Maternal satisfaction has become a major outcome measure, mentioned in several important documents and strategies concerned with childbirth; it is used to reflect the quality of maternity service provision. Anaesthetists have an important role to play in maternal satisfaction, since for many women aspects of their analgesia and anaesthesia can have an enormous effect on how they view their overall experience, in some cases irrespective of what happened in other areas of their care. Conversely, mothers’ rating of their satisfaction with analgesia or anaesthesia in general, and different techniques in particular, may be affected by several factors unrelated to the anaesthetic itself. Despite this, studies comparing different techniques often quote measures of global satisfaction as evidence that one technique is superior to another. Similarly, obstetric anaesthetists are encouraged to assess and audit maternal satisfaction with the obstetric anaesthetic service as a marker of quality of performance, and patient feedback has been proposed as an important component in the process of consultants’ revalidation.
Problems and special considerations
Apart from the confounding effects of various unrelated factors, as described above, another difficulty relates to the measuring tool used to assess satisfaction. Methods used have varied from simple ‘satisfaction scales’, such as a visual analogue scale or verbal rating scale, to complex evaluations of different modalities that combine to produce a positive experience of childbirth such as fulfilment (e.g. happiness), lack of distress (e.g. pleasure) and physical wellbeing (e.g. lack of pain). The simpler systems will always be more attractive to busy clinicians such as anaesthetists than the more complex and time-consuming ones, even though simple questions such as ‘Are you satisfied?’ or ‘Rate your satisfaction on a scale of 1-10’ are not very useful as objective outcome measures. The Royal College of Anaesthetists currently recommends that satisfaction with labour epidural analgesia should be verbally rated, as excellent, satisfactory, unsatisfactory or no benefit.
Studies suggest that factors associated with dissatisfaction include being excluded from one’s care and decisions relating to it, poor communication and lack of information, bad outcome (although there maybe strong satisfaction with the medical care if this is perceived to have been good) and being led to expect a particular event and then not experiencing it (e.g. receiving assurance that an epidural will be available but not receiving it because the anaesthetist is unavailable).
Despite initial assumptions that effective analgesia in labour automatically guarantees maternal satisfaction, this is not necessarily the case, and factors such as control and involvement in decision making may be more important. It is often suggested that satisfaction is increased when motor block is minimised by using low-dose epidural techniques or patient-controlled epidural analgesia.
Management options
Until more work is done on the interplay between specific factors that contribute to maternal satisfaction, obstetric anaesthetists have to fall back on the use of vague and nonspecific methods of assessing it. It is probably more important to assess dissatisfaction, which may indicate deficiencies in service and facilitate quality improvement, but any single measure of satisfaction is only as good as the methods used to obtain it. It is also important to ensure that if a mother has had a bad experience in childbirth but the anaesthetic care has been good and appropriate, her adverse opinion should not extend to include the anaesthetist, although achieving this may be difficult.
Attention meanwhile should be paid to those factors that have been shown to be important in promoting maternal satisfaction, such as involving the mother in decisions, keeping her informed, being prompt and courteous and other desirable general professional attitudes. Similarly, any expression of dissatisfaction should be taken seriously and an attempt made (and recorded in the notes) to discuss the particulars of the case, perhaps by offering an appointment at a later date. Medicolegal experience supports this approach as one of the most important factors in preventing subsequent legal action.
Key points
• Maternal satisfaction is an increasingly recognised but poorly defined measure of quality of care.
• Involving women in their care, good communication and honesty are important factors in increasing maternal satisfaction.
• Women expressing dissatisfaction should be identified and offered the opportunity to discuss their care further with a senior member of staff.
Further reading
Dickinson JE, Paech MJ, McDonald SJ, Evans SF. Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labour. Aust N Z J Obstet Gynaecol 2003; 43: 463-8.
Duale C, Nicolas-Courbon A, Gerbaud L, et al. Maternal satisfaction as an outcome criterion in research on labor analgesia: data analysis from the recent literature. Clin J Pain 2015; 31: 235-46.
Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002; 186: S160-72.
Robinson PN, Salmon P, Yentis SM. Maternal satisfaction. Int J Obstet Anesth 1998; 7: 32-7.