to determine pertinent attributes of women's hospital experience related to the delivery of their children and to use open-ended responses from women to develop a taxonomy for classifying patient satisfaction in obstetrics.

STUDY DESIGN

By using clinimetric methods, we interviewed 67 obstetric patients during their postpartum hospital stays, asking open-ended questions about their satisfaction with care. Responses were transcribed, arranged into distinct groups, and organized as a taxonomy of patient satisfaction.

RESULTS

The final taxonomy derived from patient responses was divided into six main axes related to physicians, nurses, other staff, special services, hospital attributes, and personal focus; a total of 51 individual items were identified related to patient satisfaction. These items have face validity, and many are not routinely included in assessments of patient satisfaction.

CONCLUSION

A simple strategy of using open-ended questions leads to a clinically relevant and easily understood classification scheme for patient satisfaction with in-hospital obstetric services.

Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labour

OBJECTIVE

To assess maternal satisfaction with childbirth and intrapartum pain relief in nulliparous women labouring at term.

METHODS

Prospective randomised clinical trial comparing epidural and non-epidural analgesic techniques on term labour outcomes in nulliparous women. Within 24 h of delivery the women were surveyed regarding their opinions about the birthing experience and the allocated analgesic regimen. A postal survey was conducted 6 months postpartum to assess opinions about intrapartum analgesia in a subsequent pregnancy.

RESULTS

A total of 992 women were randomised to receive continuous midwifery support (CMS) or epidural (EPI) analgesia on presentation for delivery. There was a high crossover rate from CMS to EPI (61.2%) and a lesser non-compliance rate in the EPI group (27.8%). The early post-partum recollections revealed a high satisfaction with epidural analgesia and lower satisfaction with alternative pain relief measures. Ten percent of women in the CMS group reported negative feelings about their allocated pain relief compared with 1% in the EPI group (P < 0.001), and 10% of all women reported negative feelings about their overall childbirth experience. At the 6-month postpartum survey factors associated with the planned use of epidural analgesia in a subsequent pregnancy were induction of labour (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2, 4.7) and prior utilisation of epidural analgesia (OR 28.1, 95% CI 14.5, 54.7).

CONCLUSIONS

Maternal satisfaction with intrapartum analgesia was significantly higher with epidural analgesia than non-epidural analgesic techniques. Overall satisfaction scores for labour and delivery were high regardless of analgesic approach, reflecting the multiple issues other than pain relief that are involved in the childbirth experience.

Feeling in control during labor: concepts, correlates, and consequences

BACKGROUND

Many studies have revealed that a sense of control is a major contributing factor to a woman's birth experience and her subsequent well-being. Since not all studies conceptualize "control" in the same way or distinguish between "external" and "internal" control, the purpose of this study is to advance understanding of how these senses of control relate to each other.

METHODS

Questionnaires were sent to women 1 month before birth to assess their preferences and expectations and at 6 weeks after birth to discover their experiences and assess psychological outcomes. Data are presented from 1146 women. Three control outcomes were considered: feeling in control of what staff do to you, feeling in control of your own behavior, and feeling in control during contractions.

RESULTS

Women were less likely to report being in control of staff (39.5%) than in control of their own behavior (61.0%). Approximately one-fifth of the sample felt in control in all three ways, and another one-fifth did not feel in control in any of them. Parity was strongly associated with feeling in control, with multiparas feeling more in control than primiparas in all cases. In logistic regression analyses, feeling in control of staff was found to relate primarily to being able to get comfortable, feeling treated with respect and as an individual, and perceiving staff as considerate. Feeling in control of one's behavior and during contractions were primarily related to aspects of pain and pain relief, but also to antenatal expectations of control. Worry about labor pain was also an important antenatal predictor for primiparas. All three control outcomes contributed independently to satisfaction, with control of staff being the most significant; relationships with emotional well-being were also demonstrated.

CONCLUSIONS

All three types of control were important to women and contributed to psychological outcomes. Internal and external control were predicted by different groups of variables. Caregivers have the potential to make a significant difference to a woman's experience of childbirth. The ways in which women are helped to deal with pain will affect internal control; the extent to which they feel that they are actually cared about, rather than care being something that is done to them, will affect external control. Both contribute to satisfaction and emotional well-being.

