Background
Women’s satisfaction with maternity care is important to healthcare professionals, hospital administrators and policy makers [
1,
2] as the feedback gleaned is used to improve maternity services [
3] and inform decisions around the use of hospital resources [
2,
4]. Besides the outcomes of maternal and infant morbidity and mortality, addressing components that constitute women’s satisfaction with maternity care should be a focus of maternity services in the 21
st century.
It is unusual for a woman to feel completely satisfied with every aspect of her care. More likely she will rank the quality of her care as satisfactory, but when asked to reflect on her experience she can often share what she liked and disliked [
5]. Two decades ago a large Australian survey found that women experience greater satisfaction with their antenatal opposed to intrapartum care [
6]. Other Australian research has found women who birth in the public sector were more likely to be satisfied than those birthing in the private sector, especially if they received professional support within 10 days post discharge [
7]. Women who have increased obstetric intervention such as induction of labour are generally less satisfied with their care [
8]. Indeed, a study comparing satisfaction with mode of birth found most women prefer a vaginal birth and that maternal satisfaction with vaginal birth was high [
9].
A systematic review suggested continuous support from caregivers markedly improves maternal satisfaction [
10]. This finding is unsurprising as continuous support has the capacity to improve comfort, emotional support, information and advocacy, thereby enhancing the perception of control [
11]. Indeed when women evaluate their experiences five factors predominate: experiences that met or exceeded expectations [
10,
12,
13]; staff qualities including quality of care and support [
2,
3,
10,
14]; involvement with decision making [
3,
6,
10,
15]; woman focused care [
2]; and systems and faculties [
2,
3,
16].
It is difficult to gauge how the issues raised by women impact their overall satisfaction [
2], since research often reports responses to measures separately [
3,
5,
14] rather than investigating components of satisfaction simultaneously or in clusters [
3]. Traditionally, the focus of obstetric maternity care has been on outcomes such as morbidity and mortality, concepts which relate to physical not psychological safety [
17]. Research has investigated satisfaction across the pregnancy and childbirth continuum, particularly during birth [
1,
3,
13,
18,
19] using a variety of methods. Quantitative methodologies have dominated [
19], where prescribed lists of categories are presented in measures, which may not be able to unravel the importance of an issue in relation to other aspects of care [
2]. These quantitative studies struggle to illustrate the richness of women’s realities that could be revealed through qualitative designs. However, the latter provide limited guidance for policy makers as the perceptions of individual women are unique and generated themes can only be utilised to enhance knowledge of the phenomenon [
13], but not as evidence to direct the focus of resources.
Although there is evidence around maternal satisfaction, in Australia there are gaps in our knowledge especially around identification of components that constitute women’s satisfaction within an urban, tertiary obstetric setting. In the absence of research, the aim of this study was to investigate women’s experiences of their maternity care within a tertiary obstetric hospital to gain insight into how women conceptualised satisfaction across the continuum of pregnancy, birth and one week post birth.
Discussion
This mixed methods analysis facilitated the exploration of women’s experiences of maternity care, allowing insight into how they conceptualized satisfaction within an urban, tertiary obstetric setting. Quantitative analysis found the majority of women would recommend the hospital to their family and friends. Those having a spontaneous vaginal birth were more likely to feel involved with their birth than those having an assisted or caesarean birth. However, the majority of women felt involved with their birth. Although the qualitative sub-themes were presented separately they were interrelated, revealing positive and negative paradigms. Our discussion will focus around; how our research resonates with the work of others, how mixed methods enhanced our research and discussion around selected opposing sub-themes.
Much of what the study found echoes the work of others internationally around the physical environment [
3], interpersonal care [
3,
16,
19], information giving [
3,
16,
19] and the role of decision making increasing women’s perception of control [
3,
16,
19]. Our study also found similarities with other Australian research, specifically in relation to how women conceptualize continuity [
2,
15], support during birth [
2,
5,
15,
30] and issues around meeting childbirth expectations [
2,
13,
30]. However, this is the first Australian study performed solely within a tertiary obstetric setting, which incorporates mixed methods across the childbirth continuum and one week post birth. Providing a connection between the quantitative and qualitative research was challenging, but enabled the researchers to answer questions that could not be answered by single methods alone [
20], such as the richness of birth experiences.
Although the qualitative results dominate this manuscript, we were able to use quantitative results from the questionnaire to highlight satisfaction with care during pregnancy, birth and the first week of the baby’s life for subgroups of women based on mode of birth. We acknowledge the quantitative methods provided limited opportunity to contextualize the women’s experiences, but they did enable our research team to utilize both numbers and words to conceptualize maternal satisfaction [
21,
23]. Quantitative analysis of mode of birth, also enabled us to reinforce our cohort was representative of women giving birth at the study centre in 2011, where 35 % delivered by caesarean and 65 % had a vaginal birth [
24].
