Women and Birth
Volume 20, Issue 3 , Pages 115-120, September 2007

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

  • Jenny Gamble

      Affiliations

    • Research Centre for Practice Innovation, Griffith University, Logan Campus Meadowbrook, Queensland 4131, Australia
    • Corresponding Author InformationCorresponding author. Tel.: +61 7 3382 1083; fax: +61 7 3382 1277.
    • ,
  • Debra K. Creedy

      Affiliations

    • Research Centre for Practice Innovation, Griffith University, Logan Campus Meadowbrook, Queensland 4131, Australia
    • ,
  • Bruce Teakle

      Affiliations

    • Maternity Coalition, Queensland Branch, Australia

Received 16 October 2006; received in revised form 12 May 2007; accepted 15 May 2007.

Article Outline

Summary 

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.

Keywords: Childbirth, Consumer satisfaction, Public opinion, Maternity services

 

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Background 

Few birthing options are available to Queensland women. Up until 2006 there were only two small birth centres which provided care to 457 women a year; representing 0.9% of the 50,777 births per annum.1 Demand for birth centre care exceeds supply by as much as 3:1 despite no advertising and numerous access barriers. Standard maternity care is medicalised with a 32% caesarean section rate2 and fragmented service delivery.3 The provision and organisation of maternity services has largely been determined by managers and providers rather than focussing on the needs of women and families.3, 4 Researching women's preferences about the provision of maternity services is overdue.

A search of the literature identified one related study on Queensland women's preferences and expectations of maternity services. Gamble and Creedy5 examined Queensland women's preference for caesarean section. They found that few women preferred a caesarean and over 50% of women preferred a vaginal birth with no pharmacological pain relief or nitrous oxide gas only for pain relief. The broader literature tends to focus on satisfaction with childbirth services. It indicates that personal control and having expectations met are the most significant predictors of all aspects of satisfaction for women.6, 7, 8, 9, 10, 11, 12, 13 Enhancing control involves providing women with unbiased information,14 supporting women's right to choose,15 enhancing feelings of confidence and calmness through being present, and providing reassurance, encouragement, and guidance if needed.10 Control and having expectations met have been positively related to women's emotional and physical health following birth.16

In the present study, three maternity consumer groups Maternity Coalition (MC), Association for Improvement in Maternity Services (AIMS), and the Home Midwifery Association (HMA) collaborated to explore women's expectations of maternity services. To date, there has been no survey of Queensland women's general preferences for maternity care.

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Method 

A short, self-report survey distributed to a convenience sample of Queensland women.

Sample 

Women attending the Mother and Baby Expo at the Brisbane Convention Centre 2003 were able to complete the survey. Women were members of the general community. Members of organisations such as the Maternity Coalition, Association for Improvement in Maternity Services, or Home Midwifery Association networks were not surveyed.

Measure 

A 13-item questionnaire was developed by members of Maternity Coalition and AIMS, based on the literature on women's preferences and satisfaction with maternity care, evidence based models of care, national and international innovations in the provision of maternity services, and recurring issues raised by women.

The questionnaire sought information about parity, place of birth, extent of continuity of carer, and quality and accessibility of postbirth care. Perception of choice in regards to birth care was assessed by three items. Women were asked about existing perception of choice in birth care generally, and preference for type of practitioner, where they give birth, and receive antenatal and postpartum care. To account for current barriers in accessing homebirth and birth centres, women were asked, “if care was free to you and you were confident of equal safety, what would be your preferred place of birth?” Options provided were “hospital”, “birth centre”, “home”, “other”. Finally women identified the level of importance of various aspects of the childbearing experience amongst a list of 13 items related to safety, bonding, successful breastfeeding, and their relationship with their care provider.

Procedure 

The survey was reviewed by three maternity researchers and a stakeholder group prior to distribution. Minor changes were made to wording. Women visiting the MC/AIMS stall at the Mother and Baby Expo were able to participate. Surveys were placed on the stall tables with a sign inviting participation. Women showing interest in the stall were invited to participate. Around 10 women declined to participate. There was no attempt to approach women in the crowd to complete the survey. Women who had birthed more than once could fill out Questions 1–6 for each birth if they wished. Otherwise they could provide responses that reflected their overall feelings. Completed surveys were placed in a locked box at the stall.

Ethics 

The survey questionnaire design and data collection was conducted by members of the consumer groups (Maternity Coalition and Association for Improvements in Maternity Services). None of the researchers had access to or awareness of the identity of any participant. As anonymous surveys were used, ethical review was not required. This is consistent with the National Health and Medical Research Council (1999) National Statement on Ethical Conduct in Research Involving Humans part 1.11.17 Potential participants were advised that the survey would be used to inform positions of the organisations and for research.