The impact of the establishment of a midwife managed unit on women in a rural setting in England

OBJECTIVE

to determine what impact the changes from consultant-led care to midwife-led care in a local maternity service have had on women using that service.

DESIGN

case study, data were collected by postal questionnaire, semi-structured, tape-recorded interviews, observations and scrutiny of records.

SETTING

a small town in rural England.

PARTICIPANTS

all pregnant women eligible for a midwife-managed unit (MMU) birth in a small rural town in England.

FINDINGS

the women using the MMU were satisfied with the care they received and the MMU style of care. Women giving birth at the MMU and at home required less pain relief and were more likely to have an intact perineum than a similar group of women giving birth in hospital. Continuity of carer did not appear to be an issue for women as long as they felt supported by a known team of midwives. Transfer for complications during the birthing process was a cause for anxiety and stress for women and their partners. Women, whilst satisfied with the MMU, would prefer the consultant-led maternity hospital to be re-established in the town. The home-birth rate rose by 28% when the consultant unit closed.

IMPLICATIONS FOR PRACTICE

while the establishment of a midwife-managed unit has provided increased choice for a minority of women, the removal of the consultant unit in the town has disadvantaged the majority of pregnant women. While guidelines are needed when establishing these units the application of restrictive inclusion and exclusion criteria can sometimes force women to make less appropriate birth choices.

Maternity satisfaction studies and their limitations: "What is, must still be best"

BACKGROUND

Health policymakers throughout the developed world are paying close attention to factors in maternity care that may influence women's satisfaction. This paper examines some of these factors in the light of observations from previous studies of satisfaction with health services.

METHODS

The Scottish Birth Study, a cross-sectional questionnaire survey, sought the views of all women in Scotland delivering during a 10-day period in 1998. A total of 1,137 women completed and returned questionnaires (response rate = 69%).

RESULTS

Women were overwhelmingly satisfied with their prenatal, intrapartum, and postnatal care. As is common in this type of study, reports of dissatisfaction were relatively low. However, differences occurred in satisfaction levels between subgroups; for example, the fewer the number of caregivers the woman had during childbirth, the more likely she was to be satisfied with the care received. A range of factors appeared to influence reported satisfaction levels, such as characteristics of the care provided and the woman's psychosocial circumstances.

CONCLUSIONS

In addition to the inherent limitations of satisfaction studies found in the literature, problems may arise if such surveys are used uncritically to shape the future provision of maternity services, because service users tend to value the status quo over innovations of which they have no experience. Therefore, although satisfaction surveys have a role to play, we argue that they should only be used with caution, and preferably as part of an array of tools.

Evaluation of satisfaction with midwifery care

OBJECTIVE

to determine if there were differences in women's satisfaction with maternity care given by doctors and midwives. In addition a simple, six-question, satisfaction questionnaire was to be tested.

DESIGN

a randomised controlled trial comparing two models of maternity care.

SETTING

a tertiary referral centre in Alberta, Canada.

PARTICIPANTS

one hundred and ninety four women with a low-risk pregnancy were randomly assigned to either the midwife care, experimental group (n = 101), or the doctor care, control group (n = 93).

INTERVENTIONS

a pilot midwifery programme was introduced into a maternity services delivery system that did not have established midwifery.

MEASUREMENTS

women's satisfaction was measured, at two weeks postpartum, with the Labour and Delivery Satisfaction Index (LADSI), general attitudes toward the birth experience, also at two weeks postpartum; with the Attitudes about Labour and Delivery Experience (ADLE) questionnaire. Fluctuations in satisfaction were measured with a Six Simple Questions (SSQ) questionnaire at 36 weeks gestation and 48 hours, two and six weeks postpartum.

FINDINGS

women in the midwife group reported significantly greater satisfaction and a more positive attitude toward their childbirth experience than women in the doctor group (p < 0.001). The SSQ demonstrated scores similar to the LADSI. Satisfaction in both groups was lowest at 36 weeks gestation and highest immediately postpartum.

KEY CONCLUSIONS

women experiencing low-risk pregnancies were more satisfied with care by midwives than with care provided by doctors. Satisfaction scores were high for both groups and may have been lower for women in the doctor group as a result of disappointment with caregiver assignment as all women had sought midwifery care. The SSQ measures similar dimensions to the LADSI but the agreement is not strong enough to recommend its use as a substitute at this time.

