In the last few weeks, several of us here at Science & Sensibility have spent time discussing various issues surrounding a woman's experience before, during and after pregnancy, labor and birth. We have contemplated risk factors for postpartum depression and how to survey pregnant women for these risk factors. We have discussed fish oil supplements that can aid in averting pregnancy-related depressive disorders. We have debated labor, delivery and postpartum milieu issues: what's best for mom and baby? We have looked at the experience of midwifery care from the patient's perspective.

In the business world, customer satisfaction surveys are incredibly important and regularly used as a means of evaluating what their customers' experiences have been like. In short, they illuminate how well a company is serving its customers and what can be done to improve that level of service. The maternity care industry, it seems, is slowly beginning to take the hint.

Last week, Swedish Midwife and researcher Anna Dencker published the findings of her study,Childbirth Experience Questionnaire (CEQ): development and evaluation of a multidimensional instrument. The purpose of this study was to test the validity of a tool that might be used to, '....aid in identifying mothers in need of support and counseling and in isolating areas of labor and birth management and care potentially in need of improvement.'

Dencker's project included developing a 22-question survey intended to pick up on signs of postpartum depression and other indications for the need of additional postpartum support, similar to the (antenatal) questionnaire referenced in Darline Turner-Lee's recent post. Dencker's study, however, also involved questioning recipients about their overall experience during the childbirth process - experiences that, when deemed 'negative' can have adverse effects on first time mothers' postpartum mental health as well as 'negative attitudes... toward future pregnancies and choice of delivery method.'

In fact, Dencker's work is not the first attempt at assessing women's childbearing experiencesfrom the patient's perspective and the resultant implications on postpartum well-being.

A 1999 article published in the BMJ by Harvard Medical School professor Paul Cleary (Dr. Cleary is now Dean of the Yale School of Public Health), called for increasing attention to patient satisfaction surveys. Debunking the old assumption that these surveys cover little more than quality of cafeteria food amidst a tool of 'minimal methodological rigor,' Cleary goes on to state, 'newer surveys and reports can provide results that are interpretable and suggest specific areas for quality improvement efforts.' In fact, the collection and assessment of patient feedback as a tool for scrutinizing quality of care seems to be the foundation upon which Dr. Cleary has built his academic career.

As many of us know, in 2002, 2006 and 2008, Childbirth Connection, in partnership with Lamaze International and Harris Interactive distributed, collected and tallied the Listening to Mothers I, Listening to Mothers II and the follow-up Listening to Mothers II/Postpartum surveys. Groundbreaking at the time, LTMI and LTMII were the first surveys at the (U.S.) national level which allowed women to speak out about their pregnancy, labor, birth and postpartum experiences. The results of these surveys completed either via telephone interview or online provided invaluable feedback for maternity care providers on the patients' perspectives of their care. More than that, they provided insight into places in which the maternity care industry can improve service - based on customer feedback.

Examples of this feedback from the LTM surveys include: a resounding theme of medical-intervention-as-the-norm during the process of labor and birth; 42% of women who wanted a VBAC were denied the option altogether; 61% of respondents planned to exclusively breastfeed following their babies' births but only 51% were actually doing so, one week postpartum (estimates of physiologic primary lactation failure as a cause for discontinuing breastfeeding range from 2-5%, therefore non-medical causes for discontinuing nursing likely made up most of the remaining 5-8%); 3% of women who experienced an episiotomy were not given the opportunity to consent to or decline the procedure. These are striking examples from which maternity care providers and facilities ought to scrutinize their own practices and, where necessary, make changes to better serve the needs of their 'customers.'

Additionally, these surveys offered maternity care providers some encouragement to continue the good work they were doing by delineating positive reports about certain aspects of the care experienced by respondents: 2% experienced all six Healthy Birth Practices encouraged by Lamaze and 70% of new mothers attended childbirth education classes.

The LTMII/PP survey, which was sent out to 900 of the 1583 respondents who completed the 2005 survey, provided guidance for clinicians for follow-up action when and if women (in a clinical setting) gained concerning scores on one of two postpartum depression screening tools and/or on a post-traumatic stress disorder screening tool. In such cases, women were referred for additional psychological evaluation and treatment.

Taking action on the results of patient satisfaction surveys is the key to opening up their greatest potential value.

Let's side step for a moment, and contemplate a metaphorical shoe manufacturing company: This company has several brands of shoes and, within those brands, several makes and models. Suppose this shoe company decided to survey all of its customers from the previous year - purchasers of every make and model of shoe. Suppose the company received an overwhelming number of complaints about one of their previously best-selling shoe models under one specific brand: the foot bed was too stiff, the heal cup created terrible blisters that caused pain and long-lasting discomfort, the toe box was cramped and unforgiving. If this company cared at all about their financial bottom line, you bet they would either do away with that model of shoe, or make changes to it to ensure a consistent quality of product compared to other brands and models of shoes and, ultimately, ensure customer retention. (Or, perhaps, the company would make these changes because they genuinely cared about how their customers felt while wearing their shoes.) Because everybody does and will continue to go on wearing shoes, this company can't afford to not respond to its customers' feedback. In fact, not only considering (and hopefully making) changes to this line of shoe should not be the end point. A shoe company worth their weight in gold would also take the next step and let their customers know about their actions: we've heard what you're saying and we're doing something about it.

Shoe manufacturing is not, of course, a life and death situation nor even a monumental long term wellness issue. One faulty shoe design would not indicate an industry-wide failure to produce high quality shoes.

Maternity care, on the other hand, is sometimes a life and death situation - and, at the very least - an industry that does impact long term well being. Likewise, individual faulty examples of poor care or negative patient experiences do not indicate an industry-wide failure. However, surveys such as those referenced in this post do not function on a microscopic level. They represent macroscopic views of a nationwide industry.

Whether we want to contemplate shoe companies, hospitals, doctor's offices or midwifery practices as businesses, or public health service institutions, the take home point ought to be the same: we can't afford to not respond to our customer's responses and we need to let childbearing women know: we hear what you're saying and we're working on doing something about it.

Published: December 15, 2010

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