Satisfaction with childbirth: theories and methods of measurement

The Impact of Prepartum Depression and Birth Experience on Postpartum Mother-Infant Bonding: A Longitudinal Path Analysis

INTRODUCTION

Negative effects of impaired postpartum mother-infant-bonding on mental health of mothers, their newborn children and subsequent child development are well documented. Previous research demonstrated an association between a negative birth experience and postpartum mental health affecting postpartum mother-infant bonding. This study investigates the extent to which prepartum depression and birth experience influence the postpartum mental health of mothers and their bonding toward their newborns, and whether these influences differ according to parity and self-reported prior mental health problems.

METHOD

Three hundred and fifty-four women (18-43 years; M = 30.13, SD = 5.10) filled in the Edinburgh Postnatal Depression Scale (EPDS), the Maternal-Fetal Attachment Scale (MFAS), Salmon's Item List (SIL) assessing the birth experience, and the Postpartum Bonding Questionnaire (PBQ) at pre- and postpartum; they were also asked about birth complications and parity status.

RESULTS

Primipara reported significantly more birth complications (p = 0.048), with path analysis confirming this result (p < 0.001). Birth complications were associated with a more negative rating of the overall birth experience (p < 0.001). Mothers with self-reported prior mental health problems had higher prepartum depression scores (p < 0.001) but did not differ in other variables from mothers without prior self-reported mental health problems. Differences in depression scores between mothers with self-reported prior mental health problems and those without vanished at postpartum assessment (p > 0.05). Path-analysis highlighted the key role of postpartum depression, which was the only significant predictor of postpartum impairment in maternal-child bonding (p < 0.001). Birth experience and prepartum depression scores exerted an indirect effect on postpartum maternal-child bonding, mediated by postpartum depression.

DISCUSSION

The present study demonstrates the relevance of prepartum mental health of expectant mothers, especially of those who self-report prior mental health problems. The results support that reducing mental health problems of pregnant mothers might contribute to a more positive birth experience and potentially reduce postpartum depressive symptoms. As postpartum depression is associated with impaired parent-child bonding, such targeted interventions could promote child development. Group differences between primiparous and multiparous mothers suggest that the birth experience may be an influential factor for postpartum mental health.

Patient Experience in Obstetrics in a Military Patient Satisfaction Survey: Findings and Recommendations for Improvement

INTRODUCTION

This study examines the care experience of obstetric patients within the Military Health System and compares them to those of medical and surgical care patients. Specifically, the study seeks to (1) examine how obstetric inpatient experience ratings differ from medical and surgical inpatient experience ratings, (2) understand specific aspects of care that drive overall experience ratings within this population, (3) test whether adherence to nursing practices such as hourly rounding and nurse leader visits affect experience ratings, and (4) describe ways that patient experience information can be presented to healthcare providers to improve performance.

MATERIALS AND METHODS

Data for this study include Military Health System patient experience survey data (based on the Hospital Consumer Assessment of Healthcare Providers and Systems) collected from 2011 through 2019. Analysis includes data collected from 338,124 patients aged 18 years and older. Our analysis involved z-test comparisons of patient experience measure scores, trend analysis, logistic regression-based driver analysis, and correlations.

RESULTS

Obstetric ratings are generally lower than those of medical and surgical patients; however, they have been improving at a slightly faster rate year over year. Effective nurse communications with patients are a particularly strong driver for improving their overall care experiences, and practices like hourly nurse rounding, nurse leader visits, and nurse-patient shift change conversations are positively correlated with obstetric patient experience ratings.

CONCLUSIONS

This study contextualizes how obstetric inpatient experience ratings differ from those of medical and surgical care patients. Healthcare administrators and policymakers should be aware that obstetric patients may have unique needs and expectations that lead to patient experience ratings differing from those of medical and surgical patients. Effective nurse-patient communications, hourly rounding, nurse leader visits, and nurse-patient shift change conversations could be strategies used to improve obstetric experience ratings.

Validation and factor structure of the Italian version of the Birth Satisfaction Scale-Revised (BSS-R)

OBJECTIVE

To validate the Italian-language version of the Birth Satisfaction Scale-Revised (BSS-R) and report key measurement properties of the tool. To evaluate the impact of antenatal class attendance on BSS-R assessed birth satisfaction.

BACKGROUND

Maternal satisfaction is one of the standards of care defined by the World Health Organisation (WHO) to improve the quality of services. The BSS-R is a multi-dimensional self-report measure of the experience of labour and birth.

METHODS

Cross-sectional instrument evaluation design examining factor structure and key aspects of validity and reliability. Embedded between-subjects design to examine known-group discriminant validity and the impact of antenatal class attendance on BSS-R sub-scale and total scores as dependent variables. After giving birth, 297 women provided data for analysis.

RESULTS

The Italian version of the BSS-R (I-BSS-R) was the key study measure. The established three-factor and bi-factor models of the BSS-R were found to offer an excellent fit to the data. Comparison of the tri-dimensional measurement model and the bi-factor model of the BSS-R found no significant differences between models. Women who attended antenatal classes had significantly lower stress experienced during childbearing sub-scale scores (I-BSS-R SE), compared to those who did not. Good convergent, divergent validity and known-groups discriminant validity were established for the I-BSS-R. Internal consistency observations were found to be sub-optimal in this population.

CONCLUSIONS

On all key psychometric indices, with the exception of internal consistency that requires further investigation, the I-BSS-R was found to be a valid translation of the original BSS-R. The impact of antenatal classes on birth satisfaction warrants further research.