IMPLICATIONS FOR PRACTICE

the significantly higher satisfaction of the women with the care provided by the midwives together with better clinical outcomes reported elsewhere suggest that the option of midwifery care should be accessible as an option for all women in Canada. Further research is suggested to determine the usefulness of the SSQ.

Immigrant women's views about care during labor and birth: an Australian study of Vietnamese, Turkish, and Filipino women

BACKGROUND

Few studies of immigrant women's views of maternity care in their new homelands have been conducted. In Victoria, Australia, approximately 1 woman in 7 giving birth was born overseas in a non-English speaking country. This paper examines the views of three groups of immigrant women about the care they received in hospital for the birth of their babies and compares the findings with a population-based statewide survey.

METHODS

Mothers in a New Country was a study of 318 Vietnamese, Turkish, and Filipino women interviewed about their maternity care experiences by bicultural interviewers 6 months after giving birth in Melbourne, Australia. The interview schedule was adapted from the 1994 Victorian Survey of Recent Mothers, a population-based postal survey of 1336 women.

RESULTS

Of the 3 groups, 27 percent of Vietnamese, 48 percent of Turkish, and 39 percent of Filipino women reported their care during labor and birth as "very good," figures significantly lower than for the statewide survey, in which 61 percent of women experiencing similar models of care described their care as "very good." This significant differential in views about care was also present for many individual aspects of care. In the current study of mothers in a new country, comments about aspects of care with which women were particularly happy and unhappy highlighted their appreciation of care that was safe, kind, supportive, and respectful, and conversely, illustrated how distressed women were when care failed to meet these basic standards.

CONCLUSIONS

What immigrant women wanted from their maternity care proved to be extremely similar to what Australian-born women--and women the world over--want. Unfortunately, immigrant women were much less likely to experience care that gave them what they wanted.

Having a baby in Victoria 1989-2000: continuity and change in the decade following the Victorian Ministerial Review of Birthing Services

OBJECTIVE

To investigate changing patterns in the provision of maternity care in Victoria based on data collected in three statewide surveys conducted in 1989, 1994 and 2000.

METHODS

Postal surveys were mailed to all women who gave birth in Victoria in one week in 1989, and in two weeks in 1993 and 1999, excluding those who had a stillbirth or neonatal death. Questionnaires were sent to women by hospitals and home birth practitioners 5-8 months after the birth.

RESULTS

71.4% of women (n = 790) returned completed surveys in 1989, 62.5% (n = 1,336) in 1994, and 67% (n = 1,616) in 2000. The proportion of women receiving public care increased from 41.1% in 1989 to 63.6% in 1999. Simultaneously, the proportion of women attending public hospital antenatal clinics decreased from 16.6% in 1989 to 8.7% in 1999. Shared care (15.8%) and combined care (29.2%), where women attend a GP or specialist obstetrician for all antenatal care and receive standard public intrapartum care in a public hospital, are now the most common models of public maternity care in Victoria. The proportion of women enrolled in public maternity care who had a known midwife caring for them in labour did not change significantly between 1993 and 1999 (34.9% vs. 30.3%, OR = 0.81 [0.7-1.0]). Sixty per cent of women had a midwife home visit after leaving hospital in 1999 compared with 23.8% in 1993.

CONCLUSIONS

The conduct of three population-based surveys at regular intervals over the past 10 years highlights major changes in the organisation of maternity care in Victoria. Comparable information cannot be derived from routine data collections. The Victorian Surveys of Recent Mothers provide an important and unique mechanism for monitoring the impact of shifts in policy and practice over the past decade.

A randomised controlled trial of maternal satisfaction with the routine examination of the newborn baby at three months post birth

OBJECTIVE

to determine whether any differences in maternal satisfaction with the examination of a newborn baby between midwives and junior paediatricians are maintained over a three-month period.

DESIGN, SETTING AND PARTICIPANTS

randomised controlled trial. Eight hundred and twenty-six mother and baby pairs in a district general hospital in South East England were randomised to a junior paediatrician or a midwife for the routine examination. Four hundred and eighty-six mothers completed a maternal satisfaction questionnaire on day-one and again three-months later. Maternal satisfaction with the examination was analysed in relation to randomised group, process and background variables.

