- Email: [email protected]
Patient satisfaction with the prenatal care provider and the risk of cesarean delivery
American Journal of Obstetrics and Gynecology (2005) 192, 2029–34
www.ajog.org
Patient satisfaction with the prenatal care provider and the risk of cesarean delivery Joel R. Cohen, MD* Kaiser-Permanente, Southern California Permanente Medical Group, Bakersfield, CA
KEY WORDS Patient satisfaction Cesarean section
Objectives: This study was undertaken to assess the relationship between patient satisfaction with the prenatal care provider and a gravid woman’s risk of cesarean delivery. Study design: Medical records of 586 consecutive deliveries in a single obstetrics department were reviewed. The delivery mode was correlated to the providers’ overall patient satisfaction score as measured by an ongoing mail survey. Mann-Whitney U tests and 2-tailed t tests were used. Results: On the basis of the prenatal provider, not the delivering physician, the cesarean section delivery rates fell into 3 groups: low rate, average rate, and high rate. There is a significant difference in both the cesarean delivery rate and the patient satisfaction survey scores between the prenatal providers in the high- and low-rate groups. Conclusion: Higher patient satisfaction scores is correlated with a lower cesarean delivery rate. Ó 2005 Elsevier Inc. All rights reserved.
Patient satisfaction is known to be correlated with patient compliance with medical care and with improved clinical outcomes.1 Compliance with medical care is strongly associated with measures of patient satisfaction. This, in turn, is associated with health improvements. An important outcome measurement of prenatal care is the cesarean delivery rate. This study sought to evaluate the association between patient satisfaction and cesarean delivery rates.
Presented at the 71st Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, October 19-24, 2004, Phoenix, Ariz. * Reprint requests: Joel R. Cohen, MD, Kaiser-Permanente, Southern California Permanente Medical Group, Kern County, Service Area, PO Box 12099, Bakersfield, CA 93389-1299. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2005.02.030
Materials and methods This study was given Institutional Review Board approval by the Kaiser-Permanente Southern California Regional Research Committee.
Population A 7-month study period, December 1, 2002, through June 30, 2003, was used as there were no changes in the provider panel, office nursing personnel, and a stable delivery environment. In this time, there were 586 live born deliveries. There were no fetal or neonatal deaths. Those patients delivered via a repeat cesarean section (100), cesarean for breech presentation (6), twins (8), delivered outside the department (37), and those with fewer than 5 prenatal visits (2) were excluded from the study database leaving 433 patients for evaluation. The prenatal charts of all live births to the KaiserPermanente obstetric and gynecologic department in the
2030 Table I
Cohen Average MAPPS survey responses, groups 1 and 3 Group 1 (lower Group 3 (higher cesarean cesarean delivery rate) delivery rate)
The provider understood your problem The provider explained what they were doing and why The provider used words that were easy to understand The provider listened to your concerns and questions You have confidence in ability and competence of your provider Your overall satisfaction with your care
9.45
8.74
9.48
8.6
9.6
9.1
9.46
8.54
9.39
8.41
9.42
8.38
Kern County Service Area at Bakersfield, Calif, were reviewed to identify the prenatal provider who saw the patient for the plurality of the prenatal visits, those occurring between the documented positive pregnancy test and delivery. Estimated gestational age was confirmed by first-trimester ultrasound. Most of the identified low-risk patients continued their prenatal care with 1 of the department’s 4 registered nurse practitioners. The remaining patients, identified with potential obstetric or medical risk factors were scheduled for follow-up with 1 of the department’s 7 board-certified or board-eligible obstetricians. All physicians were American trained, though some have previous foreign certificates. All patients were seen at least monthly through 34 to 36 weeks and weekly after that. Nonstress testing was started routinely at 41 weeks. Postdates labor inductions were scheduled at 41 weeks 3 days. The known potential significant risk factors were added to the database and confirmed by chart review; these included a patient’s age, parity, estimated gestational age, fetal weight, and pregnancy complications.