All the right moves: why in utero transfer is both important for the baby and difficult to achieve and new strategies for change

The best way to ensure that preterm infants benefit from relevant neonatal expertise as soon as they are born is to transfer the mother and baby to an appropriately specialised neonatal facility before birth (“ in utero”). This review explores the evidence surrounding the importance of being born in the right unit, the advantages of in utero transfers compared to ex utero transfers, and how to accurately assess which women are at most risk of delivering early and the challenges of in utero transfers.

Accurate identification of the women most at risk of preterm birth is key to prioritising who to transfer antenatally, but the administrative burden and pathway variation of in utero transfer in the UK are likely to compromise optimal clinical care. Women reported the impact that in utero transfers have on them, including the emotional and financial burdens of being transferred and the anxiety surrounding domestic and logistical concerns related to being away from home. The final section of the review explores new approaches to reforming the in utero transfer process, including learning from outside the UK and changing policy and guidelines. Examples of collaborative regional guidance include the recent Pan-London guidance on in utero transfers. Reforming the transfer process can also be aided through technology, such as utilising the CotFinder app.

In utero transfer is an unavoidable aspect of maternity and neonatal care, and the burden will increase if preterm birth rates continue to rise in association with increased rates of multiple pregnancy, advancing maternal age, assisted reproductive technologies, and obstetric interventions. As funding and capacity pressures on health services increase because of the COVID-19 pandemic, better prioritisation and sustained multi-disciplinary commitment are essential to maximise better outcomes for babies born too soon.

"I am alive; my baby is alive": Understanding reasons for satisfaction and dissatisfaction with maternal health care services in the context of user fee removal policy in Nigeria

Background

The main policy thrust in many sub-Saharan Africa countries’ aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood.

Methods

This study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011–2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis.

Results

The overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers’ attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care.

Conclusion

The findings establish a high level of beneficiaries’ satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers.

The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk

BACKGROUND

The measurement and interpretation of patient experience is a distinct dimension of health care quality. The Midwives @ New Group practice Options (M@NGO) randomized control trial of caseload midwifery compared with standard care among women regardless of risk reported both clinical and cost benefits. This study reports participants' perceptions of the quality of antenatal care within caseload midwifery, compared with standard care for women of any risk within that trial.

METHODS

A trial conducted at two Australian tertiary hospitals randomly assigned participants (1:1) to caseload midwifery or standard care regardless of risk. Women were sent an 89-question survey at 6 weeks postpartum that included 12 questions relating to pregnancy care. Ten survey questions (including 7-point Likert scales) were analyzed by intention to treat and illustrated by participant quotes from two free-text open-response items.

RESULTS

From the 1748 women recruited to the trial, 58% (n = 1017) completed the 6-week survey. Of those allocated to caseload midwifery, 66% (n = 573) responded, compared with 51% (n = 444) of those allocated to standard care. The survey found women allocated to caseload midwifery perceived a higher level of quality care across every antenatal measure. Notably, those women with identified risk factors reported higher levels of emotional support (aOR 2.52 [95% CI 1.87-3.39]), quality care (2.94 [2.28-3.79]), and feeling actively involved in decision-making (3.21 [2.35-4.37]).

CONCLUSIONS

Results from the study show that in addition to the benefits to clinical care and cost demonstrated in the M@NGO trial, caseload midwifery outperforms standard care in perceived quality of pregnancy care regardless of risk.

Women's experiences of maternity care in England: preliminary development of a standard measure

BACKGROUND

As maternity services evolve and the population of women served also changes, there is a continuing need to effectively document the views of women with recent experience of care. A woman's maternity experience can have a positive or negative effect upon her emotional well-being and health, in the immediate and the long-term, which can also impact the infant and the wider family system. Measuring women's perceptions of maternity services is an important way of monitoring the quality of care provision, as well as providing key indicators to organisations of the services that they are providing. It follows that, without information identifying possible areas in need of improvement, it is not clear what changes should be made to improve the experiences of women during their journey through maternity services from pregnancy to the early weeks at home with a new baby . The objective is to describe the development process and psychometric properties of a measure of women's experience of maternity care covering the three distinctly different phases of maternity - pregnancy, labour and birth, and the early postnatal period.

METHODS

Data from a national survey of women who had recently given birth (n = 504) were used. Exploratory and confirmatory factor analytic methods were employed. The measure was assessed for underlying latent factor structure, as well as for reliability, internal consistency, and validity (predictive, convergent and discriminant).

RESULTS

The models developed confirmed the use of three separate, but related scales about experience of maternity care during pregnancy, labour and birth and the postnatal period. Data reduction was effective, resulting in a measure with 36 items (12 per scale).

CONCLUSION

The need for a psychometrically robust and qualitatively comprehensive measure of women's experience of maternity care has been addressed in the development and validation of this prototype measure. The whole measure can be used at one time point, or the three separate subscales used as individual measures of experience during particular phases of the maternity journey with identified factor structures in their own right.

Perceptions and experiences of labour companionship: a qualitative evidence synthesis

BACKGROUND

Labour companionship refers to support provided to a woman during labour and childbirth, and may be provided by a partner, family member, friend, doula or healthcare professional. A Cochrane systematic review of interventions by Bohren and colleagues, concluded that having a labour companion improves outcomes for women and babies. The presence of a labour companion is therefore regarded as an important aspect of improving quality of care during labour and childbirth; however implementation of the intervention is not universal. Implementation of labour companionship may be hampered by limited understanding of factors affecting successful implementation across contexts.

OBJECTIVES

The objectives of the review were to describe and explore the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders regarding labour companionship; to identify factors affecting successful implementation and sustainability of labour companionship; and to explore how the findings of this review can enhance understanding of the related Cochrane systematic review of interventions.

