AJOG-anti-phb paper ~ section on Patient Satisfaction

by faithgibson on January 5, 2013

Patient satisfaction

The raison d’etre for planned home birth is increased patient satisfaction. The RCOG-RCM statement emphasizes that the focus should not be exclusively on the physical safety of planned home birth. It is also important to “acknowledge and encompass issues surrounding emotional and psychological well-being.” Birth for women is a rite of passage and a family life event, as well as being the start of a lifelong relationship with her infant.”10

The RCOG-RCM statement is correct to emphasize the biopsychosocial importance of planned home birth.29, 33 Its biopsychosocial advantages include continuity of an empathetic caregiver, the comfort of home, greater control by the pregnant woman, fewer interventions, and less defensive medicine. These advantages become even more salient if the hospital birth option includes provision of care by nonobstetric physicians or poorly supervised trainees and physicians new to practice, lack of in-house anesthesia or neonatal care, and increased intervention rates driven by defensive medicine or unprofessional self-interest to avoid lengthy attendance at labor.

The high rates of transport undercut the raison d’etre of planned home birth. Emergency transport, even in its most humane forms, is psychologically and socially disruptive for the pregnant woman whose expectation to deliver at home has suddenly been dashed. The expectation of normal vaginal delivery at home without intervention is put at risk by the higher rates of operative and cesarean deliveries compared with women who labor in the hospital.34 It is therefore not surprising that a study of Dutch women revealed that the self-reported, persistent levels of frustration including serious psychologic problems in transported women compared with those who labored in a hospital persisted even up to 3 years after birth in 17% of all transported women.35 Most relevant reasons were the necessity of transport from home to the hospital, the inability to cope with pain, the unexpected increased rate of operative deliveries, anxiety about losing the infant during transport, and the dissatisfaction with caregivers. This paper documents that planned home birth, often unpredictably and suddenly, fails to fulfill what is promised to pregnant women and therefore expected by them. Unfortunately, none of the other studies has systematically investigated satisfaction/dissatisfaction with planned birth in an intention-to-treat model.

It also has been demonstrated in the Netherlands that among low-risk women the rate of operative deliveries is higher when they are managed by an obstetrician instead of a midwife.36 This is explained by the high rate of continuous fetal heart rate monitoring and impatience of the obstetrician to tolerate a longer labor time.

Much can and should be done to create a home-like, psychologically, and socially supportive hospital birth to support the legitimate expectations of women for a humane, safe, and undisrupted labor experience with full back-up immediately available.37 Hospital managers and obstetricians should be aware of the fact that a home-like equipped delivery room can reduce the woman’s need for pain relief, even reduce the rate of operative deliveries or episiotomies and increase patient satisfaction.38 It is also useful if pregnant women and their partners are already familiar with the delivery rooms within a hospital and all possibilities of pain relief. A Cochrane review has stated that a continuous 1-to-1 care during delivery can reduce per se operative interventions at the second stage of labor.39

In summary, planned home birth often does not satisfy its raison d’etre, improved patient satisfaction. Professional responsibility requires physician leaders to take measures to improve patient satisfaction, by creating home-birth-like environments that are appropriately staffed not only to ensure patient safety, which is the paramount professional responsibility, but also to ensure patient satisfaction.38 Successful collaborative experience with midwives, either within the hospital or home-birth centers with access to full back-up, have recently been reported.40, 41, 42, 43 We fully support and endorse professionally responsible midwifery but reject professionally irresponsible home-birth midwifery and advocacy of it.

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