Research type 
Qualitative
Region 
National
Year of report 
2010

Summary of findings

 

The satisfaction curve was ‘u’ shaped. Across the ‘seldom-heard’ sample, satisfaction with antenatal care and postnatal care at home was consistently high. It was hospital care that was routinely the cause of most dissatisfaction, particularly postnatal care in hospital. Expectations A majority of first time parents reported that they did not have expectations of maternity services. (Most – but not all - second time parents felt that they knew what to expect, based on previous experience). Two key assumptions were made about maternity services: 1. Service users (whether first or second time parents) expected “to be treated well”. There were many examples of hospital experiences from across the ‘seldom heard’ sample where service users felt that this expectation had been disappointed. Not feeling that the service ‘cared’ was the major theme to emerge from this research. 2. An ongoing relationship with a midwife throughout the maternity journey was a consistent expectation across the ‘seldom heard’ audience, particularly amongst first-time parents. Typically, satisfaction was higher amongst those who felt that they had an ongoing relationship with a midwife and lower amongst those who did not. Overall, when service users were aware of what to expect from maternity services, satisfaction tended to increase. When not aware of what to expect, satisfaction tended to decrease. In future, maternity services should consider whether and how to manage service users’ expectations. It will be particularly important to make service users aware of what to expect from hospital services during labour, birth and post-natal care, since this was currently the major source of dissatisfaction. For those new to the UK, the service has the opportunity to set expectations. For those born in the UK, services can start managing expectations at the first point-of-contact (currently the GP) and by improving attendance at antenatal classes. Attendance at antenatal classes was low across the seldom-heard audiences, particularly amongst teenage, single, Pakistani/Bangladeshi and traveller groups, as well as mothers from large families e.g. Turkish and African. A minority who had attended antenatal classes felt that they had been a positive and useful experience. Satisfaction Common factors influencing satisfaction across the seldom heard audience The need for maternity services to engage with groups of service users in a way that demonstrates an understanding of their cultural needs In particular: • Becoming ‘part of the family’ for African parents-to-be; • Providing age appropriate care for teenage parents-to-be; • Offering single mothers-to-be a sense of recognition; • Demonstrating sensitivity to the cultural preferences of Bangladeshi and Pakistani parents-to-be; • Engaging with traveller mothers-to-be ‘on their terms’ The need for maternity services to communicate effectively with different groups of service users from across the seldom heard audience In particular: • Generally improving clarity and direct style of communication preferred by Turkish, African Caribbean and African audiences; • Clear communication regarding choice for the African, Bangladeshi/Pakistani and African Caribbean audiences; • Maintaining an ongoing dialogue with those seeking a particularly close relationship with maternity services (teenage and single mothers to-be). • Encouraging dialogue and offering reassurance to Somali parents-to-be; • Ensuring that Bangladeshi and Pakistani parents-to-be feel sufficiently informed; • Listening to the needs of parents-to-be with disabilities so they feel more in control. The need for maternity services to engage more service users from seldom heard audiences with antenatal services (i.e. antenatal classes) In particular: • Encouraging women with experience of child rearing to attend e.g. Turkish and African mothers-to-be; • Offering antenatal classes which will appeal to different groups e.g. ‘mum only’ (for single and teenage mothers to-be) or ‘women only’ for (Pakistani/Bangladeshi mothers-to-be) or ‘at home’ (for traveller mothers-to-be). The need for maternity services to offer practical support to enable seldom heard groups to engage with maternity services In particular: • Offering single mothers-to-be convenient options for accessing services; • Links to wide-ranging social support for Turkish parents-to-be; • Improving clarity of communication between Turkish, French African and asylum seeker audiences, by involving interpreters where necessary The commonly voiced desire for an ongoing relationship with a midwife was an expression of the wish to improve communication between those providing and using maternity services. In order to fulfil expectations of improved communication without an ongoing relationship with a midwife, the service will need to synthesise a dialogue. This will involve linking different face-to-face interactions along the maternity services pathway, supported by written information. Sensitivity to feeling ‘judged’ when using maternity services was a theme across the ‘seldom heard’ audiences. In this context, cultural misunderstandings could be taken to heart and negatively influence satisfaction. Whilst there were examples of cultural misunderstandings, on other occasions women seeking to explain poor experiences chose to suggest that the service had treated them unfairly, due to their cultural background. Health professionals acknowledged that tension between cultural beliefs and professional advice was likely to be a factor influencing satisfaction. Currently, awareness and understanding of choice varied – particularly between first (less informed about health services) and second (more informed about health services) generations. Health professionals reported that expectations of choice are generally increasing. However, the full range of options need to be publicised for the benefit of the least informed amongst the ‘seldom heard’ groups – otherwise most assume that choices do not exist. Overall, choice emerged as having the potential to increase satisfaction amongst seldom-heard audiences, particularly African and African Caribbean. Trusted relationships with health professionals encouraged service users to value choice. If feeling unsupported regarding choice (i.e. if opportunities to make choices were communicated ineffectively or choices made were not perceived to be respected) the ability to make choices tended to become less meaningful. In future, expectations about choice need to be managed in order to avoid conflict and disappointment (and therefore the suspicion that being offered choice is not meaningful). Choice needs to be communicated effectively by promoting opportunities to make choices, as well as defining the limits of patient choice (i.e. when patient choices may or may not be available or when choices were clinical, rather than patient choices). Ultimately, a majority felt that satisfaction was more likely to grow from being treated with dignity and respect, rather than being offered choice