SEARCH METHODS

We searched MEDLINE, CINAHL, and POPLINE K4Health databases for eligible studies from inception to 9 September 2018. There were no language, date or geographic restrictions.

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; focused on women's, partners', family members', doulas', providers', or other relevant stakeholders' perceptions and experiences of labour companionship; and were from any type of health facility in any setting globally.

DATA COLLECTION AND ANALYSIS

We used a thematic analysis approach for data extraction and synthesis, and assessed the confidence in the findings using the GRADE-CERQual approach. We used two approaches to integrate qualitative findings with the intervention review findings. We used a logic model to theorise links between elements of the intervention and health and well-being outcomes. We also used a matrix model to compare features of labour companionship identified as important in the qualitative evidence synthesis with the interventions included in the intervention review.

MAIN RESULTS

We found 51 studies (52 papers), mostly from high-income countries and mostly describing women's perspectives. We assessed our level of confidence in each finding using the GRADE-CERQual approach. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this.Labour companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating non-pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (low confidence). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision-making.Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign-born women in high-income settings may appreciate support from community-based doulas to receive culturally-competent care (low confidence).Factors affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).We compared our findings from this synthesis to the companionship programmes/approaches assessed in Bohren's review of effectiveness. We found that most of these programmes did not appear to address these key features of labour companionship.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several of these review findings. Further research, especially in low- and middle-income settings and with different cadres of healthcare providers, could strengthen the evidence for low- or very low-confidence findings. Ahead of implementation of labour companionship, researchers and programmers should consider factors that may affect implementation, including training content and timing for providers, women and companions; physical structure of the labour ward; specifying clear roles for companions and providers; integration of companions; and measuring the impact of companionship on women's experiences of care. Implementation research or studies conducted on labour companionship should include a qualitative component to evaluate the process and context of implementation, in order to better interpret results and share findings across contexts.

Just another ordinary bad birth? A narrative analysis of first time mothers' traumatic birth experiences

A difficult birth experience can have long lasting psychological effects on both mother and baby and this study details four in-depth accounts of first time mothers who described their birth experience as traumatizing. Narrative analysis was used to record discrepancies between the ideal and the real and produced narrative accounts that highlighted how these mothers felt invisible and dismissed in a medical culture of engineering obstetrics. Participants also detailed how their birth experience could be improved and this is set in context alongside current recommendations in maternal health care and the complexities of delivering such care in UK health settings.

Development of a questionnaire for assessing the childbirth experience (QACE)

Background

Due to its potential impact on women’s psychological health, assessing perceptions of their childbirth experience is important. The aim of this study was to develop a multidimensional self-reporting questionnaire to evaluate the childbirth experience.

Methods

Factors influencing the childbirth experience were identified from a literature review and the results of a previous qualitative study. A total of 25 items were combined from existing instruments or were created de novo. A draft version was pilot tested for face validity with 30 women and submitted for evaluation of its construct validity to 477 primiparous women at one-month post-partum. The recruitment took place in two obstetric clinics from Swiss and French university hospitals. To evaluate the content validity, we compared item responses to general childbirth experience assessments on a numeric, 0 to 10 rating scale. We dichotomized two group assessment scores: “0 to 7” and “8 to 10”. We performed an exploratory factor analysis to identify underlying dimensions.

Results

In total, 291 women completed the questionnaire (response rate = 61%). The responses to 22 items were statistically significant between the 0 to 7 and 8 to 10 groups for the general childbirth experience assessments. An exploratory factor analysis yielded four sub-scales, which were labelled “relationship with staff” (4 items), “emotional status” (3 items), “first moments with the new born,” (3 items) and “feelings at one month postpartum” (3 items). All 4 scales had satisfactory internal consistency levels (alpha coefficients from 0.70 to 0.85). The full 25-item version can be used to analyse each item by itself, and the short 4-dimension version can be scored to summarize the general assessment of the childbirth experience.

Conclusions

The Questionnaire for Assessing the Childbirth Experience (QACE) could be useful as a screening instrument to identify women with negative childbirth experiences. It can be used as both a research instrument in its short version and a questionnaire for use in clinical practice in its full version.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1462-x) contains supplementary material, which is available to authorized users.

Client-Related Factors Associated with a "Less than Good" Experience of Midwifery Care during Childbirth in the Netherlands

BACKGROUND

A "less than good" experience during childbirth can affect a mother's early interaction with her child and may significantly influence a woman's emotional well-being. In this study, we focus on clients who experienced midwifery care provided during childbirth as "less than good" care. The aim of this study was to understand the relationship between client-related factors and the experience of midwifery care during childbirth to improve this care.

METHODS

This study was part of the "DELIVER study" where mothers report on the care they received. We used generalized estimation equations to control for correlations within midwife practices. Forward multivariate logistic regression analyses were conducted to model the client-related factors associated with the experienced midwifery care during childbirth.

RESULTS

We included the responses of 2,377 women. In the multivariable logistic regression model, odds of reporting "less than good care" were significantly higher for women who experienced an unplanned cesarean birth (OR 2.21 [CI 1.19-4.09]), an instrumental birth (OR 1.55 [CI 1.08-2.23]), and less control during the dilation phase (OR 0.98 [CI 0.97-0.99]) and pushing phase (OR 0.98 [CI 0.97-0.99]).

DISCUSSION

Birth-related factors were more likely than maternal characteristics to be associated with the experience of midwifery care during childbirth. We conclude that there is room for midwives to improve their care for women during childbirth particularly in improving the patient centeredness of the care provider, using strategies to enhance sense of control, and focusing on the particular needs of those who experience instrumental vaginal or unplanned cesarean births.

