An evaluation of Midwifery Group Practice:

Article Outline

• Summary
• Introduction
• Participants and methods
  • Aims
  • Maternal Satisfaction Questionnaire
  • Sample
  • Data collection
  • Data analysis
  • Ethical considerations
• Results
  • Continuity of care
  • Accessibility of services
  • Personal and professional attributes of the midwife
  • Closing comments
  • Responses to the structured questionnaire
• Discussion
• Conclusion
• Acknowledgements
• References
• Copyright

Summary 

Background

Midwifery Group Practice (MGP) is a continuity of midwifery care model for women of all levels of pregnancy risk available at a tertiary metropolitan hospital in Australia. This paper presents Part II of the demonstration study exploring the effectiveness of MGP, and reports on women’s satisfaction with the model of care.

Methods

A Maternal Satisfaction Questionnaire was developed and sent to all women (n=120) enrolled in MGP over a three-month period. The questionnaire comprised two open-ended questions asking women to list up to three things they liked and did not like about MGP, and a structured section exploring levels of satisfaction through a five-point Likert response format. The open-ended questions were analysed using qualitative content analysis, and analysis of the structured part of the questionnaire was undertaken by comparing mean scores of satisfaction ranging from −2 (very negative attitudes) to +2 (very positive attitudes).

Results

Of the 120 women who were sent a Maternal Satisfaction Questionnaire, 84 returned their questionnaire (70% response rate). Three overarching themes were identified in the content analysis of open-ended questions, namely: Continuity of care; Accessibility; and Personal and professional attributes of the midwife. Analysis of the structured part of the questionnaire showed that women were satisfied with the care they received in MGP, as indicated by positive scores on all questions.

Conclusions

Women being cared for in MGP are satisfied with their care.

Keywords: Midwifery, Continuity of care, Satisfaction, Maternal satisfaction, Demonstration study

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Introduction 

An important component of research into the effectiveness of health care is the exploration of consumer views of the services provided.¹ In relation to maternity care, women’s satisfaction is an indicator of the quality of the care they receive,², ³ and has been identified as one of the core set of outcome measures for evaluating models of maternity care.⁴

A number of studies of maternity care have shown that women are often dissatisfied with the care they receive, and in particular express dissatisfaction with fragmented care,⁵, ⁶ lack of control,², ³, ⁵ inconsistent advice⁶, ⁷ and long waiting times.⁶, ⁷ Continuity of midwifery care models have been implemented with the aim of addressing these issues and improving women’s satisfaction with their care.⁸, ⁹ Improved satisfaction with maternity care has the potential to have positive benefits for women both physically and psychologically.², ⁹

With the increasing popularity of midwifery continuity of care researchers have begun to explore women’s satisfaction with the care they receive within these models.¹⁰, ¹¹ Turnbull et. al.,¹² for example, compared midwife-managed care with shared care (where care is divided among midwives, obstetricians and general practitioners) on clinical outcomes measures and women’s satisfaction with care. They found greater satisfaction with care for women in the midwife-managed care programme. Increased women’s satisfaction was also found in a recent Australian randomised controlled trial exploring women’s satisfaction with team midwifery care,¹⁴ and in a Canadian study of satisfaction with maternity care given by doctors compared with midwives.³

This paper comprises Part II of the demonstration study exploring the effectiveness of Midwifery Group Practice (MGP), a model of continuity of midwifery care implemented at a tertiary metropolitan hospital in Australia, in January 2004. Women self-select for participation in MGP after being informed about their various choices of care at the hospital at their first antenatal visit. Other models of care offered at the hospital include: Medical (Traditional) Antenatal Care; Midwives’ Antenatal Clinic; Shared Antenatal Care with a General Practitioner; and Private Obstetrician.

In Part I of the demonstration study we reported on the clinical outcomes of MGP compared with ‘Other’ modes of care available at the hospital. In this, Part II of the study, we present the results of the analysis of women’s satisfaction with the MGP model of care.

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Participants and methods 

Aims 

To determine women’s satisfaction with the MGP model of care.