Data analysis 

Data were analysed using SPSS Version 13 for Windows. Nominal or ordinal data was analysed using Chi-square tests. Possible differences between women who had previously given birth and those who had not borne a child were examined using Chi Square. An alpha level of 0.05 was used for all statistical tests.

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Results 

Sixty-three women completed the survey. Twenty-four women (38.1%) had not borne any children, 23 (36.5%) had given birth to one child and 16 (25.4%) had given birth to more than one child. Parity for the sample is shown in Table 1. Most parous women reported that they had given birth in hospital (79.5%, n=31) while the remaining women in this group (20.5%, n=8) had attended a Birth Centre. No women reported giving birth at home. There were no statistically significant differences in responses on any variable between women who had given birth before and those who had not.

Table 1. Parity
No. of childrenn%
02438.1
12336.5
2812.7
357.9
423.2
511.6

Choice in birth care for previous birth 

For women experiencing previous births (n=39), half felt they had choice in birth care (51.2%, n=20). The remaining participants felt they had little (38.5%, n=15) or no (10.3%, n=4) choice in birth care. The differences between women's perception in the choice in birth care were statistically significant (χ2(2)=12.05, p=0.002).

Continuity of carer for pregnancy, birth and postnatal care 

A little over half the multiparous participants reported that their pregnancy, birth and postnatal care were received from the same person (53.8%, n=21). Some participants received pregnancy, birth and postnatal care from a few different people (28.2%, n=11) and a lot of people (18%, n=7). These differences were statistically significant (χ2(2)=8.00, p=0.018).

Quality of relationship with person providing most care during birth 

Most multiparous participants reported a “comfortable” relationship with the person who cared most for them during birth (53.9%, n=21). One quarter of women (25.6%, n=10) reported a very close relationship with the person who cared most for them during birth. Conversely, 20.5% (n=8) of participants felt that the person who cared most for them during birth was “like a stranger”. These differences were statistically significant (χ2(2)=7.538, p=0.023).

Access to care after birth 

Access to postbirth care was described by over half the multiparous women as “mediocre” (59%, n=23) while 28.2% (n=11) of participants felt that access was frequent and easy. Only 10.2% (n=4) of participants indicated that care after childbirth was “hard to access and unhelpful” or “non-existent” (2.6%, n=1). These differences were statistically significant (χ2(3)=27.474, p<0.001).

Choice in birth care 

Over half the multiparous participants felt that they have “little choice in birth care” (59%, n=23) or no choice in birth care (5.1%, n=2). Remaining participants reported “plenty” of choice (35.9%, n=14). These differences were statistically significant (χ2(2)=16.00, p<0.001).

Final decision for birthing 

In relation to final decision-making roles for birth, 93.7% (59 out of 63) of all participants reported that the mother should make the final decision in birth. Around 68.3% (n=43) of participants reported that the doctor should make the final decision in birth (χ2(1)=8.397, p=0.004). There was some disagreement in regards to the role of the father, midwife, and hospital in the final decision. Two-thirds (66.7%, n=42) indicated that the father should not be making the final decision (χ2(1)=7.00, p=0.008). Most participants (79.4%, n=50) felt that the midwife should not be making the final decision in birth (χ2(1)=21.73, p<0.001) and 98.4% (n=62) of participants indicated that the hospital should not be making the final decision in birth (χ2(1)=59.06, p<0.001).

Preferred birth care assistance 

Over half of participants preferred their birth care to be from a chosen midwife with access to medical backup (57.9%, n=37) while 25.8% (n=16) of participants preferred birth care from a known obstetrician with ward midwife support. Only 11.3% (n=7) of participants preferred birth care from ward midwives with medical support and 3.2% (n=2) of participants preferred birth care from their GP. The differences in women's preferences were statistically significant (χ2(3)=46.26, p<0.001).

Preferred place of birth 

Participants’ preference for place of birth differed significantly (χ2(2)=18.381, p<0.001). The majority of participants preferred to give birth either at a hospital (44.4%, n=28) or at a birth centre (47.6%, n=30). Only 7.9% of women preferred to give birth at home (n=5).

Preferred place of birth given confidence of equal safety and free care 

Given confidence of equal safety and free care, half the participants would prefer to give birth at a birth centre (50%, n=31). Hospital was preferred by 25.8% (n=16) of participants, and 24.2% (n=15) of women preferred to give birth at home. These differences were statistically significant (χ2(2)=7.78, p=0.02).

Important aspects of the maternity experience 

Women reported on the degree of importance placed on various aspects of pregnancy, labour, birth and postnatal care, and the childbearing experience. A Chi-square goodness of fit test found a statistically significant difference in participants’ perception for each item. This data is displayed in Table 2.

