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Obstetrics services - womens' perspectives
411
ht. J. Gynaecol. Obstet., 1984,221 411-414 International Federation of Gynaecology & Obstetrics
OBSTETRICS
LIDIJA
SERVICES
- WOMENS’ PERSPECTIVES
ANDOLSEK
Department of Obstetrics and Gynecology,
Medical Centre, University “Edvard Kardelj” Ljubljana, Ljubljana (Yugoslavia)
Abstract Andol$ek L (Department of Obstetrics and Gynaecology, Medical Centre, University “‘Edvard Kardelj” Ljubljana, Yugoslavia). Obstetric services ~ Womens ’ perspectives. Int J Gynaecol Obstet 22: 471-474, 1984 To obtain women’s views of obstetric care 400 randomly selected mothers were interviewed postnatally. Since family planning is a constitutional right and all related services free of charge and virtually 100% of pregnant women attend the antenatal clinic, the questions asked were mainly oriented to evaluation of existing obstetric practice. Women were generally satisfied with labor and delivery care (71.2%). but as many as 88.2% of them expressed their dissatisfaction with postnatal care practice. Our women opted for optimal hospital perinatal care - a home-like postnatal care, possibilities for better bonding between mothers and newborn infants and more open, individually oriented communication with medical staff Keywords: Health care, Changing role of women; Family planning; Antenatal care; Women’s health experience; Postnatal care practice. Introduction How women feel about their obstetrical care is difficult to describe in general terms since the political and social structure of societies and their medical systems vary 0020-7292/84/$03.00 0 1984 International Federation Published and Printed in Ireland
around the world as do the conditions in which women live and work. Therefore, the answer depends upon a wide variety of factors. The most important, I believe, are: the status of women in society and their awareness of their rights, the economic position of the women and their families, traditional and cultural approaches to birth on the one hand and the development and organizational structure of maternal and child health services on the other. Despite these many variations, one can generalize that in the past the doctor-patient relationship during pregnancy was characterized by dependency of the female patient on her obstetrician-gynecologist, for which the parent-child relationship [7] seemed to be the model. The present generation of women want much more than this. Today women question current health care practice and demand participation in decisions concerning various aspects of their reproductive life. They want obstetrical care which will be tailored to their changing needs and health attendants who will be willing to meet their requirements, What are these changing needs? The changing role of women in society has affected the structure of the family and the relationships within it, and has consequently influenced the fulfillment of women’s role as mothers. Women around the world are more and more aware that they can be both employed workers and mothers and can perform both roles efficiently. More specially, women are also more and more conscious that labor Int J Gynaecol Obstet 22
of Gynaecology
& Obstetrics
412
Andoliek
and delivery are only one phase of the reproductive process, and that the newborn’s health depends on the best possible antenatal and perinatal care. Right for family planning Starting with the concept that one of the conditions for the infant’s optimal health and welfare is selection of the optimal time of birth, the ability of parents to determine the number of children and the interval between their births, has to become a fundamental human right all over the world. But a legal right to family planning is not sufficient. Parents need adequate information, motivation and knowledge about fertility regulation methods, and available and accesible services. An tena tal care As a result of increased use of family planning, more and more children are born wanted. At the same time, each individual pregnancy is of great importance to the parents: modern reproductive medicine has created the expectation of the mother-to-be that every pregnancy will result in the birth of a live, healthy infant. In countries where the health service has recognized these demands, antenatal care is becoming the key-stone of maternity care. Programs of antenatal care differ in countries around the world and are related to the available resources and manpower but women generally express satisfaction with this part of their maternal care, which has by now become a tradition in many countries. The actual birth setting The choice of birth setting has become more controversial in some countries in recent years, and the views of some obstetricians and some women differ on this point substantially. The most usual practice, historically and in various cultures, has been for women to deliver at home. Obstetricians, however, stress the importance of hospital childbirth for the safety of the mother and her child, and base this argument on mortality and morbidity statistics [ 4,6]. Int J Gynaecol Obstet 22
It took many years for childbirth to be transfered to hospitals. When the effort of obstetricians, public health officials and others in most developed countries succeeded in hospitaling the majority of parturient women, many of them began to express dissatisfaction with the hospital setting for normal childbirth. What are the reasons for this dissatisfaction? Mothers having their babies at home feel that they are active creators, not passive patients. They also believe that the birth at home has far reaching effects not only for themselves and the baby, but for the family. These are the results of studies performed in Great Britain 121 and in the United States [31. In these countries several attempts have been made to meet the needs of women either by providing special support and assistance to women who wish to deliver at home or by establishing special in-hospital setting (Family Centered Maternity Care -- FCMC model [ 5 I, Alternate Birth Center - ABC [ 5 1, the Birthing room concept [ 11. In our country we try to establish a reasonable equilibrium between modem obstetric practice, the preference of mothers and their families, and our existing hospital facilities. About 500,000 women, since 1954, in the age group 15-49 years, have obtained care. free of charge, from well organized maternal and child health programs which include family planning services, antenatal. perinatal as well as postnatal care. Material and methods We interviewed 400 mothers who delivered from the middle of April to the middle of July, 1982. These women were selected randomly and represented a 5% sample of all women who deliver yearly in our hospital. Mothers who had experienced abnormal abnormal labor. or delivered pregnancies, abnormal babies were excluded. All interviews were conducted by the same social worker on
Womens’ perspectives 413
Table 1. Selected
charcteristics
Age (years)
No.