Patient satisfaction survey tool An internal Member Assessment of Physician/Provider Services (MAPPS) survey tool was used to assess patient satisfaction with the prenatal provider. This tool was developed more than 15 years ago to measure patient satisfaction. After a visit in the office, patients were randomly assigned to receive a mail-in survey regarding an index visit. The surveys asked the patient to score the provider on 8 areas of the interaction by using a 10-point scale of satisfaction from definitely would not agree (score of 0) to definitely would agree (score of 10). The
surveys were returned to a third-party vendor to record and to collate the responses. The responses are available to the providers on a semiannual basis. As these scores are considered confidential, personnel information access was not granted to individual provider survey scores. After the providers were grouped on the basis of their prenatal patients’ eventual cesarean rate, the grouped names were submitted to the medical group administrator. The administrator then pulled the survey results for the period ending in December 2002 for the individual providers in each group and provided summed and averaged results for each group. Because there were only 2 providers in the middle cesarean rate group, those whose patients were delivered by cesarean at 11% to 13% rate, no survey results were made available to the investigator. Six of the 8 MAPPS survey questions were selected for the purposes of this study (Table I).
Hospital care and labor management All 7 physicians provided 24-hour in-house obstetric care on a rotational basis. Patients presented for hospital management in labor. Postdates labor inductions were offered at 41 weeks and scheduled for 41 weeks 3 days’ gestation, without regard to the prenatal physician. Other indicated labor inductions were started at the time of diagnosis. No 1 physician was more or less likely to deliver a patient from any 1 prenatal provider. Physicians were compensated on an hourly basis, not on the basis of the number of procedures performed. Standard hospital protocols were used for procedures such as oxytocin, diabetes management in labor, and epidural anesthesia. Statistical analysis of cesarean section rates and MAPPS survey scores was performed with the Mann-Whitney U test, a comparison to the mean, and a 2-tailed t test.
Results The rates for primary cesarean delivery based on prenatal provider are summarized in Table II. The overall rate of cesarean delivery was 14.2%.The cesarean rate for women with prenatal care by a physician was higher than that for women cared for by nurse practitioners (17.1% vs 9.8%, P = .35) There was a trimodal distribution of cesarean rates among the patients, based on their prenatal provider. Group 1 had a cesarean section rate of 4.7% to 7.7%, group 2 had a rate of 10.7% to 13.8%, and group 3 had a cesarean delivery rate of 16.7% to 22%. Group 2, as previously mentioned, was excluded from further analysis because the MAPPS survey scores were not provided because of the confidential personnel nature of the information. Group 1 had a significantly lower cesarean delivery than group 3 (P ! .03). Maternal and neonatal characteristics were similar for these 2 groups (Table III).
Cohen
2031
Table II Total vaginal and cesarean deliveries arrayed by prenatal provider, group 1 (low rate of cesarean delivery), group 2 (mid rate), and group 3 (high rate of cesarean delivery) Group 1
Group 2
Group 3
Provider type
RNP
MD
RNP
RNP
MD
MD
MD
MD
RNP
MD
Deliveries: Vaginal Cesarean Total % Cesarean
41 2 43 4.6
44 3 47 6.3
29 2 31 6.5
40 3 43 7
36 3 39 7.6
35 3 28 10.7
50 8 58 13.8
25 5 30 16.7
43 12 55 21.8
46 13 59 22
RNP, Registered nurse practitioner; MD, medical doctor.
Medical and obstetric diagnoses and hospital measures such as the use of pitocin, epidural anesthesia, and neonatal intensive care unit admissions were similar in the 2 groups. The MAPPS patient satisfaction survey scores were significantly higher in group 1 compared with group 3, for the average response for the questions under study (P ! .002) (Table I).
Table III
Maternal and neonatal characteristics
Fetal weights (g) Vaginal Cesarean delivery Parity Vaginal Cesarean delivery
Group 1
Group 3
P value
3628 2484
3674 2542
.12 .27
0.7 0.6
1.0 0.7
.13 .83
Comment Improving patient satisfaction with care has been identified as a business necessity by many health plans primarily for reasons of sales and member retention.1 Higher patient satisfaction may also lead to better patient compliance with treatment plans and improved clinical outcomes.2 This seems to be the case with certain chronic conditions,3 but has not been thoroughly studied with obstetric care and outcomes. Some studies do suggest higher patient satisfaction and differences in some measurable outcomes, such as treatment of anemia with midwifery care or general practitioner care.4,5 One study does report a lower incidence of cesarean delivery caused by the labor and delivery management described as ‘‘supportive midwifery care.’’3 No previous identifiable studies have correlated patient satisfaction with the prenatal care provider and a woman’s eventual risk of cesarean delivery. In the year 2000, the American College of Obstetricians and Gynecologists issued a conclusion to a task force study of cesarean section deliveries in the United States.6 In this study, the authors discussed the heightened level of concern regarding the increasing use of cesarean section deliveries in the United States. This study demonstrates a correlation between prenatal provider patient satisfaction scores and the patient’s risk of having a cesarean delivery. It identifies another potential avenue of research into alternatives to reduce the use of cesarean delivery.