Table 2. Importance of aspects of the maternity experience
No importanceA little importanceSome importance no. (%)ImportantVery importantChi-square goodness of fit
Birth safety––1 (1.6)1 (1.6)61 (96.8)144.4(3)***
Avoiding pain in birth6 (9.7)3 (4.8)13 (21)18 (29)22 (35.5)13.7(5)*
Bonding with baby––––63 (100)55.2(1)***
Privacy in birth2 (3.2)–3 (4.8)6 (9.5)52 (82.6)61.0(4) ***
Feeling in control during birth–1 (1.6)1 (1.6)2 (3.2)59 (93.6)118.8(4)***
Relationship with caregiver–––7 (11.1)56 (88.9)20.7(2)***
Testing and monitoring in birth1 (1.6)4 (6.3)15 (23.8)11 (17.5)32 (50.8)25.1(5)***
Place of birth––3 (4.8)12 (19)48 (76.2)30.1(3)***
Education about birth 1 (1.6)1 (1.6)4 (6.4)57 (90.4)105.5(4)***
Prenatal care––2 (1.6)5 (8.1)56 (90.3)59.4(3)***
Postnatal care–––3 (4.8)59 (95.2)52.3(2)***
Support with housekeeping4 (6.3)3 (4.8)7 (11.1)18 (28.6)31 (49.2)21.1(5)**
Successful breastfeeding–1 (1.6)1 (1.6)1 (1.6)60 (85.2)164.1(4)***

*p<0.05.

**p<0.01.

***p<0.001.

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Discussion 

This small survey confirmed that women are concerned about safety for their baby and seek control and participation in decision making during birth. This finding is consistent with other studies.3, 6 Other studies have also demonstrated that most women value maternity care including educational preparation for birth, and want to breastfeed successfully.18, 19 Similarly, many women reported a lack of choice in birth care and poor quality postpartum care.3

Avoiding pain in labour was rated as least important by respondents. While labour pain is associated with maternal satisfaction it may be the ability to manage pain rather than pain avoidance that is important.20 The literature indicates that effective analgesia during labour is not specifically related to satisfaction with several studies showing high satisfaction amongst women choosing natural childbirth, e.g.21, 22 Mothers reporting painful labours may also report satisfaction with labour and birth if able to manage the pain. Several studies have reported that pain does not predict total satisfaction with childbirth or components of satisfaction.6, 23, 24

The present study contributes to our understanding of women's preferred place of birth with three quarters of participants reporting that the place of birth was very important or quite important (76.2%). No respondents considered place of birth as unimportant. While most respondents (nearly 80%) had given birth in hospital and none had given birth at home, only 40% preferred hospital as the place of birth. Birth centres were the most popular option, and 7.9% preferred to give birth at home. However, when women were asked their preferred birth place when assured of equal safety between the birth setting options and cost free care, the percentage of women preferring to give birth in hospital dropped to 25.8%. The percentage of women preferring to give birth in a birth centre rose slightly to 50% and there was a three fold increase (24.2%) in the number of women preferring to birth at home. This data is in contrast the number of women who are able to access a homebirth in Queensland (<0.5%) or birth centre care (<1%).2 In the Netherlands, which has a strong tradition of homebirth, up to 70% of women prefer to give birth at home.25

Homebirth is as safe as hospital birth for low-risk women,26, 27, 28 however this does not seem to be the perception of women. It may be that the complex professional discourses about homebirth obfuscate the safety of homebirth, making choices on this issue more difficult.

Women's relationship with the care provider was considered important by all participants and rated as very or quite important for the majority of women. While around half reported a comfortable relationship with the person who cared most for them during birth only a quarter had a very close relationship with their birth care provider. A further one-fifth of participants perceived the person who cared most for them during birth as a “stranger”. Given the choice, nearly 60% of participants preferred their birth care from a chosen midwife with access to medical backup. Around 10% of participants preferred birth care from ward midwives with medical support. However, this option, ward midwives providing care with medical support, is the most common model for the provision of maternity services in the public sector. While there is widespread acknowledgement that midwives need to be fully utilised in the provision of maternity services, the process of reorienting care to provide women with access to a known midwife is slow. In Queensland, prior to the State-wide review of maternity services in 2004–2005, 19 reviews of maternity services had been conducted.3 All reviews highlighted that models of maternity care should be reoriented to better utilise midwives. In the current study, very few women preferred birth care from a general practitioner (GP). The relatively low level of support for this option may reflect the limited opportunity to experience GPs involvement in intrapartum care particularly in urban areas.3

While mothers’ reported high levels of continuity of carer with around 20% of participants’ indicating that their pregnancy, birth and postnatal care were received from the same person, this cannot be fully accounted for by the percentage of women in the sample who accessed birth centre care. Few Queensland women have access to continuity of care in the public sector and this data may reflect that a high percentage of participants accessed private obstetric services. However, even in the private obstetric model, midwives provide much of the labour and postnatal care in conjunction with a private obstetrician. It may be that women considered that they received care from the same person because they perceived that this person was directing care. It may also highlight the invisibility of midwives.29, 30 The incongruence between the results for this question and the context of maternity care in Queensland makes interpretation difficult.

