Womens evaluations of intrapartum and postpartum care

Abstract: The overall aim of this thesis was to increase understanding of women s evaluations of intrapartum and postpartum care. Evaluations of specific aspects of care, general assessments of intrapartum and postpartum care, and predictors of not being satisfied were investigated, as well as negative experiences of postpartum care, as expressed in women s own words. The four papers included in this thesis are based on selected quantitative data (Papers I-III) and qualitative data (Paper IV) from a national prospective longitudinal study (the KUB study: Women s Experiences of Childbirth). During a period of three weeks, evenly spread over one year (in May and September 1999 and January 2000), women were recruited at their first booking visit at an antenatal clinic. In total, 593 (97%) antenatal clinics participated in the recruitment. According to the Swedish Medical Birth Register, 4600 women were eligible for study. Approximately 3000 Swedish-speaking women were surveyed at three time points: early pregnancy, two months and one year postpartum. The number of respondents to the first questionnaire was 3061, to the second 2762 and to the third 2563. To assess representativity, the background characteristics of the study sample were compared with the total Swedish birth cohort of women in 1999. When asked to give an overall assessment of their experiences at two months after the birth, 10% of new mothers were not satisfied with intrapartum care and 26% were not satisfied with postpartum care. A more detailed analysis, including specific questions related to different aspects of care (interpersonal care, information and decision-making, information and support, the physical environment, medical check-ups and breastfeeding support) revealed a larger percentage of dissatisfied mothers. By this method, 33% were not satisfied with intrapartum care when assessments on the different dimensions were taken into account simultaneously, and 47% were dissatisfied with postpartum care. These findings illustrate the complexity of care evaluations, and that single-item questions may underestimate negative experiences. When taking all aspects of intrapartum and postpartum care into account, those related to emotional dimensions of care seemed to influence women s assessments the most. Interactions with the caregiver and the interpersonal manner of the caregiver were particularly important. Further important factors were: having sufficient time for personal support, as well as information and involvement in care decisions. Findings indicate that women should be given the opportunity to talk through their birth experience postpartum and air their own questions and concerns. On the postpartum ward, lack of attention to the mother herself was identified as a problem. Dissatisfaction with time available for support and care, was not necessarily too short, but rather inappropriate or not tailored to individual needs. Similarly, the duration of the hospital stay was not seen as sensitive to individual needs. A lack of balanced breastfeeding information and support, with the absence of a tolerant and respectful attitude to mothers who experience difficulties, was reported. The physical environment, both during and after the birth, was associated with women s negative experiences of care. Smaller units and family-oriented wards, where the baby s father could stay overnight, were associated with a positive experience of postpartum care. Some maternal characteristics and health problems during pregnancy related to how care was experienced. Pregnant women who experienced many physical problems had an increased risk of a more negative assessment of both episodes of care, and the risk increased with the number or severity of symptoms. Women with higher depressive symptoms and lower sense of coherence were primarily dissatisfied with interpersonal care as well as information and decision-making during labour. The opposite was found in women who were very satisfied with postpartum care. The outcome of labour and birth, such as infant health, affected women s ratings of intrapartum care. A woman s feelings during labour also seemed to influence the way she rated intrapartum care retrospectively. Altogether 150 women gave written negative comments about postpartum care in response to an openended questionnaire. Problems described by women were: lack of opportunity to rest and recover, nonindividualised information and breastfeeding support, and inappropriate symptom management.