Limitations Although this study correlates patient satisfaction with cesarean delivery, it does not define the causal link. This
study was possible because of the stability of the practice, the hospital setting over the selected time frame, and a practice style that allows for comparison of the obstetric outcomes of the individual prenatal providers. This study represents a unique use of the patient satisfaction survey tool. Future studies should address in more detail the aspects of the patient-provider relationship that lead to improved satisfaction and outcomes and identify the link between these 2 measures. The weaknesses of this study lie in the small numbers, the anonymity of the MAPPS survey respondents, and in the confidential treatment of the satisfaction survey results; full disclosure might have identified particular areas for focused study.
References 1. Safran D, Taira D, Rogers W, Kosinski M, Ware J, Tarlov A. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-20. 2. Adams R, Smith B, Ruffin R. Impact of the physician’s participatory style in asthma outcomes and patient satisfaction. Ann Allergy Asthma Immunol 2001;86:263-71. 3. Butler J, Abrams B, Parker J, Roberts J, Laros R. Supportive nursemidwife care is associated with a reduced incidence of cesarean section. Am J Obstet Gynecol 1993;168:1407-13. 4. Tucker JS, Hall MH, Howie PW, Reid ME, Barbour RS, Florey CD, et al. Should obstetricians see women with normal pregnancies? A multicentre randomized controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians. BMJ 1996;312:554-9. 5. Stewart M. Effective Physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:1423-33.
2032 6. Freeman R, Cohen A, Depp R, Frigoletto F, Hankins G, Lieberman E, et al. Evaluation of cesarean delivery. Washington (DC): The American College of Obstetricians and Gynecologists; 2000.
Editor’s note: This manuscript was revised after these discussions were presented.
Discussion DR VERN KATZ, Eugene, Ore. Dr Cohen has reported today on an interesting study that examines the relationship between patient satisfaction with their prenatal provider and their eventual mode of delivery. The importance of the relationship between a pregnant woman and her care provider is in itself an aspect of pregnancy that we as physicians have always been affected by and impressed with throughout our careers. Before looking at this study, let us take a moment to reflect on that aspect of the doctor-patient relationship. Many of us choose obstetrics as a specialty because of our early experiences in medical school. These experiences were shaped by the interactions with pregnant women at an incredibly vulnerable time in their lives, a time when they put trust in us during the amazingly powerful birth experience. We were touched by it, and touched by the doctor-patient bond, which for many of us affected our expectations of medicine as a specialty. Importantly, as we progressed in training and spent more time with our patients in the prenatal clinics, we came to understand that the bond was strengthened into a much stronger relationship with our patients. All of us know the bond we have with women who we take care of for their pregnancies. It is stronger than most all other doctor-patient relationships. The midwife-patient bond is similarly as strong. When women talk about their birth experiences, their rite of passage, their physician or midwife is the central figure. For both women and their providers, the relationship is indescribably powerful. Returning to Dr Cohen’s article, what I found fascinating about this study was the hypothesis, that there might be a relationship between a patient’s satisfaction with their provider and the likelihood of cesarean section. It is intuitive that the patient-physician relationship will affect outcomes to some extent for medical diseases, perhaps affecting length of survival with chronic conditions. It is less intuitive though that cesarean section rates would be affected. We would all agree that there are multiple factors that we do not understand that contribute to success of vaginal birth. I would not have thought until I read this article that how much a woman liked her physician was one of them. The prenatal clinics in the Kaiser system in Bakersfield provided a good setting to begin to examine this question. There is a fairly confined/closed population with a small fixed rotation of delivering physicians. The
