Abstract
‘By investigating women's experiences of specific aspects of care … we were able to identify problem areas, and estimate how big the problem was…’
Interest in patients' satisfaction with care has increased dramatically over the last two decades.
Studies on patient satisfaction.
The purpose of satisfaction measures is to understand patients' experiences of healthcare, and to obtain information about the quality of care in order to identify problem areas [1].
The concept ‘satisfaction’ has been recognized as multidimensional and complex in nature, since patients may be satisfied with one aspect of care but not with another, and experiences may fluctuate across different caregivers. For this reason, single studies where patients are asked to summarize their experience of an entire episode of care have been criticized.
In a nationwide Swedish sample of nearly 3000 new mothers, we asked about specific aspects of care, and also about women's overall experiences. The specific questions about intrapartum care covered three main areas (relationship with caregiver, information/decision making and physical environment) and the specific questions about postpartum care covered four areas (relationship with caregiver, information/decision making, medical check-ups and breastfeeding support). We found nine distinct patterns representing women's different experiences with respect to the three dimensions of intrapartum care [2] and eight patterns in relation to postpartum care [3]. For example, 32% of the women were very satisfied with all four dimensions of postpartum care and 6% were very dissatisfied with all aspects. The other 62% were found in the remaining six groups characterized by a variation of satisfaction and dissatisfaction with the respective care dimensions. By investigating women's experiences of specific aspects of care in this way we were able to identify problem areas, and estimate how big the problem was by counting the number of women in each cluster. One important finding was that very few women were dissatisfied with all aspects of intrapartum and postpartum care, suggesting that ideas about some patients having a general complaining attitude were not supported.
Besides the multidimensionality of the patient satisfaction concept, the high levels of satisfaction have been frequently discussed. In general, negative statements regarding care have been difficult to obtain, even when less favorable experiences are apparent. It has been suggested that patients need to be exposed to very poor quality-of-care before they express dissatisfaction. This has been explained by patients' gratitude, loyalty and confidence in the healthcare system or by culpability, where patients do not express criticism if the caregivers seem to have been doing their best. High satisfaction ratings are not only reported in studies of older patients, but also in younger populations who may be more outspoken. In our own study of recent mothers, 90% reported a ‘very positive’ or ‘positive’ experience of intrapartum care and 74% of postpartum care, when asked to make a global assessment.
‘…it is easier to disclose dissatisfaction with care when asking specific rather than global questions.’
When we investigated satisfaction by means of the specific dimensions of care, however, fewer women were satisfied: 67% with intrapartum care and only 53% with postpartum care. These findings demonstrate that it is easier to disclose dissatisfaction with care when asking specific rather than global questions.
Single global items may be associated with high satisfaction ratings also for another reason. When a person is asked to assess an entire caring episode the response may be affected, not only by the perception of care, but also by the physical and psychological outcome. The assessment of intrapartum care, for example, could be influenced by the experience of labor and the birth of the baby. Childbirth is a dramatic event usually characterized by hard work, pain and finally relief and happiness when meeting with the baby. Since childbirth has a happy end in most cases, these feelings may explain the high satisfaction scores. The fact that many studies do not treat satisfaction with intrapartum care as an outcome separate from satisfaction with childbirth illustrates this dilemma.
We are not arguing that global questions should be left out from studies of patient satisfaction, but rather that one needs to reflect on what they measure. Global questions probably give a picture of a person's general feelings about the caring episode, including the perception of care and its health outcomes. Such questions may therefore help in understanding patients' experiences, which is the first part of the definition of patient satisfaction earlier referred to [1]. The second part of the definition, to obtain information about the quality-of-care in order to identify problem areas, is probably better addressed by specific questions.
Global questions can also be helpful when outcomes are compared, for instance in randomized, controlled trials, or when comparing different episodes of care with varying content. The comparison between women's global assessment of intrapartum and postpartum care in our study was helpful by showing that postpartum care seemed to constitute the real problem.
However, even if this interpretation of our findings is probably correct, owing to the big difference in women's responses to intrapartum and postpartum care, and also because similar findings have been reported by researchers from other countries [4], the varying content of intrapartum and postpartum care needs to be taken into account. Intrapartum care is characterized by being intense, dramatic and, in most countries, highly technological, and its primary aim to manage labor and birth in a way that optimizes infant and maternal health, is straightforward and unambiguous. Postnatal care, on the other hand, is less technological, rarely acute, and has a stronger focus on information and support. The primary aim is less evident. Whereas support of breastfeeding and baby care are well established aims, maternal rest is not, and clinical practices regarding length of stay, domiciliary support and the involvement of the father may differ between clinics. As a consequence of these differences, the high rates of satisfaction with intrapartum care may to some extent be explained by met expectations, and the lower rates of satisfaction with postpartum care by unmet or unclear expectations.