Almost 50% of women reported that support with housekeeping was very important or quite important. The meaning of “housekeeping” may be variable. Participants may have had different interpretations of which tasks/chores were included and been unsure about whether chores such as shopping, cooking, and washing were included or excluded. Support is a key issue in the provision of maternity services. Practical support such as housekeeping and childcare assistance, educational support, emotional support, social support have variously been associated with levels of satisfaction and women's physical and emotional health.31, 32, 33 However, understanding which women benefit most from which type of support and when that support is required is still unclear.

Limitations 

There are limitations associated with a small survey with a self-select sample. Participation may have been more attractive to women representing particular sections of the childbearing population. The collection of additional socio-demographic data from participants would have assisted in determining sample representativeness. From the available data it seems that women accessing birth centres were overrepresented in the sample as less than 1% of Queensland women are able to access birth centre care.1 These women may have more favourable attitudes towards homebirth and more inclined to choose homebirth than women preferring hospital care, especially if assured of equal safety and cost. Of the women who had given birth previously, knowing the percentage that had used a private obstetrician would enable their responses to be contextualised and interpreted. Thirty-eight percent of the sample consisted of women who had never given birth before suggesting that this sample was not drawn predominantly from women already engaged in the consumer movement for maternity services reform as mothers make up the majority of members.

Assessing women's reasons for their preferences would have enriched the data and value of this study. Specifically, information on women's reasons for their preferred birth setting, and their preferred carer would be helpful. Understanding what women interpreted as receiving care “mostly from the same person” would be interesting and additional or different questions were needed for this item.

Implications for practice and research 

Women need access to options in childbearing including choice of setting and primary care provider. More needs be done to align the provision of maternity services with women's preferred care options. Women need education about their birth options. It seems that some women may be misinformed about the safety of homebirth and that making decisions based on incorrect perception may limit access to their preferred options. This is an ongoing issue for the provision of childbirth education.

It seems that consumers need collaboration with researchers at all levels to pursue issues that are important to them and affect the experiences of birthing women. Researchers should actively seek out consumer groups to determine important questions about maternity care. There are inherent limitations with satisfaction studies. For instance, women tend to positively evaluate what they know over innovations and their views change over time with more negative aspects surfacing later.34, 35 Similarly, conceptualising and measuring satisfaction and quality poses difficulties.34, 36 There is a tendency to over-rely on satisfaction surveys completed around the time of discharge from hospital3 and perhaps longitudinal methods should be employed or the involvement of consumers on advisory boards.

Researchers can be informed by the knowledge and insights of consumers. In the present study, some topics were addressed in ways which yielded useful information. For example, the question regarding preferred birth setting was asked in two different ways, with the follow-up question addressing the perceived barriers to various birth settings. The exploration of this issue in the survey may be a useful approach in assessing women's preference on other topics where varying levels of understanding/knowledge may distort responses. The approach taken in the present survey may be particularly useful in assessing women's preference for caesarean section as it seems that many women are misinformed about the relative risks and benefits of surgical birth.

There is a consistent correlation between women having their expectations for labour and birth met, satisfaction with childbearing, and women's postpartum emotional health.6, 37 To facilitate women's achievement of their expectations it is important to know what they prefer, not just if they are satisfied with the care received, and the importance they place on various aspects of care. This may vary between populations. Further research is needed into the multiple factors contributing to the development of women's expectations.

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Conclusions 

Few studies have investigated the extent to which maternity services are focussed on women's needs. The results of this small exploratory study with a self-select, non-representative sample should be interpreted with caution however, it has identified that women are concerned about safety for their baby and seek control and participation in decision making during birth, but may be misinformed about the risks and benefits of various options. When assured of safety, preferences for the place of birth and carer change.

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Acknowledgements 

Thank you to the Home Midwifery Association, Maternity Coalition, and Association for Improvement of Maternity Services for distributing the survey. Thank you also to Dr. Sarah Buckley for help developing the questionnaire. There has been no financial assistance associated with this project.

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PII: S1871-5192(07)00050-9

doi:10.1016/j.wombi.2007.05.003

Women and Birth
Volume 20, Issue 3 , Pages 115-120, September 2007

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