FINDINGS

high satisfaction with the examination was reported by most mothers (day-one: 82%; three-months: 79%). At day-one, mothers whose babies were examined by a midwife were more satisfied with the examination (crude odds ratio (OR) for the lowest tertile of satisfaction 0.49, 95% CI 0.32-0.73). However, after controlling for provision of health education during the examination (e.g. discussing feeding, sleeping and skin care) and continuity of care provided, maternal satisfaction was no longer related to status of examiner (adjusted OR 0.83, 95% CI 0.52-1.33). Three months later, there was no significant difference in maternal satisfaction with midwife and junior paediatrician examinations of the newborn baby (crude OR 0.89, 95% CI 0.58-1.37). Discussion of health-care issues by the examiner during the examination was significantly related to increased satisfaction even at three-months. Three month ratings of low satisfaction with the examination were most strongly predicted by current maternal depressive mood, even when other factors were adjusted for (adjusted OR 2.58, 95% CI 1.19-5.59).

KEY CONCLUSIONS

from the mother's perspective, the quality of midwife examination is at least as satisfactory as that of junior paediatricians and this perception is maintained over a three-month period. Satisfaction can be significantly enhanced if the examiner provides information on behavioural and health-care issues. The examination of the newborn baby provides an important window of opportunity for sharing information on newborn behaviour and care issues.

Comprehensive measurement of maternal satisfaction: the modified Mason Survey

A three-stage process was undertaken to identify and modify a tool that was capable of measuring the many aspects of maternal satisfaction relevant to Australian women. First, the scope of maternal satisfaction to be measured was defined by summarizing available literature and surveys purporting to measure maternal satisfaction (including surveys used in maternity services in New South Wales). The multidimensional nature of maternal satisfaction was confirmed, with 16 core aspects (common to the literature and local surveys) and nine additional unique aspects of maternal satisfaction being identified. Second, these core and additional aspects were used to examine the comprehensiveness of the Mason Survey, a survey recommended by the National Health and Medical Research Council of Australia for use in maternity services. Eighty-eight per cent of the core and additional aspects (22/25) were found to be present in the Mason Survey. Third, an expert panel further modified the Mason Survey by removing items not applicable to the Australian context. The modified Mason Survey is a comprehensive measure of maternal satisfaction suitable for Australian women and capable of providing valuable information on the quality of services and future planning for maternity services.

Routine examination of the newborn and maternal satisfaction: a randomised controlled trial

OBJECTIVE

To determine whether the routine examination of the newborn by a midwife compared with a junior paediatrician (SHO) affects maternal satisfaction with this examination.

METHODS

Randomised controlled trial: 826 mother and baby pairs in a district general hospital in south east England were randomised to a paediatric SHO or a midwife for the routine newborn examination. Maternal satisfaction with the examination was analysed in relation to intervention group, process, and background variables.

RESULTS

Some 81% of mothers reported that they were satisfied or very satisfied with the newborn examination. Mothers assigned to a midwife were more satisfied with the newborn examination (crude odds ratio (OR) 0.54 (95% confidence interval (CI) 0.39 to 0.75), p < 0.001). However, after provision of health education during the examination, continuity of care provided, and history of miscarriage had been controlled for, status of examiner was no longer related to maternal satisfaction (adjusted OR 0.82 (95% CI 0.57-1.20), NS). The discussion of healthcare issues by the examiner (adjusted OR 0.49 (95% CI 0.34 to 0.70), p < 0.001) and continuity of care (adjusted OR 0.43 (95% CI 0.23 to 0.81), p < 0.01) were both related to enhanced satisfaction, and history of miscarriage (adjusted OR 1.61 (1.08 to 2.40), p < 0.05) was associated with lower maternal satisfaction with the newborn examination. Midwives (61%) were more likely than SHOs (33%) to discuss healthcare issues, such as feeding, sleeping, and skin care.

CONCLUSIONS

Mothers were more likely to be satisfied with the newborn examination by a midwife than an SHO because midwives were more likely to discuss healthcare issues during the examination and were able to provide continuity of care. However, midwife examinations according to exclusion criteria agreed with trial midwives excluded half of all newborns, and criteria may have to be reconsidered for practice implementation.

Normality and collaboration: mothers' perceptions of birth centre versus hospital care

OBJECTIVE

to describe women's perceptions of care in Western Australian birth centres following a previous hospital birth.