Amount, Source, and Quality of Support as Predictors of Women's Birth Evaluations

BACKGROUND

This paper examines the separate effects of the perceived amount, source, and quality of support during labor and delivery on women's positive and negative evaluations of their birth experiences.

METHODS

Data come from the Listening to Mothers I and II (LTM) surveys (n = 2,765). Women's perception of support was regressed separately onto indices of positive and negative words that women associated with their labor and delivery.

RESULTS

The total number of support sources, type of support person, and quality of support all impacted women's birth evaluations across different regression models, controlling for demographics, birth interventions, and other birth characteristics. Support overall had a greater effect on increasing women's positive evaluations, but was not as protective against negative evaluations. Support from medical and birth professionals (doctors, nurses, doulas) had the greatest effect on women's positive evaluations. Good partner support was complexly related: it was associated with less positive evaluations but also appeared to have a protective effect against negative birth evaluations.

DISCUSSION

Support in childbirth is a complex concept with multiple dimensions that matter for women's birth evaluations. Support from nursing staff, doctors, and doulas is important for enabling positive evaluations while support from partners is more complexly related to women's evaluations. Research on support for laboring women should more extensively address the division of labor between different sources of support.

Psychiatric outcomes after childbirth: can posttraumatic growth protect me from disordered eating symptoms?

PURPOSE

While many studies on mood disorder and posttraumatic stress disorder (PTSD) following childbirth have been conducted, little is known regarding posttraumatic growth (PTG) and disordered eating in the postpartum period. This study aims to (a) identify the typology of women following childbirth based on anxiety, depressive, PTSD symptoms and level of PTG and (b) evaluate whether these profiles differ on disordered eating symptoms.

METHODS

Up to 2 years after childbirth, 306 French-speaking mothers [mean age (SD) = 29.4 (4.6) years] completed questionnaires assessing PTSD, depressive, anxiety and disordered-eating symptoms and level of posttraumatic growth.

RESULTS

Four profiles were highlighted: a first one labeled growing cluster (22.2 % of the sample, n = 68), a second one labeled low level of symptoms cluster (37.6 % of the sample, n = 115), a third one labeled vulnerable cluster (21.6 % of the sample, n = 66) and a last one labeled anxious-depressed-traumatized cluster (18.6 % of the sample, n = 57). Our findings also highlight an impact of these profiles on disordered eating symptoms, suggesting that disordered eating in postpartum would not be the result of pregnancy.

CONCLUSION

Consistent with our expectation, our findings suggest a potential protective role of posttraumatic growth on the development of disordered eating symptoms. Further researches focusing on traumatic experience, disordered eating and posttraumatic growth in postpartum are warranted.

Social psychological predictors of satisfaction with intrapartum and postpartum care - what matters to women in Czech maternity hospitals?

OBJECTIVE

To identify the social psychological factors affecting women's evaluation of care provided in Czech maternity hospitals using following criteria: satisfaction with intrapartum and postpartum care, willingness to return to a given hospital and to recommend the hospital to others.

METHODS

762 women completed a 71-item original Czech questionnaire KLI-P designed to measure the psychosocial climate in both delivery and after-birth unit on six scales. The sample was representative of the Czech parturients population. Multivariate logistic regression was used to investigate the predictive value of the questionnaire scales for maternal satisfaction, willingness to return to and to recommend a given hospital.

RESULTS

For delivery unit, the satisfaction predictors were: helpfulness and empathy of midwives (Χ²=48.9), communication of information and availability of caregivers (Χ²=16.6), helpfulness and empathy of physicians (Χ²=10.9), symmetrical and respectful attitude of staff members (Χ²=9.7) and physical comfort and services (Χ²=7.6). The predictors of satisfaction with after-birth unit included helpfulness and empathy of the staff (Χ²≥42.1), communication of information and availability of caregivers (Χ²=52.5), physical comfort and services (Χ²=30.6), control and involvement in decision-making (Χ²=6.6) and parity (Χ²=8.6). The factors influencing women's willingness to return to and to recommend a hospital differed from the predictors of general satisfaction.

CONCLUSIONS

The satisfaction factors revealed in this research correspond predominantly to the results of studies conducted in other countries (warm, non-formal and supportive approach, sufficient and well-timed provision of information and explanation, availability of caregivers, physical environment). However, participation in decision making, which has been repeatedly shown to be among the strongest predictors of childbirth satisfaction, was not important for the Czech parturients' satisfaction with intrapartal care. This finding can be explained by different attitudes and expectations of both parturients and caregivers in a post-totalitarian country.

Searching for Medical Substances Safe for Mother and Child, Facilitating the Delivery of Pain Management and Decreasing Exhaustion--Evaluation of Obstetric Gel by Pregnant Women

The aim of the present study was to determine whether applying obstetric gel, a noninvasive method of pain management that is safe both for the mother and the child, during labor influences delivery satisfaction by facilitating pain management and decreasing exhaustion. Forty-seven primiparous women were included in the study: 23 on whom during the delivery gel was used and 24 whose delivery proceeded without the use of a gel (control group). The following research tools were used for the evaluation of satisfaction with the course of the delivery: Visual Analogue Scale (VAS), self-authorship survey, and the State-Trait Anxiety Inventory. There were no significant differences in intensification of pain in the first and second periods of delivery, exhaustion after delivery and intensification of pain in the second period of delivery, and increased anxiety between the study group and the control group. Our results suggest that application of obstetric gel during the first and second period of delivery does not significantly influence women's satisfaction with the course of delivery.

Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania

Background

Interventions to reduce maternal mortality have focused on delivery in facilities, yet in many low-resource settings rates of facility-based birth have remained persistently low. In Tanzania, rates of facility delivery have remained static for more than 20 years. With an aim to advance research and inform policy changes, this paper builds on a growing body of work that explores dimensions of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania.

Methods

This research drew on in-depth interviews with 112 respondents including women who delivered in the preceding 14 months, their male partners, public opinion leaders and community health workers to understand experiences with and responses to abuse during childbirth. All interviews were recorded, transcribed, translated and coded using Atlas.ti. Analysis drew on the principles of Grounded Theory.

Results

When initially describing birth experiences, women portrayed encounters with providers in a neutral or satisfactory light. Upon probing, women recounted events or circumstances that are described as abusive in maternal health literature: feeling ignored or neglected; monetary demands or discriminatory treatment; verbal abuse; and in rare instances physical abuse. Findings were consistent across respondent groups and districts. As a response to abuse, women described acquiescence or non-confrontational strategies: resigning oneself to abuse, returning home, or bypassing certain facilities or providers. Male respondents described more assertive approaches: requesting better care, paying a bribe, lodging a complaint and in one case assaulting a provider.

Conclusions

Many Tanzanian women included in this study experienced unfavorable conditions when delivering in facilities. Providers, women and their families must be made aware of women’s rights to respectful care. Recommendations for further research include investigations of the prevalence and dimensions of disrespectful care and abuse, on mechanisms for women and their families to effectively report and redress such events and on interventions that could mitigate neglect or isolation among delivering women. Respectful care is a critical component to improve maternal health.

Impact of mode of delivery on the birth experience in first-time mothers: a qualitative study

Background

The birth of a first child is an important event in a woman’s life. Delivery psychological impacts vary depending on whether delivery has been positively or negatively experienced. Delivery experience determinants have been identified but the understanding of their expression according to the mode of delivery is poorly documented. The purpose of the study was to determine important elements associated with women’s first delivery experience according to the mode of delivery: vaginal or caesarean section.

Methods

Qualitative approach using thematic content analysis of in-depth interviews conducted between 4 and 6 weeks’ postpartum, in 24 primiparous women who delivered at Geneva University Hospital in 2012.

Results

Perceived control, emotions, and the first moments with the newborn are important elements for the experience of childbirth. Depending on the mode of delivery these are perceived differently, with a negative connotation in the case of caesarean section. Other elements influencing the delivery experience were identified among all participants, irrespective of the mode of delivery. They included representations, as well as the relationship with caregivers and the father in the delivery room, privacy, unexpected sensory experiences, and ownership of the maternal role. Women’s and health professionals’ representations sometimes led to a hierarchy based on the mode of delivery and use of analgesia.

Conclusions

The mode of delivery directly impacts on certain key delivery experience determinants as perceived control, emotions, and the first moments with the newborn. The ability/inability of the woman to imagine a second pregnancy is a good indicator of the birth experience. Certain health professional gestures or attitudes can promote a positive delivery experience. We recommend to better prepare women during prenatal classes for the eventuality of a caesarean section delivery and to offer all women and, possibly, their partners, the opportunity to talk about the experience of childbirth during the postpartum period. The results of this study suggest that further research is required on the social representations of women and health professionals regarding the existence of a hierarchy associated with the mode of delivery.

[Satisfaction with obstetrical care: development and validation of a scale on quality of care]

OBJECTIVES

To develop and validate a subjective and multidimensional scale to measure satisfaction in obstetrical care (SSO) during labour, delivery and two hours postpartum, which is relevant to the French-speaking context.

PATIENTS ET METHODS

Forty partially directed patient interviews during the 48 hours after delivery and four care-giver interviews were conducted to build up the questionnaire. After a prior feasibility study on 40 patients, the psychometric validity of the questionnaire was evaluated by calculating the Cronbach coefficient of reliability for 432 patients.

RESULTS

Hundred and eighty items were initially obtained after content analysis of the patient interviews. Expert meetings finally selected 49 items classified within 5 dimensions. The feasibility study showed that the questionnaire was easily accepted and understood with a mean time of 15 minutes to answer it. Cronbach coefficients were respectively at 0.941, 0.949, 0.808, 0.814 et 0.869 for the 5 dimensions.

DISCUSSION AND CONCLUSION

SSO questionnaire is a reliable and relevant scale to measure immediate postpartum quality of care in French.

Maternal satisfaction with organized perinatal care in Serbian public hospitals

Background

Understanding the experiences and expectations of women across the continuum of antenatal, perinatal, and postnatal care is important to assess the quality of maternal care and to determine problematic areas which could be improved. The objective of this study was to identify the factors associated with maternal satisfaction with hospital-based perinatal care in Serbia.

Methods

Our survey was conducted from January 2009 to January 2010 using a 28-item, self-administered questionnaire. The sample consisted of 50% of women who expected childbirths during the study period from all 76 public institutions with obstetric departments in Serbia. The following three composite outcome variables were constructed: satisfaction with technical and professional aspects of care; communication and interpersonal aspects of care; and environmental factors.

Results

We analyzed 34,431 completed questionnaires (84.2% of the study sample). The highest and lowest average satisfaction scores (4.43 and 3.25, respectively) referred to the overall participation of midwives during delivery and the quality of food served in the hospital, respectively. Younger mothers and multiparas were less concerned with the environmental conditions (OR = 0.55, p = 0.006; OR = 1.82, p = 0.004). Final model indicated that mothers informed of patients’ rights, pregnancy and delivery through the Maternal Counseling Service were more likely to be satisfied with all three outcome variables. The highest value of the Pearson’s coefficient of correlation was between the overall satisfaction score and satisfaction with communication and interpersonal aspects of care.