Cohen variable of who is performing delivery is removed from the experiment. Patients saw whoever was on-call when they went into labor, and protocols of delivery were fairly standard. When the random satisfaction scores were evaluated, women with lower, albeit only slightly lower, satisfaction scores were found to have a slightly higher cesarean section rate. Or more precisely, in this study, the providers with a higher satisfaction score from their patients had patients who ended up with a lower cesarean section rate. This is, as Dr Cohen has stated, a small study over a short time, and is therefore hypothesis generating. As Dr Cohen has stated, the issues of causality are yet to be determined. We do not know about selection biasdcertain providers receiving certain patients by reputation or patient problems, and multiple other potential sources of bias. Perhaps the nurse is an independent variable that affected a doctor’s satisfaction score. With a fairly tight satisfaction score rangedlittle changes may cause large changes in outcome. I look forward to follow-up evaluations that expand the study of this relationship and teases out the variables that affect it. Dr Cohen, I have a few questions for you: 1. Did you see any relation with provider’s age, gender, or ethnicity, and satisfaction scores or outcomes? 2. Why was the cesarean rate higher for smaller infants? 3. You stated that the surveys were given after the first visit with their providers. When were they usually completed bydwhich trimester, or after deliverydas this may have affected responses? DR JOHN LENIHAN, Tacoma, Wash. Since you have a system in which the patients were delivered by whomever was on-call, and maybe there was a 1 in 10 chance that their personal provider was on-call, would that not be a bigger interference with the outcome? I wonder if patient satisfaction with their provider should instead be patient satisfaction with the whole system. If you are seeing someone in a clinic type system like Kaiser Permanente, maybe the patients are unhappy with the system. That is, dissatisfaction was not with the provider, it was with the system. Was there any data on individual providers? Did any have more problems with unhappy patients than others? Is there a way, if you do identify patients who are unhappy that are more likely to have adverse outcomes, to identify them earlier in the process, maybe to change providers or somehow improve the outcomes? DR PAUL KAPLAN, Eugene, Ore. Did you divide the elective cesarean deliveries from those that were unscheduled? Can your data prove the opposite hypothesis: that patients who had cesarean sections were less satisfied and therefore were more likely not to be happy with their provider? When did the patients return the
www.ajog.org
Patient satisfaction with the prenatal care provider and the risk of cesarean delivery Joel R. Cohen, MD* Kaiser-Permanente, Southern California Permanente Medical Group, Bakersfield, CA
KEY WORDS Patient satisfaction Cesarean section
Objectives: This study was undertaken to assess the relationship between patient satisfaction with the prenatal care provider and a gravid woman’s risk of cesarean delivery. Study design: Medical records of 586 consecutive deliveries in a single obstetrics department were reviewed. The delivery mode was correlated to the providers’ overall patient satisfaction score as measured by an ongoing mail survey. Mann-Whitney U tests and 2-tailed t tests were used. Results: On the basis of the prenatal provider, not the delivering physician, the cesarean section delivery rates fell into 3 groups: low rate, average rate, and high rate. There is a significant difference in both the cesarean delivery rate and the patient satisfaction survey scores between the prenatal providers in the high- and low-rate groups. Conclusion: Higher patient satisfaction scores is correlated with a lower cesarean delivery rate. Ó 2005 Elsevier Inc. All rights reserved.
Patient satisfaction is known to be correlated with patient compliance with medical care and with improved clinical outcomes.1 Compliance with medical care is strongly associated with measures of patient satisfaction. This, in turn, is associated with health improvements. An important outcome measurement of prenatal care is the cesarean delivery rate. This study sought to evaluate the association between patient satisfaction and cesarean delivery rates.
Presented at the 71st Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, October 19-24, 2004, Phoenix, Ariz. * Reprint requests: Joel R. Cohen, MD, Kaiser-Permanente, Southern California Permanente Medical Group, Kern County, Service Area, PO Box 12099, Bakersfield, CA 93389-1299. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2005.02.030
Materials and methods This study was given Institutional Review Board approval by the Kaiser-Permanente Southern California Regional Research Committee.