The synopsis of women dissatisfied with their care, captured dimensions where difficulties were encountered, especially the impression of not having their wishes listened to so their expectations of care could not be addressed. This was illustrated through the themes of ‘caring without caring’ and being ‘handled incorrectly’. Others have described the negative impact when communication issues result in expectations not be respected [
1,
5,
31,
32]. Research suggests women may actively construct schema of their maternity care expectations, which are used retrospectively to evaluate their experiences [
30]. It has also been found that although women may have multiple expectations for birth, specific expectations are prioritized.
It has been suggested that withholding information can disempower women [
19], so if things do not unfold smoothly they may perceive a profound loss of control. In our study this was illustrated through the recollections of women who ‘did not know why’, especially those who were trying to make sense of a caesarean birth or intervention where they perceived clinicians had not listened to their needs. Others have suggested that a woman’s personality can hinder or assist adaptation to life events [
32‐
34]. Indeed, women who are confident to question their clinicians about the why and how, may be more likely to prompt shared decision making with their clinicians [
34]. This was demonstrated by the sub-theme ‘explained’ everything, where having ones questions answered, enabled women to make sense of interventions. This ability to question enhanced their ability to navigate themselves through complex maternity systems [
35], so women were less likely to perceive they ‘did not know why’, or feel caregivers ‘did not listen to their needs’.
Overall the sub-themes of the WA women who were satisfied illustrated they had everything explained, by caregivers who went above and beyond. The tertiary obstetric hospital environment did not diminish their experience, as they perceived wide spectrums of support from their caregivers [
10,
36], highlighted by the sub-theme ‘the best place to be’. These reflections show the stereotyped difficulty [
16,
19] around the provision of care for complex pregnancies can be overridden. Women’s expectations of maternity care were not only met but exceeded as their individual, idiosyncratic, contextual factors were acknowledged enhancing their perception of control [
12,
37,
38]. Others have reported similar narratives [
2,
19,
39] suggesting these common threads reflect the constituents of women centred care [
2].
Conversely when the tertiary obstetric hospital environment hospital environment did diminish women’s satisfaction with maternity care, it was shaped by sub-themes such ‘did not listen to my needs’ and ‘a different one every time’. Indeed, a recent randomised controlled study compared group based antenatal care to standard care [
40] finding group based care fostered better engagement with midwives and less deficiency with information giving around care. The decreased involvement of women in their care decisions [
41] has been shown to negatively affect their satisfaction [
23,
42]. Being coerced to accept clinical advice caused tension, especially if the advice negated woman’s requests entirely, was presented without rationale and did not reflect the woman’s birth plan. Women’s stories revealed the power of maternity clinicians to shape the ethical and moral environment of provision of care [
43]. Encountering these negative experiences jeopardised women’s satisfaction with their maternity care.
Limitations
There were a number of limitations. Women in this study received care within one tertiary maternity hospital, which provides care for a significant proportion of high risk pregnancies within one Australian state. The optimum time for recall around birth experience is dependent on personal preference, we acknowledge this could have had an impact in relation to the response rate and findings. The self-selection of women for qualitative interview could have resulted in responders at both extremes of satisfaction. The sample comprised English speaking women giving birth to a live infant and is not representative of all birthing women in WA. Although all women surveyed had birthed a live infant, we were unaware if they had birthed a healthy child, willingness to disclose this information during interview was the woman’s choice. Therefore the context of the study must be considered when interpreting generalizability of the findings to other settings.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
LL was responsible for the proposal, ethics approval, development of the data collection tool and coordination of the study. For the quantitative data she assisted with the mail out and data entry into SPSS. She performed the quantitative data analysis. For the qualitative data she interviewed the women and participated in thematic analysis. She drafted the article and was responsible for the final editing which incorporated the team member’s comments. YH assisted LL with the proposal and ethics approval and development of the data collection tool. For the qualitative data she participated in the thematic analysis. She assisted LL with the drafting of the manuscript. FR assisted with the data entry into SPSS. For the qualitative data she interviewed the women and participated in thematic analysis. She made comment on the final article. CC assisted with the data entry into SPSS. For the qualitative data she interviewed the women and participated in thematic analysis. She made comment on the final article. LW assisted with the quantitative data collection. She coordinated the mail out and data entry into SPSS. She made comment on the final article. All authors read and approved the final manuscript.