Research objectives

 

Government policy outcomes for maternity are dependent on the successful engagement of and support provided to women and their partners before, during and after pregnancy and birth. Quantitative evidence suggests that satisfaction with maternity care is lower in NHS trusts in London than in other parts of England: in fact 19 of 27 of London-based trusts have been identified as ‘least well performing’. With quantitative evidence demonstrating that satisfaction levels were lower than average in London, NHS London felt that there was a clear need to identify and address the needs of women accessing maternity services in the capital. The national quantitative survey identified a number of groups who responded more negatively to questions about the quality of care before, during and after birth. These groups were: - Younger women (i.e. under 30 years old); - Women from black and minority ethnic groups (to questions about care during labour and birth); - Women with a self-reported disability; - Single women (i.e. those without a husband or partner). NHS London wanted to understand further the expectations, experiences and needs of these women and their partners in London. However, the projects primary purpose was to hear from those who were least likely to have engaged with the national survey. It was important to include groups of particular importance to NHS London due to their higher levels of poor outcomes and/or higher incidence within the population of London. When discussed collectively, these groups are referred to as ‘seldom heard’ throughout this summary. The overall purpose of the research was to identify opportunities to transform women’s experience of maternity services in London.

Background

 

Government policy outcomes for maternity are dependent on the successful engagement of and support provided to women and their partners before, during and after pregnancy and birth. Quantitative evidence suggests that satisfaction with maternity care is lower in NHS trusts in London than in other parts of England: in fact 19 of 27 of London-based trusts have been identified as ‘least well performing’. With quantitative evidence demonstrating that satisfaction levels were lower than average in London, NHS London felt that there was a clear need to identify and address the needs of women accessing maternity services in the capital. The national quantitative survey identified a number of groups who responded more negatively to questions about the quality of care before, during and after birth. These groups were:

  • Younger women (i.e. under 30 years old)
  • Women from black and minority ethnic groups (to questions about care during labour and birth)
  • Women with a self-reported disability
  • Single women (i.e. those without a husband or partner).

NHS London wanted to understand further the expectations, experiences and needs of these women and their partners in London. However, the projects primary purpose was to hear from those who were least likely to have engaged with the national survey. It was important to include groups of particular importance to NHS London due to their higher levels of poor outcomes and/or higher incidence within the population of London. When discussed collectively, these groups are referred to as ‘seldom heard’ throughout this summary. The overall purpose of the research was to identify opportunities to transform women’s experience of maternity services in London.