c/r
>19 20 24 25 79 30 34
25 168 125 52
6.2 42.0 31.2 13.1
35 39 <4(1
21 9
5.2 2.3
of women
interviewed
Parity
Primiparous Multiparous
No.
188 212
(total no. 400). %
47 53
the day of discharge from the hospital. Nearly three quarters (73.3%) of women interviewed were 7 1 -~30 years old, 91.2% were married, and 6 1.5c/c had 9- 12 years education. Fortyseven percent were primiparas (see Table I). All women attended routine antenatal clinics just as do other pregnant women (98% of pregnant women in the republic ofslovenia attended antenatal clinics in 1981) 25% attended special educational programs in preparation for labor. and about 1.5% of husbands attended part of this program and labor itself. The women delivered in a modern delivery suite which opened in 1976 and they were cared for by midwives and/or obstetricians. The postnatal hospital stay lasted 3-5 days. During the last years we had approximately 30,000 births in Slovenia - as many as 99% of parturient women delivered in hospital and among them 8000 were in our department. Among 53% multiparous women interviewed, a majority of them (86%) delivered previously in our maternity suite. At present we do not have facilities for family member visits, nor do we provide rooming-in. What are our findings? Birth setting Twelve percent of women expressed a desire to deliver at home but with the condition that the same quality of medical care be assured as in hospital. This request is, of course, impossible for us to realize. In addition, home conditions are occasionally quite inadequate and there is not enough help to take care of the baby and the house as well.
Marital status
No.
Married Single Widowed Divorced
365 29 2 4
%
Education
No.
%
97 246 57
24.2 61.5 14.3
(years) 91.2 7.2 0.6 1.0
>9 9- 12 <13
Labor and delivery Almost three-quarters of women interviewed (71.2%) were satisfied with the labor and delivery care they received. Pain relief was appreciated by a majority. In the group of 115 unsatisfied women (28.8%), the majority complained about not room for the delivery having a private (36.5%). They were disturbed by the presence of other parturient women as well as by numerous health personnel and students. Nearly the same percentage of unsatisfied women would have preferred more attention and more individually-oriented communication with medical staff. Very few women complained about the specific medical care; the only procedure questioned was the use of local anesthetic for the repairing of the episiotomy (27.8%). Postnatal care The interview confirms our previous observations that the majority of women (88.2%) question postnatal conditions in the hospital. The principal complaint concerned the accommodation (66.5%) and approximately a quarter of women (26.1%) expressed dissatisfaction with the newborn care practice such as having a central nursery and providing inadequate instructions for breast feeding. When asked what should be changed in our current practice, nearly three quarters of all women (70.5%) expressed their conviction that a hospitalization for more than 5 days is not necessary and 39.3% considered 3 days to be sufficient. They also expressed preference for family visits and more home-like accomInt J
Gynaecol Obstet 22
414
Andolzek
modation. As for newborn care, 16.3% voted for complete and 83.7% for partial roomingin (rooming-in during the day), and for better communication with the medical and nursing staff. , Discussion In countries like ours, where maternal care is organized optimally and is provided free-ofcharge, public health officials and medical workers might be misled into passivity by the belief that maternity care has also in practice reached such a high level that it requires no further improvement. Our query, however, has shown that this is not the case. Although all our services (family planning, antenatal, perinatal and postnatal care) are not only freely accessible but also free-of-charge, our consumers do not only question housing facilities but miss, above all, things that might be changed by only a little more good will: more home-like accommodation and atmosphere and a less rigid hospital regime, more information about infants’ care and feeding and more individually oriented communication with medical and nursing staff. In the formation of a new obstetrics unit which is planned in Ljubljana, the consumers’ preferences will be taken into account. Until recently patients have not participated in making policy for their own maternity care. The time has come for this to change. Women should be fully informed about their care and must participate in decisions that impinge on how and how well that care is delivered. Any discussion of what women want will remain unsettled if real obstacles to meeting these needs are not recognized. Therefore, it
Int J Gynaecol Obstet 22
is necessary to continuously evaluate and revise services offered to the mother, the newborn infant and the family. The common goal of maternity care professionals and the consumers is the best possible health for mother and child. Both parties must do everything possible to achieve this goal. A&no wledgements The author MaZek, social interviews and maternity ward
is deeply grateful to Maca worker, who performed the to the nursing staff of the for their assistance.