DESIGN, SETTING AND PARTICIPANTS

an exploratory design was used to study the care experiences of 17 women recruited from three Western Australian birth centres. Data were obtained from in-depth interviews that explored women's perceptions of their care in both the birth centre and hospital context.

FINDINGS

four key themes emerged from the analysis: 'beliefs about pregnancy and birth', 'nature of the care relationship', 'care interactions', and 'care structures'. The themes of 'beliefs about pregnancy and birth' and 'nature of the care relationship' are discussed in this paper. Beliefs about pregnancy and birth refer to the philosophical underpinnings of pregnancy and birth held by women and their carers. Nature of the care relationship identifies women's perceptions of their relationship with health professionals. Care interactions and care structures will be described in a subsequent paper.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The women's comments suggested differences in philosophy between hospital and birth-centre settings. The philosophy and beliefs of caregivers was an important component of the care experience. Women valued the normality of the birth-centre approach and the opportunity to experience the birth of their child with collaborative support from a midwife.

An investigation into the feasibility of comparing three management options (augmentation, conservative and water) for nulliparae with dystocia in the first stage of labour

OBJECTIVE

to evaluate the feasibility of a randomised controlled trial (RCT) examining the effect of three options (augmentation, conservative and water) for the management of dystocia in nulliparae. The main objectives were to explore the feasibility of trial procedures in the clinical environment, consent rates and acceptability of the management options to women, local incidence of dystocia in nulliparae and the size of the subsequent study.

DESIGN

a two part study: a pilot, RCT with follow-up through to delivery with postnatal maternal surveys, and a case review of nulliparae with dystocia.

SETTING

a large maternity unit in the South of England in May-July 1997 inclusive.

PARTICIPANTS

nulliparae with dystocia in the first stage of labour who had an otherwise uncomplicated obstetric background.

INTERVENTIONS

women in the pilot RCT received one of three management options: labouring in a waterbirth pool, conservative management or augmentation of labour, which is the standard management of women with dystocia condition in the Unit.

FINDINGS

it is feasible to conduct an RCT of management of dystocia in the Unit. Seventy per cent (95% confidence interval 47% to 87%) of women approached agreed to participate. Conservative management was the least acceptable option to women and has been dropped from the subsequent trial. The audit provided some idea of possible differences in operative delivery and epidural rates depending on augmentation or not. A sample of 220 women should be large enough to detect moderate changes and will require a 2-year recruitment period.

CONCLUSIONS

a subsequent trial is feasible and is now underway. It has the potential to provide information enabling women and practitioners to have a greater choice of care options in the presence of dystocia, or provide a good basis for an even larger trial.

Single room maternity care and client satisfaction

BACKGROUND

Single room maternity care is the provision of intrapartum and postpartum care in a single room. It promotes a philosophy of family centered care in which one nurse cares for the family consistently throughout the intrapartum and postpartum periods. At B.C. Women's Hospital, a tertiary level obstetric teaching hospital in Vancouver, British Columbia, a seven-bed, single room maternity care unit was developed and opened as a demonstration project. As part of the evaluation of this unit, client satisfaction was compared between women enrolled in single room maternity care and those in a traditional setting.

METHOD

The study group included 205 women who were admitted to the single room maternity care unit after meeting the low-risk criteria. Their responses on a satisfaction survey were compared with those of a historical comparison group of 221 women meeting the same eligibility criteria who were identified through chart audits 3 months before the single room maternity care unit was opened. A second, concurrent comparison group comprised 104 women who also met eligibility criteria.

RESULTS

Study group women were more satisfied than comparison groups in all areas evaluated, including provision of information and support, physical environment, nursing care, patient education, assistance with infant feeding, respect for privacy, and preparation for discharge.

CONCLUSIONS

Single room maternity care was associated with a significant improvement in client satisfaction because of many factors, including the physical setting itself, avoidance of transfers, and improved continuity of nursing care.

