Births of the nation: women's experiences of childbirth in Ireland
Survey shows care rated highly but ‘worryingly’ high levels of patients feel they are not listened to
The survey shows satisfaction varies in different parts of the whole maternity journey, from the start of pregnancy to the six-week postnatal check-up. Photograph: Thinkstock
It might go against the media grain, but let’s start with the good news: the majority of women are very satisfied with their experiences of the Irish maternity care system.
That’s according to the latest data released exclusively to The Irish Times from the 2014 “What Matters to You” survey, conducted by the Association for Improvements in the Maternity Services (AIMS) – Ireland.
With almost 3,000 of the women who gave birth in Ireland between 2010 and 2014 responding to the online survey that covered all aspects of maternity care, there is no other source of satisfaction rating with those numbers, says Aims chairwoman Krysia Lynch, a statistician by training.
“[The majority of] a large number of women, across the range of different hospitals and non-hospital options, are saying they were satisfied.”
It’s important that first-time expectant parents hear this and not just the individual horror stories that are rightly highlighted by the media.
Some 79.4 per cent of women rate their care during pregnancy as excellent or good and more than 80 per cent say the same of their care through labour; a slightly higher percentage again apply those ratings to the care at birth. “Nobody wants to highlight the failings of the maternity service more than me,” says Lynch, but, at the same time, “we need the good stories to balance the poorer stories”.
However, breaking the figures down, the survey shows satisfaction varies in different parts of the whole maternity journey, from the start of pregnancy to the six-week postnatal check-up.
Almost 80 per cent of women are very happy with their care during pregnancy but this is down from almost 94 per cent in a similar Aims survey in 2010. Some 5.4 per cent rate it as poor or very poor.
A striking feature of the satisfaction ratings is that they drop sharply when it comes to the information, as opposed to the care, given. This disparity indicates, says Lynch, that there is a significant difference between the way women perceive the quality of their clinical care and how that care is discussed with them. The highest number of “poor” and “very poor” ratings goes to the information women are given during labour (16.4 per cent combined) and after birth (17 per cent), with a similar verdict given by 12 per cent about information received during pregnancy.
Just over 14 per cent of respondents either disagreed, or strongly disagreed, with the statement that they were listened to in labour. A similar percentage neither agreed nor disagreed, leaving only 30 per cent strongly agreeing.
“Given recent headlines about the importance of listening to women in the maternity services, this figure is worrying,” says Lynch.
In the current context of the number of women and babies who have had adverse outcomes, whether it is morbidity or mortality, “the key thread running through it all is that they weren’t listened to”, she points out.
Post natal care
Although greater dissatisfaction with post natal care is evident, the ratings have improved since the 2010 survey. The “excellent” and “good” ratings rose from 25.9 per cent to 28.3 per cent and from 25.9 per cent to 35.5 per cent respectively. The “poor” rating dropped from 21.8 per cent in 2010 to 14 per cent in 2014.
Care of new borns
Nearly half of women (49.2 per cent) thought the care their babies received was excellent, slightly up on 2010, with a further 35.5 per cent rating it as good. Some 4.2 per cent rated it as poor or very poor.
A quarter of all women said they would have liked to have left hospital sooner. This is surprising, considering that women here spend an average of only two days in hospital after giving birth, which is just over half the time that most of our European counterparts spend in a maternity unit, according to OECD figures.
It could be a reflection of the dissatisfaction with postnatal care in hospital or, as Lynch suggests, because three-quarters of respondents were at least second-time mothers and were keen to return home to their other children. Just 7 per cent would like to have had a longer stay.
Support from PHN
Views on the backup provided by public health nurses (PHNs) have improved significantly since 2010, but there is still considerable dissatisfaction. Some 32.3 per cent rate PHN support as excellent, compared with just 24.6 per cent in 2010; 12.5 per cent say it is poor, down from 20.6 per cent four years ago.
Three-quarters of women say they were not given a patient satisfaction form to fill out after having given birth. The majority of those who were, filled it in while still receiving care from the health professionals they were rating, “which is not best practice”, remarks Lynch. And none of them rated their care in these forms as less than fair, with 90 per cent divided evenly between saying it was excellent or good.
Although two-thirds of women rated the care they had received at their six-week check up as excellent or good, this is also the aspect that receives the highest “very poor” rating of any in the survey, at 6.9 per cent. Lynch attributes this to the variability in the provider of that check-up: women may return to the maternity hospital or go to their GP.