Maternal Satisfaction Questionnaire 

In order to assess women’s satisfaction, a ‘Maternal Satisfaction Questionnaire’ was developed. The questionnaire is simple in format and able to be completed in a short amount of time. Identifying data were not collected. Questions 1 and 2 were open-ended and asked women to list up to three things they liked and did not like about their care. Of the three things they did not like, they were asked to identify those they would most like to change. Questions 3–8 relate to levels of satisfaction with continuity of carer. These questions were used, with permission, from a questionnaire developed by Shields et. al.⁹ The questionnaire was tested for content validity, construct validity and internal consistency, with a Cronbach alpha score for each dimension that ranged from 0.7 to 0.9 indicating instrument reliability. The questions were structured as completed statements and included: I saw too many different people; I received too much conflicting advice; My care was very good; The MGP midwives gave similar information; My primary midwife was always there when I needed her; I had to report my story to lots of different people; I would recommend this service to family and friends; I would support WCH to continue and expand this service. Women were invited to respond by using the five-point Likert response format ranging from ‘strongly agree’ (point 1) to ‘strongly disagree’ (point 5). Questions 9 and 10 indicate the level of support women have for the service.

A pilot questionnaire was sent to 20 women for comment and feedback on the format of the questionnaire. Twelve were returned, of which only two made comments as to format and ten made comments reflecting their experience of care. Based on this feedback, the evaluation group made a decision that the questionnaire would be used as developed.

Sample 

Maternal Satisfaction Questionnaires were sent to all women enrolled in MGP in the months of July, August and September 2004. Of the 120 women who were enrolled during this period, 84 returned the questionnaire (70% response rate).

Data collection 

The questionnaire was mailed to women three months after the birth of their baby. This time period was chosen as research has shown that some women experience a ‘halo effect’ immediately after the birth of their baby, and tend not to criticise their care. Given time to reflect, women give a more critical account of their experience.¹⁵ A covering letter was included informing women that they may choose to complete the questionnaire or not, that a reminder letter would be sent in three weeks’ time to all women, and that return of the questionnaire would be taken as consent. A reply paid envelope was also included for return of the questionnaire.

Data analysis 

The open-ended questions (questions 1 and 2) were analysed using a process of qualitative content analysis, at a manifest level, which described the visible and obvious components of the responses.¹⁶ First, the responses were coded to categorise and quantify the data.¹⁷ Using the data management system NVivo¹⁸ each response was assigned a code that reflected the core meaning or theme. Responses with a similar core meaning were assigned the same code. For example, the individual responses continuity of care all the way through, familiar midwives and seeing the same person each time were all coded to the node ‘continuity of care/familiarity’. The responses under each code were than quantified by recording their frequency (Table 1, Table 2). The codes were then clustered into themes.

Table 1. Codes for responses to ‘Things I really liked’

Table 2. Codes for responses to ‘Things I really didn’t like’

Analysis of the structured part of the questionnaire (questions 3–10) was undertaken as per Shields et al.⁸ Following the reversal of the scoring of negatively worded items, response categories were recoded in order to produce a mean score for each question ranging from −2 (very negative attitudes) to 2 (very positive attitudes). Recoding occurred as follows: 1 scored as 2, 2 scored as 1, 3 scored as 0, 4 scored as −1, and 5 scored as −2.

Ethical considerations 

Ethics approval was gained from the hospital’s Human Research Ethics Committee for the distribution of the consumer satisfaction questionnaire. Confidentiality and anonymity were maintained throughout the evaluation process.

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Results 

Of the 120 women who were enrolled during this period, 84 returned the questionnaire (70% response rate). The content analysis of the responses to the open-ended questions resulted in: 84 (100%) women listing responses to ‘things I really liked’, yielding 227 individual comments; 48 (57%) women listing responses to ‘things I really didn’t like’, yielding 77 individual comments; 8 (15%) women listing responses to ‘what they most wanted to change’, yielding 14 individual comments (as there were so few responses to this question they have been incorporated into the analysis below rather than listed separately). As discussed earlier, the codes identified in the content analysis were clustered into themes. Three overarching themes were identified, namely: Continuity of care; Accessibility; and Personal and professional attributes of the midwife.

Continuity of care 

Women identified continuity of care as the primary aspect of MGP that they ‘liked’. Women defined continuity as seeing the same person for most of their care throughout antenatal visits, labour and postnatal care. This allowed for familiarity between them and their midwife, stories need not be repeated, and midwives were familiar with the women’s individual needs. Many women noted that the continuity of care with one midwife, or sometimes two, allowed them the opportunity to build a relationship with the midwives that was based on trust and provided them with a sense of comfort and safety. The following comment illustrates this:

… the whole pregnancy and birth journey was enriched and made easier knowing that support was always there (Respondent 9).

The respondents generally referred to ‘my midwife’, denoting the one to one relationship developed throughout the pregnancy. However, this also led to a level of expectation that the lead midwife would always be available, especially during labour. It was difficult for the women to accept the lead midwife’s rostered ‘days off’ and annual leave, which were viewed as particularly negative for women who felt unfamiliar with the other midwives. Lack of continuity of care with the lead midwife thus became the most frequent ‘dislike’ about the women’s experience (n=20).