A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia

Birthing centre care offers women with a low risk of complication in pregnancy an alternative to conventional care for the birthing of their baby. It is important these two forms of care are appropriately assessed. A randomised controlled trial comparing the newly opened birthing centre with the established conventional delivery suite was conducted at the then Queen Victoria Hospital, Adelaide, South Australia. The outcomes measured included maternal satisfaction, costs and clinical outcomes both for mother and baby which related to the need for Caesarean section, episiotomy or tear rate and method of feeding. Two hundred and one women attending the hospital's antenatal clinic were randomly allocated to either birthing centre or delivery suite care. One hundred women were allocated to the birthing centre. No differences were found in either group related to clinical outcomes or costs. The only difference in maternal satisfaction was the choice women made for their next birth. More women in the birthing centre group felt they were encouraged to breastfeed immediately after birth. While the numbers in this study were too small to detect any but large differences in outcome, birthing centre care should remain an option for women and further studies undertaken with larger numbers.

Seeing the wood for the trees: defining the forgotten concept of patient dissatisfaction in the light of patient satisfaction research

Studies of patient satisfaction are regarded by many as the most important way to obtain patients' views. To date, relatively few studies have focussed specifically on dissatisfaction. Concerns have been expressed about the validity of the concept of satisfaction. Dissatisfaction, however, has received little attention since it has been assumed to be the opposite of satisfaction and thus already defined. Therefore a series of assumptions have also been made about dissatisfaction, which may or may not compromise its validity or usefulness. The aim of this review is to clarify the concept of dissatisfaction by examining what studies of patient satisfaction can and cannot tell us about dissatisfaction; identifying assumptions; and finally by suggesting how research might best be oriented to accommodate the complexity of patient experiences.

Women's experiences of transfer from a midwife-led to a consultant-led maternity unit in the UK during late pregnancy and labor

PURPOSE

This study explored the experiences of women who were transferred from a midwife-led to a distant consultant obstetric unit before or during labor.

BACKGROUND

Little attention is given to the psychological impact of transfer, particular when it takes place prior to labor.

METHOD

Narrative and progressively focused interviews were conducted with 18 women who faced or experienced transfer prior to or during labor. The data were analyzed using a grounded theory approach.

RESULTS

The core category in the transferred group was loss. This related to loss of choice, control, continuity, and support and was associated with anger and resentment. Distress appeared most common when transfer took place late in a healthy pregnancy when the mother recognized no risk to the baby.

CONCLUSIONS

More attention needs to be paid to the psychological impact of transfer from midwife-led to consultant-led care, particularly where this involves a change of location or midwife.

The development of a maternal satisfaction scale for caesarean section

Satisfaction has become an important outcome measure. The purpose of this study was to develop a valid, reliable maternal satisfaction scale for women undergoing caesarean section. After Research Ethics Board approval, each patient gave verbal consent. To ensure face validity, patients were interviewed before and after caesarean section. Interviewing until no new items were generated ensured content validity. A draft scale using a 7 point Likert scale was given to 115 patients. Items endorsed by less than 15% of patients were deleted. Item-total correlations, principal component and factor analysis were performed and items in factors with less than three items or complex loadings excluded. Correlating the new scale to a Visual Analogue Scale (VAS) for satisfaction assessed construct validity. Reliability, as measured by internal consistency, was tested using Cronbach's alpha. Twenty-five women were interviewed for item generation. Patients were both nulliparous and multiparous and all received regional anaesthesia for elective or non-emergent caesarean section. Six items of the 33 on the draft scale were excluded because of lack of endorsement. Five items were excluded after principal component and factor analysis and two after item-total correlations. The correlation between the scale total and the VAS was 0.48. Cronbach's alpha was 0.82 for the total scale. Maternal sense of control was the item most related to satisfaction. This scale provides more detailed information than a simple VAS. In the population studied, this tool was found to be a valid and reliable method for assessing maternal satisfaction in women undergoing non-emergent caesarean section.

Managing labor using partograms with different action lines: a prospective study of women's views

BACKGROUND

The precise timing of medical intervention for women in prolonged labor is the subject of considerable debate. The partogram action line is a tool to assist practitioners in the correct diagnosis of prolonged labor. Despite its widespread use, the precise timing of the action line has not been rigorously studied, and women's views have rarely been sought. The aim of this study was to assess the effect on maternal satisfaction of managing labor using partograms with action lines drawn at 2, 3, or 4 hours to the right of the alert line.

METHODS

As part of a large pilot randomized controlled trial, women's views were explored using a specifically designed questionnaire that was completed by 615 primiparas 2 days after giving birth. The quantifiable data were analyzed by comparing means using ANOVA followed by the Scheffe test.

RESULTS

Women in the 2-hour arm were significantly more satisfied than those in the other two arms (p < 0.001), despite having the most obstetric intervention.