Population A 7-month study period, December 1, 2002, through June 30, 2003, was used as there were no changes in the provider panel, office nursing personnel, and a stable delivery environment. In this time, there were 586 live born deliveries. There were no fetal or neonatal deaths. Those patients delivered via a repeat cesarean section (100), cesarean for breech presentation (6), twins (8), delivered outside the department (37), and those with fewer than 5 prenatal visits (2) were excluded from the study database leaving 433 patients for evaluation. The prenatal charts of all live births to the KaiserPermanente obstetric and gynecologic department in the
2030 Table I
Cohen Average MAPPS survey responses, groups 1 and 3 Group 1 (lower Group 3 (higher cesarean cesarean delivery rate) delivery rate)
The provider understood your problem The provider explained what they were doing and why The provider used words that were easy to understand The provider listened to your concerns and questions You have confidence in ability and competence of your provider Your overall satisfaction with your care
9.45
8.74
9.48
8.6
9.6
9.1
9.46
8.54
9.39
8.41
9.42
8.38
Kern County Service Area at Bakersfield, Calif, were reviewed to identify the prenatal provider who saw the patient for the plurality of the prenatal visits, those occurring between the documented positive pregnancy test and delivery. Estimated gestational age was confirmed by first-trimester ultrasound. Most of the identified low-risk patients continued their prenatal care with 1 of the department’s 4 registered nurse practitioners. The remaining patients, identified with potential obstetric or medical risk factors were scheduled for follow-up with 1 of the department’s 7 board-certified or board-eligible obstetricians. All physicians were American trained, though some have previous foreign certificates. All patients were seen at least monthly through 34 to 36 weeks and weekly after that. Nonstress testing was started routinely at 41 weeks. Postdates labor inductions were scheduled at 41 weeks 3 days. The known potential significant risk factors were added to the database and confirmed by chart review; these included a patient’s age, parity, estimated gestational age, fetal weight, and pregnancy complications.
Patient satisfaction survey tool An internal Member Assessment of Physician/Provider Services (MAPPS) survey tool was used to assess patient satisfaction with the prenatal provider. This tool was developed more than 15 years ago to measure patient satisfaction. After a visit in the office, patients were randomly assigned to receive a mail-in survey regarding an index visit. The surveys asked the patient to score the provider on 8 areas of the interaction by using a 10-point scale of satisfaction from definitely would not agree (score of 0) to definitely would agree (score of 10). The
surveys were returned to a third-party vendor to record and to collate the responses. The responses are available to the providers on a semiannual basis. As these scores are considered confidential, personnel information access was not granted to individual provider survey scores. After the providers were grouped on the basis of their prenatal patients’ eventual cesarean rate, the grouped names were submitted to the medical group administrator. The administrator then pulled the survey results for the period ending in December 2002 for the individual providers in each group and provided summed and averaged results for each group. Because there were only 2 providers in the middle cesarean rate group, those whose patients were delivered by cesarean at 11% to 13% rate, no survey results were made available to the investigator. Six of the 8 MAPPS survey questions were selected for the purposes of this study (Table I).
Hospital care and labor management All 7 physicians provided 24-hour in-house obstetric care on a rotational basis. Patients presented for hospital management in labor. Postdates labor inductions were offered at 41 weeks and scheduled for 41 weeks 3 days’ gestation, without regard to the prenatal physician. Other indicated labor inductions were started at the time of diagnosis. No 1 physician was more or less likely to deliver a patient from any 1 prenatal provider. Physicians were compensated on an hourly basis, not on the basis of the number of procedures performed. Standard hospital protocols were used for procedures such as oxytocin, diabetes management in labor, and epidural anesthesia. Statistical analysis of cesarean section rates and MAPPS survey scores was performed with the Mann-Whitney U test, a comparison to the mean, and a 2-tailed t test.
Results The rates for primary cesarean delivery based on prenatal provider are summarized in Table II. The overall rate of cesarean delivery was 14.2%.The cesarean rate for women with prenatal care by a physician was higher than that for women cared for by nurse practitioners (17.1% vs 9.8%, P = .35) There was a trimodal distribution of cesarean rates among the patients, based on their prenatal provider. Group 1 had a cesarean section rate of 4.7% to 7.7%, group 2 had a rate of 10.7% to 13.8%, and group 3 had a cesarean delivery rate of 16.7% to 22%. Group 2, as previously mentioned, was excluded from further analysis because the MAPPS survey scores were not provided because of the confidential personnel nature of the information. Group 1 had a significantly lower cesarean delivery than group 3 (P ! .03). Maternal and neonatal characteristics were similar for these 2 groups (Table III).