Quick summary

 

The overall purpose of the research was to identify opportunities to transform women’s experience of maternity services in London. The research highlighted that the satisfaction curve was ‘u’ shaped. Across the ‘seldom-heard’ sample, satisfaction with antenatal care and postnatal care at home was consistently high. It was hospital care that was routinely the cause of most dissatisfaction, particularly postnatal care in hospital. The common factors influencing satisfaction across the audience were:

  • The need for maternity services to engage with groups of service users in a way that demonstrates an understanding of their cultural needs
  • The need for maternity services to communicate effectively with different groups of service users from across the seldom heard audience
  • The need for maternity services to engage more service users from seldom heard audiences with antenatal services (i.e. antenatal classes)
  • The need for maternity services to offer practical support to enable seldom heard groups to engage with maternity services Ultimately, a majority felt that satisfaction was more likely to grow from being treated with dignity and respect, rather than being offered choice

Audience Summary

Gender

 
Female

Ethnicity

 

Mixed including African, Caribbean, Pakistani, Bangladeshi, Somali, Turkish, Traveller

Methodology

Methodology

 

A qualitative approach was adopted, due to the need to explore and understand the range and nature of views, experiences and behaviours amongst women from seldom heard groups. A mix of qualitative interviewing approaches were employed, including: • depth interviews; • friendship paired depth interviews (two respondents); • and triad interviews (three respondents). The individual or small group format was designed to ensure that respondents felt confident and comfortable to articulate their views about very personal experiences. The fieldwork schedule was structured as follows: 1. Health Professionals: Initially, 12 depth interviews (1 hour duration) were conducted with health professionals involved in delivering maternity services to ‘seldom heard’ groups. 2. Women: Subsequently, 12 two-part customer journey depth interviews (each of 1 hour duration) were conducted with women from ‘seldom heard’ groups expecting their babies within 3-4 weeks. These pre and post birth interviews were designed to capture a sense of ‘real time’ maternity experience 3. Women: 24 depth and 24 pair depth or triad interviews (all1.5 hours duration) were conducted with women who had given birth within the past 6-8 weeks. 4. Partners: In addition, 12 depth interviews (1.5 hours duration) were conducted with fathers whose babies had been born in the past 6-8 weeks. Four fathers were partners of women taking part in the friendship pair/triad interviews. 5. Two observation days were undertaken at centres attended by ‘seldom heard’ groups. A series of 15-20 minute conversations were conducted. These sessions were designed to capture more informal data. The research method was designed to achieve robust qualitative findings,corroborated by different interview approaches. The majority of mothers interviewed in the friendship pairs/triads were asked to recall their experience of maternity services retrospectively (albeit within the very recent past: all had given birth within the previous 8 weeks). Their retrospective views were supported by: 1. The experience of mothers currently using maternity services. Our 12 ‘customer journeys’ provided us with ‘real time’ evidence that the themes to emerge from the friendship pair/triad sample were current. In addition, these interviews allowed us to focus on antenatal experiences which tended to be overshadowed by labour, birth and post natal experiences for the majority of the sample. However, the same ‘U’ shaped satisfaction curve (as described in section 4) emerged across the customer journey sample. 2. The experience of mothers captured in much less formal interview setting, at groups in the community. Once again, these shorter interviews confirmed that the themes to emerge from the friendship pair/triad sample had not been ‘hot-housed’ (i.e. artificially exaggerated due to the interview format). The qualitative sampling was purposive (i.e. non-random) and designed to reach particular ‘seldom heard’ groups. As in all qualitative research, the sample sought to reflect, rather than represent, the relevant research population Per audience: 1 x customer journey, 2 pair depths/triads with mothers, 2 depth interviews and/or triad with mothers, 1 x depth interview with fathers In addition: • 1 x depth interview with health professionals working with each of the communities (12 depth interviews in total); • 1 day at a baby clinic and 1 day at a Sure Start centre which generated 20 x 15 minute informal ‘conversations’.

Data collection methodology

 
Depth interviews

Sample size

 

n=c. 90 (24 depth interviews and 24 pair/triads with women, 12 partner depth interviews)

Fieldwork dates

 

Feb 2010

Contact Name

 
Josie Farnsworth

Role

 
Researcher

Agree to publish

 

Private

Research agency

 
Research Works

COI Number

 
300494