A lack of continuity was also noted when the woman was admitted to the postnatal ward following delivery. In the MGP model women are admitted to the postnatal ward if they choose not to go home early, or they or their infant require hospitalisation. In addition to visits from the lead midwife, the midwives on the ward provide midwifery care and advice. This change in caregivers impacted on the satisfaction of some women, as indicated by the following comment:

My only concern with my care whilst in Postnatal Ward was too many midwives attending me with conflicting advice (Respondent 29).

One woman described the difference in care between MGP and the general postnatal ward as: the ‘philosophy is quite different’. Not all women spent time in the postnatal ward following the birth of their baby, instead being discharged home early to the care of their MGP midwife.

Within the MGP model, when a woman returns home she is visited in her home by her lead midwife up to six weeks postnatally, the frequency dependent on her needs. This was highly valued by women, who identified this as an aspect of their care that they really liked. The postnatal care provided in the home was also commented on frequently for the flexibility and accessibility of care it offered, as discussed below.

Accessibility of services 

There were two aspects of the accessibility of the MGP service that were identified by the women, namely the ‘on-call’ system and ‘flexibility of care’. The MGP model of care provides a 24-h ‘on-call’ system for midwifery consultation. This aspect of the model was described by many women as reassuring because help ‘was only a phone call away’ and women had ‘Easy access to midwives over the telephone’.

However a minority (n=6; 7%) of women experienced problems with the paging system, which was identified as an aspect of their care that they did not like. Some experienced difficulties when the response from the midwife was delayed or the call was not returned. One person indicated this problem was resolved. Others were disappointed that they did not speak to their lead midwife.

‘Flexibility of care’ was another aspect of the accessibility of services that women identified as a positive feature of their care. The flexibility of home visits was frequently highlighted as an aspect of the MGP service the women ‘really liked’. One woman commented that some antenatal visits were conducted at her workplace, which she found very convenient. Overall the response from women indicated that the provision of midwifery care within the model was prompt, with minimal waiting times for antenatal appointments, with some women being able to compare this with their previous experiences of long waiting times in antenatal clinics.

Personal and professional attributes of the midwife 

The personal attributes of the midwives were frequently reported as aspects of their care the women really liked. The ‘friendly’ attitude was a popular descriptor of not only the lead midwife, but of all the midwives involved in MGP. Midwives were described as non-judgemental in their approach, encouraging, supportive, and demonstrating ‘genuine care’.

Care provided to women was described as personalised, professional, individualised, family-centred and comprehensive. One woman described the MGP service as: ‘I felt like I had a friend in the hospital’ (Respondent 43). This comment seemed to capture the sentiments of many of the responses, with the midwives being viewed as someone who would respectfully listen to the women, as a friend would.

Midwives were described as ‘very knowledgeable’ and ‘resourceful’ and their experience was appreciated in relation to the advice they were able to impart. As one woman commented: ‘all of my questions were answered informatively giving me peace of mind’. A minority (n=6) of women commented on information they felt was lacking. These comments were in relation to information on how ‘the system worked’ when they commenced MGP care, while others felt that some of their symptoms were not acted upon until they worsened (e.g., mastitis).

Information provided by the midwife underpinned the women’s comments in relation to feeling confident about making their own decisions and being given ‘the freedom of choice’. For the majority of women, communication between the midwives and communication with medical staff was positively commented on. Midwives within MGP were congratulated for the consistency of care and information the women received from different midwives. Midwives were mentioned by name and the positive experiences of the pregnancy and birth were consistently attributed to the care provided by MGP midwives.

Closing comments 

Finally, women were invited to write ‘other comments’ at the conclusion of the questionnaire. Many gave a summary of their previous responses but others commented specifically on the ‘safety’ of conducting MGP within a tertiary care hospital:

Combining the benefits and safety of a modern facility with the most personal and caring service I believe is possible (Respondent 70).

Some women were able to make positive comparisons of the MGP model of care with the birthing models experienced for previous births:

I have had my children with an obstetrician, under the birthing centre and MGP, and MGP was the most satisfying level of care so far (Respondent 47).

Frequent comments were written expressing the need to continue and expand the service and the feeling of being fortunate to be able to access MGP.

Responses to the structured questionnaire 

In addition to the open-ended questions, participants also responded to eight questions presented in a structured format. Table 3 illustrates the mean response to each of these questions, where a positive score denotes a positive response.

Table 3. Mean responses to Maternal Satisfaction Questionnaire

Please note the range of possible mean scores is as follows: −2 (very negative attitudes), −1 (negative attitudes), 0 (neutral), 1 (positive attitudes) and 2 (very positive attitudes).

