First Class Delivery: The Importance of Asking Women What They Think About Their Maternity Care

What do women think about their maternity care? For British women the answer to this question appears in an extensive and fascinating national survey of mothers who gave birth in 1995 in England and Wales. First Class Delivery: A NationalSurvey of Women's Views of Maternity Care (1) was conducted by the Audit Commission and analyzed in collaboration with the National Perinatal Epidemiology Unit in Great Britain. The 45-page survey was sent to a random sample of 3500 recent mothers when their babies were about four months old. They were asked to describe the care they received before, during, and after birth and what they thought and felt about their care. Almost 2500 women (67%) replied, and 43 percent provided additional comments when asked, “Is there anything else you would like to tell us about your care while you were pregnant or since you have had your baby?”

The Audit Commission oversees the external audit of the National Health Service and Local Authorities in England and Wales, and part of its work is to conduct national studies of “value for money.” The National Perinatal Epidemiology Unit is a multidisciplinary research group within Oxford University that receives its primary funding from the Department of Health.

What springs to my mind immediately on reading First Class Delivery is the question, “Why can't more research groups and government health agencies find out what women think about their maternity care in other countries—the United States, for example?” It is clear that women want to talk about their care. Women want to have input. Why else would so many be willing to spend time answering a 45-page questionnaire when they have a four-month-old baby? As one woman said, “I am pleased to fill in this questionnaire because it will help others know how they should have been treated.”

Surveys that ask women about their pregnancy and childbirth experiences have tremendous potential for bringing about needed and wanted changes in services and care. Following on the heels of the landmark report Changing Childbirth (2), this survey should lead to recommendations for improving the effectiveness, efficiency, and economy of maternity care in Great Britain. A similar Australian survey, Having a Baby in Victoria (3), was conducted by the Health Department in the state of Victoria, providing a wealth of information from users of maternity services, that was then used to initiate changes in practices and care.

Recognizing the importance of seeking women's views of their care has been slow in coming to national and state agencies and organizations in the United States. The Department of Health in one state, Missouri, did a small survey in 1993, and published their report, Show Me … Buyer's Guide: Obstetrical Services (4). This, too, was a successful effort to evaluate the quality and costs of maternity care, using the responses of women who had recently given birth in that state in conjunction with input from a committee of health care consumers and providers.

The recently revised Guidelines for Perinatal Care (5), written by the American Academy of Pediatrics and American College of Obstetricians and Gynecologists, which provides the standard for maternity care, has given its support to the idea of seeking consumer input (reviewed on p 135). In the first chapter it notes, “In family-centered perinatal services, women and their families are involved in all aspects of planning, delivering, and evaluating health care services…. Women should participate in the development and evaluation of perinatal care systems. Focus groups or surveys are two methods used to collect the views of women. These methods can provide information about both personal and systems barriers to the use of appropriate care ….” (pp 10,12). Recent changes in health care delivery and the development of managed care systems in the United States certainly cry out for evaluation by the users of maternity services.

Isn't it time to launch a national survey of new mothers to determine “value for money” of maternity care in the United States? In every country? The British survey could easily serve as a model, simply adapting the questions to fit the country's health systems or services and care. Just as in Great Britain, a government health agency could collaborate with a perinatal research unit to develop and conduct the survey.

What questions should be asked? In the British survey, the findings of which are described in First Class Delivery, women reported on the care they received in pregnancy, including patterns of care, type of caregivers, and antenatal screening tests; the care they received in childbirth, including induction and augmentation, monitoring during labor, pain relief, type of delivery, position at delivery, and episiotomy; hospital postpartum care; care at home; women's health after the birth; and breastfeeding. The women's evaluations of their care included the kindness, support, and respect they received; their confidence in staff; their confidence in clinical care; information and communication; their options and involvement in decision making; caregivers and continuity of caregiver; staffing; and good care. Women whose babies were cared for in a neonatal unit evaluated the care received. The report's final chapter focuses on implications of the findings for practice and research.

From these findings one can see the great variation in women's care, a wide range of positive and negative views on care, and that “not all women want the same things.” The authors were able to generalize about some components of care, such as:

These findings are not surprising, and they agree with studies of what women want in the way of care in other countries. In the United States, the U.S. Certificate of Live Birth, revised in 1989, gathers a good deal of information about pregnancy, birth, and the newborn, including place of birth, type of attendant at birth, number of prenatal visits, pregnancy history, medical and lifestyle risk factors in this pregnancy, obstetric procedures, complications of labor and delivery, method of delivery, and newborn health. The resulting data are compiled into an annual “Report of Final Natality Statistics” and periodic special reports on aspects of childbearing, providing a comprehensive overview of maternal and newborn health and use of services.

This is valuable information, but we need more. As First Class Delivery notes, “Women deserve to have their views taken into account.” We need to combine hard data with soft data—the familiar clarion call of social scientists in many countries for many years. Practice should be based on both the scientific evidence and women's evaluations of care. Women can tell the caregivers and policy makers where the gaps are, what the problems or barriers are, whether or not institutions are meeting accepted national guidelines, what kind of care they are receiving, the effects of major changes in practice or services, and how well their own and their family's needs are being met by care providers. As Leah Albers observed, “We would do well to remember that around every pregnant uterus is a woman, and we need to start listening” (L. Albers, personal communication, Feb 1998).

The compilation of all this valuable material into a report such as First Class Delivery (a great title!) can provide government health agencies and policy makers with key information that can then be used to improve care and services and safely cut costs. Once again, a British report on maternity care has shown the way to other countries, so let us hope that the example will come to their attention and arouse a desire to follow suit.