Conclusions

Our study illuminated the importance of interpersonal aspects of care and education for maternal satisfaction. Improvement of the environmental conditions in hospitals, the WHO program, Baby-friendly Hospital, and above all providing all pregnant women with antenatal education, are recommendations which would more strongly affect the perceptions of quality and satisfaction with perinatal care in Serbian public hospitals by women.

Measures of satisfaction with care during labour and birth: a comparative review

Background

Satisfaction is the one of the most frequently reported outcome measures for quality of care. Assessment of satisfaction with maternity services is crucial, and psychometrically sound measures are needed if this is to inform health practices. This paper comparatively reviews current measures of satisfaction with care during labour and birth.

Methods

A review of the literature was conducted. Studies were located through computerised databases and hand searching references of identified articles and reviews. Inclusion criteria were that the questionnaire was a multi-item scale of satisfaction with care during labour and birth, and some form of psychometric information (either information about questionnaire construction, or reliability, or validity) had to be reported.

Results

Nine questionnaires of satisfaction with care during labour and birth were identified. Instruments varied in psychometric properties and dimensions. Most described questionnaire construction and tested some form of reliability and validity. Measures were generally not based on the main theoretical models of satisfaction and varied in scope and application to different types of samples (e.g. satisfaction following caesarean section). For an in-depth measure of satisfaction with intrapartum care, the Intrapartal-Specific Quality from the Patient’s Perspective questionnaire (QPP-I) is recommended. Brief measures with good reliability and validity are provided by the Six Simple Questions (SSQ) or Perceptions of Care Adjective Checklist (PCACL-R).

Conclusions

Despite the interest in measures of satisfaction there are only a small number of validated measures of satisfaction with care during labour and birth. It is important that brief, reliable and valid measures are available for use in general and specific populations in order to assist research and inform practice.

Effects of labor support from close female relative on labor and maternal satisfaction in a Thai setting

OBJECTIVE

To evaluate the efficacy of a close female relative providing emotional and physical support during active labor and birth.

DESIGN

Randomized, two-group controlled clinical trial.

SETTING

Regional teaching hospital in the eastern part of Thailand with 782 beds.

PARTICIPANTS

Primiparous women (N = 120) whose gestational ages were ≥ 36 weeks and who had uncomplicated pregnancies.

METHODS

Participants were randomly assigned to receive usual care and support from a chosen close female relative from admission until 2 hours after birth or usual care only. Within 24 hours of birth, labor outcomes (length of labor & type of birth) and levels of maternal satisfaction were assessed.

RESULTS

Those in the experimental group had a significantly shorter duration of active labor and were more satisfied with their childbirth experiences than those in the control group. Differences between groups with respect to incidence of spontaneous delivery were not found.

CONCLUSIONS

A close female relative was effective in providing supportive care during labor and delivery. The integration of this nursing intervention for women and their families at public hospitals in Thailand is supported.

Psychometric properties of the Confidence and Trust in Delivery Questionnaire (CTDQ): a pilot study

Background

Assessing expecting mother’s opinions prior to birth draws a comprehensive picture for the caregivers about their emotional state and their expectations. Some questionnaires to cover these aspects do exist. This study aims to present the psychometric properties of a new instrument, the Confidence and Trust in Delivery Questionnaire (CDTQ) a short but reliable a self-report instrument that focuses on confidence and trust as meaningful dimensions for expectant mothers.

Methods

A pilot validation study of 221 women 6 weeks before childbirth was conducted in Germany between October 2007 and June 2008. To detect structural relations between the items, factor and reliability analyses were applied to the CTDQ items. Factor analysis was performed by means of principal components analysis and varimax rotation. Internal reliability was assessed by Cronbach’s alpha. External validation was performed using the sense of coherence (SOC) scale.

Results

The CTDQ comprises of 11 items. We found a 4-factor structure. The internal consistency of the whole item pool (Cronbach’s α = 0.79) and the 4 subscales [confidence in labor (α = 0.82); partner’s support (α = 0.62); trust in medical competency (α = 0.68); being informed (α = 0.60)] can be regarded as sufficient or even excellent. The 4 factors explained 69.6% of total variance. Except for a high intercorrelation (0.70) between “partner’s support” and “trust in medical competence”, the subscales show low intercorrelations, indicating an adequate independence of the respective subscales. Regarding the external validity we found minor respective moderate correlations with the SOC scale.

Conclusions

Our data suggest that the CTDQ is a useful instrument to assess confidence and trust in delivery. With 4 clinically relevant dimensions, the CTDQ is now open for further studies in the field of labor.

The assessment of satisfaction with care in the perinatal period

Patient satisfaction is frequently used to evaluate the quality of medical care and to guide the development of health care services. Improved satisfaction is a goal recommended by the Institute of Medicine and the government of the United Kingdom for health care reform. During the perinatal period, dynamic changes in physical and psychological state impose unique challenges in the assessment of satisfaction. This article reviews the measurement of satisfaction with care, together with factors that may influence satisfaction and its measurement during the perinatal period. Recommendations are also provided for further research and development of satisfaction instruments and potential interventions to improve satisfaction with perinatal care.

[Assessment of maternal satisfaction with epidural analgesia during labour]

OBJECTIVE

To measure the overall satisfaction of obstetrics patients with epidural analgesia during labour, and in particular, with the technique and other subjective factors.

MATERIAL AND METHODS

An anonymous questionnaire was administered over a three-month period to patients who received analgesia to control pain during labour and who had vaginal delivery, in order to obtain information of the satisfaction with technique and their care.