CONCLUSIONS

For women in prolonged labor, obstetric intervention can be an acceptable or even favorable option. Midwives and obstetricians need to provide labor management that takes into account the preferences of the women to whom they give care.

Women's perceptions of midwifery care: a longitudinal study to shape curriculum development

BACKGROUND

Health and education services are increasingly expected to focus on the consumer. The perceptions of childbearing women should be incorporated into midwifery curricula, but often they are given minimal attention or not sought for this purpose. This study was designed to enable the views and experiences of local women to influence curriculum development in a large university in England.

METHODS

A descriptive, longitudinal, qualitative study was conducted using semistructured and unstructured interviews with women, and data from their maternity records. Forty-one pregnant women were recruited and interviewed during pregnancy, in the early postpartum period in hospital, and in their homes 2 to 3 weeks after the birth.

RESULTS

Themes were clustered into three categories: the characteristics and qualities of the caregivers, the individualized nature of care, and the clinical competence of the caregivers. Continuity of caregiver was desired but accepted as probably unrealistic by many. Developing a "special" trusting relationship with a female midwife was perceived as essential to promoting a positive childbirth experience. Clinical competence was expected and largely experienced. Negative feelings related to individual caregivers more than the type of care given.

CONCLUSIONS

Most women had positive experiences, finding midwives and doctors with good knowledge, interpersonal skills, and abilities. Examples of poor communication skills and interprofessional conflict indicated a need to give priority to developing and assessing students' interpersonal skills. Evidence of interprofessional conflict acted as the catalyst to merge midwifery with the department of obstetrics in the university to enhance interprofessional learning.

Decision making in analyses of women's birth stories

BACKGROUND

Complex interactions occur among women and caregivers throughout labor. Analyzing women's birth stories provides a rich data source on these interactions. The purpose of this qualitative study was to clarify how decisions were made in labor by analyzing women's birth stories.

METHODS

A convenience sample of 15 primiparous and multiparous Midwestern women contributed a total of 33 birth stories. Qualitative methods were used, including analyses of the content and themes of stories.

RESULTS

The primary types of decision making that were identified ranged on a continuum from unilateral to joint (shared), and were associated with various emotions expressed by the women.

CONCLUSIONS

A model of decision making was derived from the data that may help caregivers change practices in ways that will benefit women. Caregivers can also benefit by understanding women's critiques of the birth care they received, and can use this knowledge to improve women's experiences of birth and therefore their satisfaction with the process.

Labor concerns of women two months after delivery

BACKGROUND

Women strive to incorporate their labor and delivery experiences into their self-system as they form an identity as a mother. As part of a larger study examining the development of maternal identity, women were asked to respond to a single open-ended question-"Is there anything about your labor and delivery that is still bothering you?"-to determine if women experienced any discrepancies between the expectations and realities of their births.

METHODS

A descriptive, qualitative design was applied to examine responses to an open-ended question from a convenience sample of 77 women from three geographically diverse Midwest hospitals who were nine weeks postpartum. Responses were subjected to content analysis to identify major categories of concerns related to labor and delivery.

RESULTS

Women expressed positive responses, which related to who helped them in labor and to the context of the experience, and frustrations, which related to pain, negative reactions to health caregivers, lack of control, and lack of knowledge.

CONCLUSIONS

These findings offer direction to health care professionals for making labor and childbirth a positive experience, thus easing the transition to motherhood.

Working with childhood sexual abuse survivors during pregnancy, labor, and birth

It is estimated that approximately 27% of women have a history of childhood sexual abuse. Long-term effects of this abuse include physical and psychologic consequences that can affect the pregnant woman during the prenatal, antenatal, and postpartum periods. Careful screening of all pregnant women and specific interventions during examinations and procedures can help survivors of childhood sexual abuse experience childbearing as healing and empowering. Care providers who are survivors of such abuse can better serve their patients by working therapeutically on their own healing.