There is no standardised format and the most common concern is that women are not asked about their emotional wellbeing. However, the care the baby receives at this stage is seen as considerably better, with more than 86 per cent of mothers rating it as excellent or good and only 0.9 per cent as very poor.
Reflecting on the results of the survey, Lynch is convinced that the real problem is a disconnect between the women’s experience and the hospital managers who need to hear it.
Very few people use official feedback channels, preferring “to whinge, moan and bitch about it” rather than taking it up with the health professionals.
These satisfaction ratings can be cross-tabulated to individual hospitals and she hopes that they will be interested in getting feedback that relates specifically to them.
In addition, she encourages women who are dissatisfied to give their views afterwards and to see it not necessarily as making a letter of complaint, but rather a note of information. “Otherwise,” she adds, “how can they make it better?”
See the full satisfaction ratings and other previously released data from “What Matters to You?” (2014) on aimsireland.ie
Voices of satisfaction . . . and dissatisfaction with experience of giving birth in Ireland
“For me the care in the labour ward was excellent on both my children; fantastic staff and, in general, I had very positive experiences. But I found the postnatal experience on both occasions to be almost traumatic – rude staff, noisy wards, etc. I couldn’t wait to get out of the place.”
“As a private patient, yes, I was listened to. As a public patient I was not listened to and I was left on my own, told not to be making a fuss when I asked repeatedly to be examined (on my second baby) as I knew I was close to delivery. I was told I wouldn’t have my baby for hours but I delivered in a room off reception, not even in a maternity/delivery ward.”
“My midwife was fantastic. As it happened quickly, she calmed me down, made me feel empowered and in control, and made it clear she would respect any decision I made during labour. A polar opposite from my first experience as a private patient.” “I feel that the system let us down. The fact that I was a public patient and that my baby was born at the weekend meant that my consultant was not present. Instead my baby was delivered by a registrar without any supervision by a more senior doctor. I would change the situation to where a midwife could make decisions regarding their area of expertise and not be overruled by a junior doctor.”
“Antenatal care was good to excellent in the community-based clinic. However, postnatal care was seriously lacking. I felt like we were just cattle being calved and left to fend for ourselves.”
“I would change the entire system. I failed to progress after a failed induction. My baby’s heartbeat dropped twice and after 12 hours he went into distress. I firmly believe that this was all unnecessary and could have been prevented. It was a very traumatic time in my life and, while I am very grateful for a beautiful healthy boy, I really believe decisions could have been made that day a lot sooner and maybe I could have been prevented the emotional turmoil I went through afterwards. An emergency [Caesarean] section is a very traumatic experience and afterwards my wound was infected for over six weeks.”
“I felt they were happy and supportive when I did things their way but when I started to ask questions and refused [to allow them] to break my waters, they got more unsupportive. Also, they kept pushing the epidural on me when I had said on admission that I didn’t want it.”
“I had a fabulous experience, and while the midwives are stretched due to the number of patients there, they were lovely and attentive, I never felt ignored or not listened to. Even though I was induced, had waters broken, put on a drip (all due to a previous stillbirth), I made all of those decisions, decided when they would do things, and how they did them. They listened carefully to me, and I was in total control of my birth (in a hospital).”
“I would change nearly everything, starting with the care providers themselves. I was given inaccurate information, lied to, given no help with coping with pain, pressured into having unnecessary interventions. I would change the settings, nothing welcoming about a hospital room.”
“Would have liked to avoid huge long waits at hospital. When you get a time for your appointment, that should be the time you are seen, not the time that you join the queue with everyone else who is waiting for the doctor to come back from lunch. Also, to see the same person every time and for staff to have name badges so you can complain, or praise their good service.” “I had a terrible experience first time round and really didn’t want to go through it again so I asked for a C-section. I spent my whole pregnancy stressed over this as, from day one, they told me it would not be an option. It ruined the experience for me and my partner. Then, at 36 weeks, they said no problem to it. If I could have opted from day one, it would have made my pregnancy much easier.”
“I felt that all the nurses were lovely and very capable but are asked to look after far too many women to give an adequate level of care to all. If I could I would change the anaesthetist as I felt uncomfortable in his presence from the outset and eventually lied about the epidural taking effect just to get him out of the room.”
From the Aims survey “What Matters to You?” (2014)