RESULTS

Of the 100 patients who responded to the questionnaire, 92% were satisfied with the technique. The mild satisfaction measured by SERVQHOS score was 3.98 (SD ± 0.64). The score for the subjective aspects was 4.10 (± 0.68), which was better than objective ones. The recommendation rate was 98% for satisfied patients and 85.7% for those who were not satisfied. There were no differences between Spanish and foreign patients in their evaluation of the satisfaction.

CONCLUSIONS

The proportion of patients satisfied with the technique was very high, and was the top rated subjective aspect (treatment and public confidence).

Birthing Positions During Second Stage of Labor and Long-Term Psychological Outcomes in Low-Risk Women

PURPOSE: To examine the long-term influence of birthing positions during the second stage of labor, as well as other factors, on birth satisfaction, self-esteem (based on the Rosenberg Self-esteem Scale [RSE]) and emotional well-being (based on the Edinburgh Postnatal Depression Scale [EPDS]).

STUDY DESIGN: Three to four years after delivery, a postal questionnaire was sent to all 3,200 women who received care in eight midwifery care practices from all over the country in 2001. Of those who responded (44%), we included 591 low-risk women in the study who were in midwife-led care at the time of birth.

MAJOR FINDINGS: Birthing positions were not related to childbirth satisfaction, self-esteem, or emotional well-being. Age between 26 and 35 years was associated with being very satisfied and with enhanced emotional well-being. Pain, fear for own or baby’s life, and negative experience with the midwife were associated with reduced satisfaction. Only age between 26 and 35 years and higher education were related to higher self-esteem.

MAIN CONCLUSION: Concern about long-term psychological outcomes is not a reason to recommend either supine or nonsupine positions. Women should use positions that are most comfortable. Further research should clarify whether having a choice in the use of birthing positions rather than the type of position influences psychological outcomes.

Becoming a Mother: Women’s Journeys From Expectation to Experience in Three European Countries

OBJECTIVE:To investigate important aspects of provision of routine antenatal care from women’s points of view in the Netherlands, Scotland, and Switzerland and to construct a conceptual model of care during pregnancy, informed by women.

DESIGN:Grounded theory using semistructured interviews to explore women’s views. The interviews were undertaken in Dutch, English, and German.

FINDINGS:In the main study, one single cross-national model emerged, which had implications for women beyond the antenatal period. “Mothering the mother” emerged as a core category. There were two subcategories: “creating a bond” and “becoming a mother.” The subcategory of “becoming a mother,” which incorporated the stages of “expecting,” “familiarizing,” and “embarking on motherhood,” is reported in this article. Women defined becoming a mother as the aim of provision of maternity care in which they described their journeys from creating expectations in early pregnancy to completing the experience approximately a year after childbirth. Mismatches between expectation and experience at the end of these journeys indicated cross-national differences in the provision of maternity care, particularly regarding the woman–care provider relationships.

CONCLUSION:The findings from this study suggest that an essential aim of the maternity services was to support women in the process of becoming a mother, in the context of their own social world. Supportive conditions include woman–care provider partnerships, involvement of women’s individual social worlds in care provision, and continuity of the care providing process. These conditions should be taken into account, while designing effective models of maternity care.

Womens' opinions on intrapartal care: development of a theory-based questionnaire

AIM

To develop a patient questionnaire specific to intrapartal care, based on the theoretical foundation of the general instrument Quality from the Patient's Perspective (QPP).

BACKGROUND

Existing general patient questionnaires do not take intrapartal care aspects fully into account, and available intrapartal-specific patient questionnaires tend to have a weak theoretical foundation.

DESIGN

A cross-sectional, nationwide study carried out during a two-week period in 2007 at Swedish maternity units.

METHOD

An intrapartal-specific QPP-questionnaire (QPP-I) was developed by combining a selection of 22 items from the short and long versions of the QPP with 10 newly constructed items. Responses were obtained from 739 women (63% response rate). The dimensionality of the QPP-I was assessed using structural equation modelling (a nested factor model). Non-parametric statistics were used for subgroup comparisons.

RESULTS

A nested model with a general factor including all 32 items and 10 subordinate factors was developed. Most scales had acceptable reliability coefficients (0.73-0.93), and a meaningful pattern of subgroup differences was obtained.

CONCLUSIONS

The QPP-I is theory based and has its roots in a patient perspective. It was developed using a nationwide sample of Swedish women receiving intrapartal care, and an advanced statistical method was used. The outcome of this initial empirical trial was promising but needs to be tested in different countries and cultures.

RELEVANCE TO CLINICAL PRACTICE

By combining womens' responses on perceived reality and subjective importance ascribed to the various aspects of care measured, the QPP-I offers the care provider better guidelines on which elements to focus quality improvement work on, than would be the case if only a rank order of perceived reality ratings was available.

Maternal satisfaction and acceptability of foetal electrocardiographic (STAN®) monitoring system

OBJECTIVE

To assess the acceptability of the foetal electrocardiographic (STAN®) monitoring system by patients at a London Hospital, before its introduction into routine clinical care.

METHOD

This was a prospective questionnaire-based study of patients who were monitored in labour by foetal electrocardiographic (STAN®) monitoring system.

RESULTS

Ninety-three percent (CI 85, 98) of the patients felt that the midwife(s) responsible for their intrapartum care took time to explain why their babies were being monitored continuously in the first instance. Ninety-nine percent (CI 93, 99.9) of patients felt that the obstetricians explained why they were being monitored continuously in labour. After delivering and having been monitored with STAN® 95% (CI 87, 99) of women felt that it was an acceptable way of monitoring their babies in labour.