The meaning of patient satisfaction: an explanation of high reported levels

The social policy background to the proliferation of patient satisfaction surveys is a desire for increased patient representation and participation. Within this context, it is assumed that satisfaction surveys embody patients' evaluations of services. However, as most surveys report high satisfaction levels, the interpretation of satisfaction as the outcome of an active evaluation has been called into question. The aim of this study is to identify whether and how service users evaluate services. This was made possible through unstructured in-depth interviews with users of mental health services and through more structured discussion around their responses on a patient satisfaction questionnaire (CSQ 18B) whose psychometric properties has been well documented. Twenty-nine people with current or recent contact with mental health services within the British National Health Service were interviewed. The data revealed that service users frequently described their experiences in positive or negative terms. However, the process by which these experiences were transformed into "evaluations" of the service was complex. Consequently, many expressions of "satisfaction" on the CSQ 18B hid a variety of reported negative experiences. An explanation for this lack of correspondence is outlined.

Communication and decision-making in labour: do birth plans make a difference?

OBJECTIVES: To assess usage of birth plans, and examine differences in social and obstetric characteristics, and intrapartum experiences of women who did and did not use a birth plan. DESIGN: Population-based survey distributed by hospitals and home birth practitioners, 6-7 months post-natally. SETTING AND PARTICIPANTS: Women who gave birth in Victoria, Australia over a 2-week period in September, 1993, excluding those who had a stillbirth or neonatal death. MAIN OUTCOME MEASURES: Use of a written birth plan; perceived helpfulness, advantages and disadvantages of birth plans; relationship between use of birth plans and overall rating of intrapartum care, and involvement in decision-making. RESULTS: Twenty per cent of women (270/1336) had prepared a written birth plan and discussed it with caregivers. Women who made use of a birth plan were more likely to be satisfied with pain relief (OR = 1.74[1.3-2.3]), but did not differ from women not completing a birth plan in terms of their overall rating of intrapartum care, or involvement in making decisions about their care. CONCLUSIONS: The lack of association between use of a written birth plan and variables assessing women's views of intrapartum care suggest there are insufficient grounds for continuing to advocate a policy of encouraging pregnant women to complete written birth plans, unless it is within the context of a well-designed randomized trial able to provide further evidence regarding their effectiveness.

Maternal perceptions of labor with fetal monitoring by pulse oximetry in a research setting

OBJECTIVE

Little research has evaluated maternal experience with fetal pulse oximetry for fetal surveillance. The purpose of this study was to compare maternal perceptions of labor with intrapartal cardiotocography with or without fetal pulse oximetry in a research setting.

METHODS

One hundred women with vaginal, vertex deliveries and uncomplicated fetal outcomes were enrolled. The study group was a subset of 50 mothers who had participated in a pulse oximetry trial. The control group of 50 mothers was monitored by cardiotocography only. Both groups were matched for age, parity, weeks of gestation, epidural anesthesia use, and duration of labor. A global measure of maternal perception of labor was established by experience with labor, general attitude toward monitoring devices, satisfaction with monitoring, nursing and medical care, and anxiety, each of which was evaluated separately. The mothers in the study group were also interviewed about aspects related to the fetal pulse oximetry research setting, such as information, movement restriction, discomfort, care, privacy, and safety. The questionnaires were based on a standardized rating scale model, and the interviews were conducted two to four days after delivery. The results were analyzed by chi-squared, paired t test, and ANOVA.

RESULTS

No significant differences were observed between the study and control participants in any parameter concerning the maternal perception of labor. Mothers' experiences with pulse oximetry as assessed by interview was overwhelmingly positive.

CONCLUSIONS

Fetal monitoring by pulse oximetry in a research setting did not affect maternal perceptions of labor. Mothers' experiences with pulse oximetry were highly positive, suggesting that research in fetal pulse oximetry need not compromise maternal perceptions of labor.

Maternal satisfaction with labour analgesia

Satisfaction with childbirth is a multidimensional issue, of which analgesia is but one component. The importance of analgesia as a contribution to overall satisfaction has been recognized increasingly in the last 50 years, but improvement in quality of available analgesia has not always resulted in commensurate improvement in satisfaction. Satisfaction by its very nature has proved to be difficult both to define and to quantify, and no reliable standards of measurement have been accepted. Pain relief in childbirth is subject to many social and cultural modifiers, which continue to change. Control of pain rather than absolute amelioration is seen by many to provide greater satisfaction. Analgesia issues still do not figure prominently in the overall satisfaction of the birthing process for the vast majority of women, despite the availability of and demand for improved methods of relief. The interpersonal relationships established between patient and healthcare providers may ultimately be of more importance in the determination of satisfaction with management.