As can be seen in Table 3, women were satisfied with the care they received, as indicated by positive scores on all eight questions. The highest scores were on questions relating to the women’s satisfaction with MGP (Questions 5, 9 and 10), demonstrating high levels of satisfaction with the MGP service in general. Lower mean scores were synonymous with issues relating to some aspects of continuity of care/carer (Questions 3, 4, 6, 8), such as seeing too many people, needing to repeat their story to an unfamiliar midwife, and conflicting advice from midwives. The specific concerns about continuity of care seen in the women’s responses to the open-ended questions offer some explanation of these scores. In particular, concerns about conflicting advice may to some extent be explained by issues relating to lack of continuity of care in the postnatal ward. Most of the women responded positively to Question 7, relating to the lead midwife always being there when needed. This is supported by the open-ended data where the women commented positively on the accessibility of the MGP service.

Thus the overall response of women who completed the questionnaire was positive, with some expressing problems they encountered in one aspect of the service that required attention. However, the majority (96%, n=80) agreed (n=9, 11%) or strongly agreed (n=71, 85%) (score of +1 and +2) to Question 9, which asked if they would recommend the service to family and friends; and 98% (n=81) agreed (n=4, 5%) or strongly agreed (n=77, 93%) to the question of whether they would support the hospital to continue and expand the MGP service (Question 10).

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Discussion 

The study was conducted in only one setting and the findings cannot be generalised to other a models of continuity of midwifery care. However, the findings reflect those of other studies demonstrating high levels of satisfaction with midwifery led care.⁹, ¹⁴ Mean responses to all of the survey questions were positive. In addition, all the participating women responded to the open-ended question asking what they liked about their care (277 individual comments were made), while only 57% responded to the questions of things they really did not like about their care (77 individual comments).

Women indicated they were very satisfied with the care they received in MGP, with 96% indicating that they would recommend the service to others. They expressed their satisfaction with continuity of care within the model, and the level of care provided by the midwives. This is reflected in the women’s responses to the open-ended questions, with continuity of care being the most commonly expressed positive aspect of the MGP model. In particular, positive aspects of continuity of care were described as the ability to build a meaningful relationship with a midwife, who understands the woman’s needs and provides her with consistent information and advice in line with those needs.

The importance of continuity of care in the form of having the same midwife through the antenatal period, labour and postnatally was evident in that the absence of the lead midwife in labour was the most frequently reported aspect of MGP that the women disliked. McCourt et al.,¹⁹ too, found women who participated in continuity of care models often had ‘raised expectations’ regarding continuity of carer. The importance attributed to this aspect of continuity of care is supported by the findings of two Australian studies of women’s satisfaction with team midwifery care.⁸, ¹⁴ By contrast, a UK study of women’s satisfaction with continuity of care¹³ and a review of the literature conducted by Green et al.¹¹ did not find increased satisfaction for women who knew their midwife in labour compared to those who did not.

The importance of continuity of care to women was also evident in the postnatal period. Women were very satisfied with being visited at home by their MGP midwife. However, some women who were admitted to the postnatal ward, where they were cared for by MGP midwives as well as other midwives on the ward, complained of receiving conflicting advice.

Women in MGP also expressed satisfaction with the on-call system, although a small number of respondents had problems with the paging system (which have since been resolved) and not always consulting with their lead midwife. The MGP midwives work in small groups and rotate the role of first on-call or ‘triage midwife’ for a rostered night. It is understandable that women sometimes feel disappointed that the lead midwife, with whom they have built a close rapport, is not always available. This highlights the importance of establishing realistic expectations with women enrolled in continuity of midwifery care. For example, Reed²⁰ stresses the importance of discussing how the ‘on-call’ system works at the first meeting to ensure women understand how group practice is structured. Similarly, McCourt and Stevens²¹ suggest midwives’ should establish boundaries with their women to ensure support without encouraging dependency.

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Conclusion 

In this paper we have reported on the results of a study aiming to explore women’s satisfaction with the MGP model of continuity of midwifery care. An important objective in the implementation of MGP was ensuring women’s satisfaction, which was assessed through the administration of a Maternal Satisfaction questionnaire to a sample of women enrolled in MGP. Overall satisfaction levels of women were very high and care from the MGP midwives was described as personalised, professional, individualised, family-centred and comprehensive.

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Acknowledgements 

We would like to acknowledge the support and assistance of the following: the members of the MGP Evaluation Group; Mrs A. Fitzgerald and Mrs E. Grant who provided the reports from the Clinical Information Services database; the midwives working in MGP; and the women who participated in program.

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