References Dobbs KB, Shy KK: Alternative birth rooms and birth options. Obstet Gynecol58: 626, 1981. Kitzinger S: Women’s experiences of birth at home. In The Place of Birth (ed S Kitzinger, JA Davis) p 135. Oxford University Press, Oxford, 1979. Mehl LE: The outcome of home delivery research in the United States. In The Place of Birth (ed S Kitzinger, JA Davis) p 93. Oxford University Press, Oxford, 1979. Oakley A: Cross-cultural practices. In Benefits and Hazards of the New Obstetrics (ed 1 Chard, M Richards) p 18. William Heineman Medical Books, London, 1977. Shanon-Babitz M: Alternatives in maternity care. In Maternity Nursing (ed SJ Reeder, L. Mastroiani, Jr, LL Martin) p 719. JB Lippincott Co., Philadelphia, 1980. Tew M: The case against hospital deliveries: the statistical evidence. In The Place of Birth (ed S Kitzinger, JA Davis) p 55. Oxford University Press, Oxford, 1979. Weiss L, Medow R: Women’s attitudes toward gynecologic practices. Obstet Gynecol54: 110, 1979. Address for reprints: Prof. Lidija Andoliek Department of Obstetrics and Gynecology Medical Centre, University “Edvard Kardelj” Ljubljana Ljubljana, Yugoslavia
ht. J. Gynaecol. Obstet., 1984,221 411-414 International Federation of Gynaecology & Obstetrics
OBSTETRICS
LIDIJA
SERVICES
- WOMENS’ PERSPECTIVES
ANDOLSEK
Department of Obstetrics and Gynecology,
Medical Centre, University “Edvard Kardelj” Ljubljana, Ljubljana (Yugoslavia)
Abstract Andol$ek L (Department of Obstetrics and Gynaecology, Medical Centre, University “‘Edvard Kardelj” Ljubljana, Yugoslavia). Obstetric services ~ Womens ’ perspectives. Int J Gynaecol Obstet 22: 471-474, 1984 To obtain women’s views of obstetric care 400 randomly selected mothers were interviewed postnatally. Since family planning is a constitutional right and all related services free of charge and virtually 100% of pregnant women attend the antenatal clinic, the questions asked were mainly oriented to evaluation of existing obstetric practice. Women were generally satisfied with labor and delivery care (71.2%). but as many as 88.2% of them expressed their dissatisfaction with postnatal care practice. Our women opted for optimal hospital perinatal care - a home-like postnatal care, possibilities for better bonding between mothers and newborn infants and more open, individually oriented communication with medical staff Keywords: Health care, Changing role of women; Family planning; Antenatal care; Women’s health experience; Postnatal care practice. Introduction How women feel about their obstetrical care is difficult to describe in general terms since the political and social structure of societies and their medical systems vary 0020-7292/84/$03.00 0 1984 International Federation Published and Printed in Ireland
around the world as do the conditions in which women live and work. Therefore, the answer depends upon a wide variety of factors. The most important, I believe, are: the status of women in society and their awareness of their rights, the economic position of the women and their families, traditional and cultural approaches to birth on the one hand and the development and organizational structure of maternal and child health services on the other. Despite these many variations, one can generalize that in the past the doctor-patient relationship during pregnancy was characterized by dependency of the female patient on her obstetrician-gynecologist, for which the parent-child relationship [7] seemed to be the model. The present generation of women want much more than this. Today women question current health care practice and demand participation in decisions concerning various aspects of their reproductive life. They want obstetrical care which will be tailored to their changing needs and health attendants who will be willing to meet their requirements, What are these changing needs? The changing role of women in society has affected the structure of the family and the relationships within it, and has consequently influenced the fulfillment of women’s role as mothers. Women around the world are more and more aware that they can be both employed workers and mothers and can perform both roles efficiently. More specially, women are also more and more conscious that labor Int J Gynaecol Obstet 22
of Gynaecology
& Obstetrics
412
Andoliek