Cohen
2031
Table II Total vaginal and cesarean deliveries arrayed by prenatal provider, group 1 (low rate of cesarean delivery), group 2 (mid rate), and group 3 (high rate of cesarean delivery) Group 1
Group 2
Group 3
Provider type
RNP
MD
RNP
RNP
MD
MD
MD
MD
RNP
MD
Deliveries: Vaginal Cesarean Total % Cesarean
41 2 43 4.6
44 3 47 6.3
29 2 31 6.5
40 3 43 7
36 3 39 7.6
35 3 28 10.7
50 8 58 13.8
25 5 30 16.7
43 12 55 21.8
46 13 59 22
RNP, Registered nurse practitioner; MD, medical doctor.
Medical and obstetric diagnoses and hospital measures such as the use of pitocin, epidural anesthesia, and neonatal intensive care unit admissions were similar in the 2 groups. The MAPPS patient satisfaction survey scores were significantly higher in group 1 compared with group 3, for the average response for the questions under study (P ! .002) (Table I).
Table III
Maternal and neonatal characteristics
Fetal weights (g) Vaginal Cesarean delivery Parity Vaginal Cesarean delivery
Group 1
Group 3
P value
3628 2484
3674 2542
.12 .27
0.7 0.6
1.0 0.7
.13 .83
Comment Improving patient satisfaction with care has been identified as a business necessity by many health plans primarily for reasons of sales and member retention.1 Higher patient satisfaction may also lead to better patient compliance with treatment plans and improved clinical outcomes.2 This seems to be the case with certain chronic conditions,3 but has not been thoroughly studied with obstetric care and outcomes. Some studies do suggest higher patient satisfaction and differences in some measurable outcomes, such as treatment of anemia with midwifery care or general practitioner care.4,5 One study does report a lower incidence of cesarean delivery caused by the labor and delivery management described as ‘‘supportive midwifery care.’’3 No previous identifiable studies have correlated patient satisfaction with the prenatal care provider and a woman’s eventual risk of cesarean delivery. In the year 2000, the American College of Obstetricians and Gynecologists issued a conclusion to a task force study of cesarean section deliveries in the United States.6 In this study, the authors discussed the heightened level of concern regarding the increasing use of cesarean section deliveries in the United States. This study demonstrates a correlation between prenatal provider patient satisfaction scores and the patient’s risk of having a cesarean delivery. It identifies another potential avenue of research into alternatives to reduce the use of cesarean delivery.
Limitations Although this study correlates patient satisfaction with cesarean delivery, it does not define the causal link. This
study was possible because of the stability of the practice, the hospital setting over the selected time frame, and a practice style that allows for comparison of the obstetric outcomes of the individual prenatal providers. This study represents a unique use of the patient satisfaction survey tool. Future studies should address in more detail the aspects of the patient-provider relationship that lead to improved satisfaction and outcomes and identify the link between these 2 measures. The weaknesses of this study lie in the small numbers, the anonymity of the MAPPS survey respondents, and in the confidential treatment of the satisfaction survey results; full disclosure might have identified particular areas for focused study.
References 1. Safran D, Taira D, Rogers W, Kosinski M, Ware J, Tarlov A. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-20. 2. Adams R, Smith B, Ruffin R. Impact of the physician’s participatory style in asthma outcomes and patient satisfaction. Ann Allergy Asthma Immunol 2001;86:263-71. 3. Butler J, Abrams B, Parker J, Roberts J, Laros R. Supportive nursemidwife care is associated with a reduced incidence of cesarean section. Am J Obstet Gynecol 1993;168:1407-13. 4. Tucker JS, Hall MH, Howie PW, Reid ME, Barbour RS, Florey CD, et al. Should obstetricians see women with normal pregnancies? A multicentre randomized controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians. BMJ 1996;312:554-9. 5. Stewart M. Effective Physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:1423-33.
2032 6. Freeman R, Cohen A, Depp R, Frigoletto F, Hankins G, Lieberman E, et al. Evaluation of cesarean delivery. Washington (DC): The American College of Obstetricians and Gynecologists; 2000.