Studies of intrapartum care have focused on areas such as continuity of care, support, information, involvement and participation in decision making and the physical environment. Alternative models of care such as birth centers, have addressed these issues by providing comprehensive care from early pregnancy to days after birth, and family-centered care in homelike and small-scale settings. Another alternative option is team midwifery within standard care, where women are offered continuity of care by one or more midwives. Evaluations of such alternatives have consistently found higher rates of satisfaction compared with standard care. However, it is often difficult to distinguish which aspect of care within the respective model that affected women's evaluations. Was it continuity of care or carer, the attitude of the caregiver, the philosophy encouraging a natural childbirth or, in birth centers, the homelike and small-scale environment?
‘Evaluations of such alternatives [with continuity of midwife care] have consistently found higher rates of satisfaction compared with standard care.’
In a review of continuity of care by midwives, Green and colleagues concluded that what matters to women is that the caregiver is kind and trustworthy [5]. Alternative models of care may shape prerequisites for such care by the selection of midwives who chose to practice within these models, by the explicit philosophy of woman centered care, and by less fragmentation of care that allows the establishment of closer relationships between midwives and the pregnant women. However, women will also find kind and sensitive caregivers in standard care.
‘When discussing improvements of patient care it is much easier to think about structural changes than changes within the established systems.’
A review of continuous support during labor in standard hospital care settings showed that the presence of a supportive person made a big difference, not only by reducing dissatisfaction with childbirth, but also by reducing the use of analgesia and operative deliveries [6]. In another review, Hodnett [7] concluded that the amount of support from caregivers, the quality of the caregiver–patient relationship and involvement in decision making were the most important aspects of intrapartum care related to satisfaction, whereas continuity of care, medical interventions and the physical birth environment were less important.
In most western societies the length of hospital stay after birth has been shortened. This reduction has largely been accepted by new mothers, but complaints about inflexible lengths of stay are common. Inadequate and inconsistent information is another issue that many women raise when asked about their experiences of care after birth [8]. Postnatal wards are often very busy and many women have difficulties getting enough rest and sleep, and this may also affect their intake of information.
In our Swedish study, 15% of the women were not satisfied with the relationship with the caregivers during their postnatal stay, approximately 24% with information and support, and 27% with breastfeeding support, and 24% with the medical check-ups of the baby and themselves.
When discussing improvements of patient care it is much easier to think about structural changes than changes within the established systems. New birth centers are one such example; establishing new birth centers would definitely improve satisfaction with antenatal, intrapartum and postpartum care. However, not all women are interested in this birth option and many do not qualify as low risk. For these women, team midwife care in collaboration with medical staff within ordinary settings could be an option that provides better continuity and higher satisfaction than standard care. Another option during labor is a doula, a person other than the woman's partner, who gives continuous support during labor. This option is becoming increasingly popular in the USA. In Sweden, the introduction of doulas on a larger scale has not been successful. However, the midwives practising in the delivery wards are now discussing how to be able to spend more time with women in labor and how to provide the best form of support.
How to improve satisfaction with postpartum care is a greater challenge. We believe that the first step is to define the aims of postpartum care, and to make this aim well known to staff as well as the new families. From our own research, we also know that postpartum units that offer the opportunity for the baby's father to stay over-night during the entire duration of the hospital stay are the most appreciated. Since the attitude of the caregiver is so important, postpartum care should be organized so that each woman recieves individual attention. Checklists can sometimes be a hinder, something for the staff to lean on but something that can make women feel like a number. A more flexible duration of the hospital stay, and options to receive home visits, would also increase satisfaction with postpartum care.
Finally, the most difficult challenge of all is that women of low socioeconomic status are least satisfied with care. One of the reasons why young women and women of low education feel less comfortable in today's clinical settings may be that most of the staff are better educated and communicate differently. This is even more of a problem for women who do not speak the local language. Good access to interpreters is necessary. There are no simple solutions, but one must not underestimate the attitude of the caregiver. It is important to take the time to see the individual behind the patient, to be attentive, kind and silent long enough to allow the person to ask her own questions.
Large studies across care settings are important in order to get an overview of which aspects of care cause women and their partners most concerns. However, regular assessments in each setting may provide more valuable information for improvements of care and increased patient satisfaction.
Footnotes
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.