and delivery are only one phase of the reproductive process, and that the newborn’s health depends on the best possible antenatal and perinatal care. Right for family planning Starting with the concept that one of the conditions for the infant’s optimal health and welfare is selection of the optimal time of birth, the ability of parents to determine the number of children and the interval between their births, has to become a fundamental human right all over the world. But a legal right to family planning is not sufficient. Parents need adequate information, motivation and knowledge about fertility regulation methods, and available and accesible services. An tena tal care As a result of increased use of family planning, more and more children are born wanted. At the same time, each individual pregnancy is of great importance to the parents: modern reproductive medicine has created the expectation of the mother-to-be that every pregnancy will result in the birth of a live, healthy infant. In countries where the health service has recognized these demands, antenatal care is becoming the key-stone of maternity care. Programs of antenatal care differ in countries around the world and are related to the available resources and manpower but women generally express satisfaction with this part of their maternal care, which has by now become a tradition in many countries. The actual birth setting The choice of birth setting has become more controversial in some countries in recent years, and the views of some obstetricians and some women differ on this point substantially. The most usual practice, historically and in various cultures, has been for women to deliver at home. Obstetricians, however, stress the importance of hospital childbirth for the safety of the mother and her child, and base this argument on mortality and morbidity statistics [ 4,6]. Int J Gynaecol Obstet 22
It took many years for childbirth to be transfered to hospitals. When the effort of obstetricians, public health officials and others in most developed countries succeeded in hospitaling the majority of parturient women, many of them began to express dissatisfaction with the hospital setting for normal childbirth. What are the reasons for this dissatisfaction? Mothers having their babies at home feel that they are active creators, not passive patients. They also believe that the birth at home has far reaching effects not only for themselves and the baby, but for the family. These are the results of studies performed in Great Britain 121 and in the United States [31. In these countries several attempts have been made to meet the needs of women either by providing special support and assistance to women who wish to deliver at home or by establishing special in-hospital setting (Family Centered Maternity Care -- FCMC model [ 5 I, Alternate Birth Center - ABC [ 5 1, the Birthing room concept [ 11. In our country we try to establish a reasonable equilibrium between modem obstetric practice, the preference of mothers and their families, and our existing hospital facilities. About 500,000 women, since 1954, in the age group 15-49 years, have obtained care. free of charge, from well organized maternal and child health programs which include family planning services, antenatal. perinatal as well as postnatal care. Material and methods We interviewed 400 mothers who delivered from the middle of April to the middle of July, 1982. These women were selected randomly and represented a 5% sample of all women who deliver yearly in our hospital. Mothers who had experienced abnormal abnormal labor. or delivered pregnancies, abnormal babies were excluded. All interviews were conducted by the same social worker on
Womens’ perspectives 413
Table 1. Selected
charcteristics
Age (years)
No.
c/r
>19 20 24 25 79 30 34
25 168 125 52
6.2 42.0 31.2 13.1
35 39 <4(1
21 9
5.2 2.3
of women
interviewed
Parity
Primiparous Multiparous
No.
188 212
(total no. 400). %
47 53
the day of discharge from the hospital. Nearly three quarters (73.3%) of women interviewed were 7 1 -~30 years old, 91.2% were married, and 6 1.5c/c had 9- 12 years education. Fortyseven percent were primiparas (see Table I). All women attended routine antenatal clinics just as do other pregnant women (98% of pregnant women in the republic ofslovenia attended antenatal clinics in 1981) 25% attended special educational programs in preparation for labor. and about 1.5% of husbands attended part of this program and labor itself. The women delivered in a modern delivery suite which opened in 1976 and they were cared for by midwives and/or obstetricians. The postnatal hospital stay lasted 3-5 days. During the last years we had approximately 30,000 births in Slovenia - as many as 99% of parturient women delivered in hospital and among them 8000 were in our department. Among 53% multiparous women interviewed, a majority of them (86%) delivered previously in our maternity suite. At present we do not have facilities for family member visits, nor do we provide rooming-in. What are our findings? Birth setting Twelve percent of women expressed a desire to deliver at home but with the condition that the same quality of medical care be assured as in hospital. This request is, of course, impossible for us to realize. In addition, home conditions are occasionally quite inadequate and there is not enough help to take care of the baby and the house as well.