CONCLUSION

In resource-limited organisation, such as the NHS, holistic approach to intrapartum care may sometimes feel difficult to achieve. However, with emphasis on women centred care and information sharing women are able to understand and comment on intrapartum monitoring systems.

A simple tool to measure patient perceptions of operative birth

OBJECTIVE

To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery.

DESIGN

Cross-sectional survey.

SETTING

A large maternity unit in England.

SAMPLE

150 women who had had an operative birth.

METHODS

We recruited women within 24 hours of birth and quantified their satisfaction with two questionnaires: PPS, and the Mackey Childbirth Satisfaction Rating Scale (CSRS; modified).

MAIN OUTCOME MEASURES

Participation rate to determine feasibility; Cronbach's alpha as measure of internal consistency; PPS satisfaction scores for groups of accoucheurs of different seniority to assess construct validity; correlation coefficient of PPS scores with total scores from the CSRS questionnaire to establish criterion validity.

RESULTS

Participation rate approached 85%. We observed high scores for most births except a few outliers. Internal consistency of the PPS was high (Cronbach's alpha=0.83). Total PPS scores correlated strongly with total CSRS scores (Spearman's r=0.64, P<0.001).

CONCLUSIONS

The PPS is a simple and valid tool for patient-centred assessments. High scores were observed for most births but there were a small minority of accoucheurs who consistently scored poorly and these data could be used during appraisal and training.

Women as consumers of maternity care: measuring "satisfaction" or "dissatisfaction"?

The measurement of "satisfaction" has been intrinsic to the models of evaluation of health care. However, a thoughtful approach to its use has not always been evident in which this concept is understood to represent a complex group of theoretical constructs involving attitudes, expectations, and perceptions that may be both positive and critical. These constructs require investigation and evaluation using recognized and developed methodologies. At the same time the importance of listening to patients and to women and their partners in evaluating and carrying out research on maternity care cannot be underestimated if the instruments used are to have construct and face validity. Qualitative data of this kind have a dual function of contributing to a more complex picture of women's experience and of suggesting that researchers need to explore the issues related to "dissatisfaction" at least as much as those arising from a positive overall view of care.

Are there inequalities in choice of birthing position? Sociodemographic and labour factors associated with the supine position during the second stage of labour

OBJECTIVE

to establish which factors are associated with birthing positions throughout the second stage of labour and at the time of birth.

DESIGN

retrospective cohort study.

SETTING

primary care midwifery practices in the Netherlands.

PARTICIPANTS

665 low-risk women who received midwife-led care.

MEASUREMENTS AND FINDINGS

a postal questionnaire was sent to women 3-4 years after birth. The number of women who remained in the supine position throughout the second stage varied between midwifery practices, ranging from 31.3% to 95.9% (p<0.001). The majority of women pushed and gave birth in the supine position. For positions used throughout the second stage of labour, a stepwise forward logistic regression analysis was used to examine effects controlled for other factors. Women aged 36 years and highly educated women were less likely to use the supine pushing position alone [odds ratio (OR) 0.54, 95% confidence intervals (CI) 0.31-0.94; OR 0.40, 95% CI 0.21-0.73, respectively]. Women who pushed for longer than 60 minutes and who were referred during the second stage of labour were also less likely to use the supine position alone (OR 0.32, 95% CI 0.16-0.64; OR 0.44, 95% CI 0.23-0.86, respectively). Bivariate analyses were conducted for effects on position at the time of birth. Age 36 years, higher education and homebirth were associated with giving birth in a non-supine position.

KEY CONCLUSIONS

the finding that highly educated and older women were more likely to use non-supine birthing positions suggests inequalities in position choice. Although the Dutch maternity care system empowers women to choose their own place of birth, many may not be encouraged to make choices in birthing positions.

IMPLICATIONS FOR PRACTICE

education of women, midwives, obstetricians and perhaps the public in general is necessary to make alternatives to the supine position a logical option for all women. Future studies need to establish midwife, clinical and other factors that have an effect on women's choice of birthing positions, and identify strategies that empower women to make their own choices.

Assessment of social psychological determinants of satisfaction with childbirth in a cross-national perspective

Background

The fulfilment of expectations, labour pain, personal control and self-efficacy determine the postpartum evaluation of birth. However, researchers have seldom considered the multiple determinants in one analysis. To explore to what extent the results can be generalised between countries, we analyse data of Belgian and Dutch women. Although Belgium and the Netherlands share the same language, geography and political system and have a common history, their health care systems diverge. The Belgian maternity care system corresponds to the ideal type of the medical model, whereas the Dutch system approaches the midwifery model. In this paper we examine multiple determinants, the fulfilment of expectations, labour pain, personal control and self-efficacy, for their association with satisfaction with childbirth in a cross-national perspective.

Methods

Two questionnaires were filled out by 605 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth either at home or in a hospital. Of these, 560 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. Labour pain was rated retrospectively using Visual Analogue Scales. Personal control was assessed with the Wijma Delivery Expectancy/Experience Questionnaire and Pearlin and Schooler's mastery scale. A hierarchical linear analysis was performed.

Results

Satisfaction with childbirth benefited most consistently from the fulfilment of expectations. In addition, the experience of personal control buffered the lowering impact of labour pain. Women with high self-efficacy showed more satisfaction with self-, midwife- and physician-related aspects of the birth experience.

Conclusion

Our findings focus the attention toward personal control, self-efficacy and expectations about childbirth. This study confirms the multidimensionality of childbirth satisfaction and demonstrates that different factors predict the various dimensions of satisfaction. The model applies to both Belgian and Dutch women. Cross-national comparative research should further assess the dependence of the determinants of childbirth satisfaction on the organisation of maternity care.