Editor’s note: This manuscript was revised after these discussions were presented.
Discussion DR VERN KATZ, Eugene, Ore. Dr Cohen has reported today on an interesting study that examines the relationship between patient satisfaction with their prenatal provider and their eventual mode of delivery. The importance of the relationship between a pregnant woman and her care provider is in itself an aspect of pregnancy that we as physicians have always been affected by and impressed with throughout our careers. Before looking at this study, let us take a moment to reflect on that aspect of the doctor-patient relationship. Many of us choose obstetrics as a specialty because of our early experiences in medical school. These experiences were shaped by the interactions with pregnant women at an incredibly vulnerable time in their lives, a time when they put trust in us during the amazingly powerful birth experience. We were touched by it, and touched by the doctor-patient bond, which for many of us affected our expectations of medicine as a specialty. Importantly, as we progressed in training and spent more time with our patients in the prenatal clinics, we came to understand that the bond was strengthened into a much stronger relationship with our patients. All of us know the bond we have with women who we take care of for their pregnancies. It is stronger than most all other doctor-patient relationships. The midwife-patient bond is similarly as strong. When women talk about their birth experiences, their rite of passage, their physician or midwife is the central figure. For both women and their providers, the relationship is indescribably powerful. Returning to Dr Cohen’s article, what I found fascinating about this study was the hypothesis, that there might be a relationship between a patient’s satisfaction with their provider and the likelihood of cesarean section. It is intuitive that the patient-physician relationship will affect outcomes to some extent for medical diseases, perhaps affecting length of survival with chronic conditions. It is less intuitive though that cesarean section rates would be affected. We would all agree that there are multiple factors that we do not understand that contribute to success of vaginal birth. I would not have thought until I read this article that how much a woman liked her physician was one of them. The prenatal clinics in the Kaiser system in Bakersfield provided a good setting to begin to examine this question. There is a fairly confined/closed population with a small fixed rotation of delivering physicians. The
Cohen variable of who is performing delivery is removed from the experiment. Patients saw whoever was on-call when they went into labor, and protocols of delivery were fairly standard. When the random satisfaction scores were evaluated, women with lower, albeit only slightly lower, satisfaction scores were found to have a slightly higher cesarean section rate. Or more precisely, in this study, the providers with a higher satisfaction score from their patients had patients who ended up with a lower cesarean section rate. This is, as Dr Cohen has stated, a small study over a short time, and is therefore hypothesis generating. As Dr Cohen has stated, the issues of causality are yet to be determined. We do not know about selection biasdcertain providers receiving certain patients by reputation or patient problems, and multiple other potential sources of bias. Perhaps the nurse is an independent variable that affected a doctor’s satisfaction score. With a fairly tight satisfaction score rangedlittle changes may cause large changes in outcome. I look forward to follow-up evaluations that expand the study of this relationship and teases out the variables that affect it. Dr Cohen, I have a few questions for you: 1. Did you see any relation with provider’s age, gender, or ethnicity, and satisfaction scores or outcomes? 2. Why was the cesarean rate higher for smaller infants? 3. You stated that the surveys were given after the first visit with their providers. When were they usually completed bydwhich trimester, or after deliverydas this may have affected responses? DR JOHN LENIHAN, Tacoma, Wash. Since you have a system in which the patients were delivered by whomever was on-call, and maybe there was a 1 in 10 chance that their personal provider was on-call, would that not be a bigger interference with the outcome? I wonder if patient satisfaction with their provider should instead be patient satisfaction with the whole system. If you are seeing someone in a clinic type system like Kaiser Permanente, maybe the patients are unhappy with the system. That is, dissatisfaction was not with the provider, it was with the system. Was there any data on individual providers? Did any have more problems with unhappy patients than others? Is there a way, if you do identify patients who are unhappy that are more likely to have adverse outcomes, to identify them earlier in the process, maybe to change providers or somehow improve the outcomes? DR PAUL KAPLAN, Eugene, Ore. Did you divide the elective cesarean deliveries from those that were unscheduled? Can your data prove the opposite hypothesis: that patients who had cesarean sections were less satisfied and therefore were more likely not to be happy with their provider? When did the patients return the