Marital status
No.
Married Single Widowed Divorced
365 29 2 4
%
Education
No.
%
97 246 57
24.2 61.5 14.3
(years) 91.2 7.2 0.6 1.0
>9 9- 12 <13
Labor and delivery Almost three-quarters of women interviewed (71.2%) were satisfied with the labor and delivery care they received. Pain relief was appreciated by a majority. In the group of 115 unsatisfied women (28.8%), the majority complained about not room for the delivery having a private (36.5%). They were disturbed by the presence of other parturient women as well as by numerous health personnel and students. Nearly the same percentage of unsatisfied women would have preferred more attention and more individually-oriented communication with medical staff. Very few women complained about the specific medical care; the only procedure questioned was the use of local anesthetic for the repairing of the episiotomy (27.8%). Postnatal care The interview confirms our previous observations that the majority of women (88.2%) question postnatal conditions in the hospital. The principal complaint concerned the accommodation (66.5%) and approximately a quarter of women (26.1%) expressed dissatisfaction with the newborn care practice such as having a central nursery and providing inadequate instructions for breast feeding. When asked what should be changed in our current practice, nearly three quarters of all women (70.5%) expressed their conviction that a hospitalization for more than 5 days is not necessary and 39.3% considered 3 days to be sufficient. They also expressed preference for family visits and more home-like accomInt J
Gynaecol Obstet 22
414
Andolzek
modation. As for newborn care, 16.3% voted for complete and 83.7% for partial roomingin (rooming-in during the day), and for better communication with the medical and nursing staff. , Discussion In countries like ours, where maternal care is organized optimally and is provided free-ofcharge, public health officials and medical workers might be misled into passivity by the belief that maternity care has also in practice reached such a high level that it requires no further improvement. Our query, however, has shown that this is not the case. Although all our services (family planning, antenatal, perinatal and postnatal care) are not only freely accessible but also free-of-charge, our consumers do not only question housing facilities but miss, above all, things that might be changed by only a little more good will: more home-like accommodation and atmosphere and a less rigid hospital regime, more information about infants’ care and feeding and more individually oriented communication with medical and nursing staff. In the formation of a new obstetrics unit which is planned in Ljubljana, the consumers’ preferences will be taken into account. Until recently patients have not participated in making policy for their own maternity care. The time has come for this to change. Women should be fully informed about their care and must participate in decisions that impinge on how and how well that care is delivered. Any discussion of what women want will remain unsettled if real obstacles to meeting these needs are not recognized. Therefore, it
Int J Gynaecol Obstet 22
is necessary to continuously evaluate and revise services offered to the mother, the newborn infant and the family. The common goal of maternity care professionals and the consumers is the best possible health for mother and child. Both parties must do everything possible to achieve this goal. A&no wledgements The author MaZek, social interviews and maternity ward
is deeply grateful to Maca worker, who performed the to the nursing staff of the for their assistance.
References Dobbs KB, Shy KK: Alternative birth rooms and birth options. Obstet Gynecol58: 626, 1981. Kitzinger S: Women’s experiences of birth at home. In The Place of Birth (ed S Kitzinger, JA Davis) p 135. Oxford University Press, Oxford, 1979. Mehl LE: The outcome of home delivery research in the United States. In The Place of Birth (ed S Kitzinger, JA Davis) p 93. Oxford University Press, Oxford, 1979. Oakley A: Cross-cultural practices. In Benefits and Hazards of the New Obstetrics (ed 1 Chard, M Richards) p 18. William Heineman Medical Books, London, 1977. Shanon-Babitz M: Alternatives in maternity care. In Maternity Nursing (ed SJ Reeder, L. Mastroiani, Jr, LL Martin) p 719. JB Lippincott Co., Philadelphia, 1980. Tew M: The case against hospital deliveries: the statistical evidence. In The Place of Birth (ed S Kitzinger, JA Davis) p 55. Oxford University Press, Oxford, 1979. Weiss L, Medow R: Women’s attitudes toward gynecologic practices. Obstet Gynecol54: 110, 1979. Address for reprints: Prof. Lidija Andoliek Department of Obstetrics and Gynecology Medical Centre, University “Edvard Kardelj” Ljubljana Ljubljana, Yugoslavia