Howell, Elizabeth A. MD, MPP
Women experience a range of physical and emotional symptoms postpartum, but many are surprised by their occurrence.1,2 Research has shown that preparation and patient education for the labor and delivery experience can help prepare women, as evident by increased satisfaction with the childbirth experience and reduced perception of pain and anxiety.3–5 It remains an open question whether such education can improve satisfaction with the clinician or reduce maternal stress associated with the postpartum experience.
In addition to the intrinsic value of a satisfied patient, satisfaction with doctors and medical treatment are important determinants of adherence to medical treatment and follow-up.6 In addition, satisfied patients are less likely to “physician shop” or disenroll from health plans.7,8 Clinicians can influence a woman’s perception of her preparation for the experience of childbirth. Receipt of information for the labor and delivery experience has been associated with obstetric patient satisfaction with the birthing experience, and insufficient information is highly correlated with dissatisfaction with care during labor.9
This study incorporates a patient-centered perspective to assess the extent to which counseling by obstetricians and midwives succeeded in preparing their patients to expect the possibility of experiencing specific, common postpartum physical and emotional symptoms and the extent to which such preparation was associated with higher levels of satisfaction with the patient’s obstetric clinician.
We previously have described our method and patient population in detail.10 Data were collected in the context of a prospective longitudinal cohort study, approved by The Mount Sinai School of Medicine Institutional Review Board.10 Our racially and ethnically diverse patient population included postpartum women who delivered without complications at a major urban tertiary care academic medical center between January and September of 2002 in New York City. Inclusion criteria for patients were age 18 years or older, English- or Spanish-speaking, and delivery of generally healthy neonates as indicated by birth weights of at least 2,500 g and 5-minute Apgar scores higher than 6. Patients were excluded if they were hospitalized for more than 3 days after vaginal deliveries and more than 5 days after cesarean deliveries. We identified postpartum women through the Labor and Delivery Log and asked consecutive eligible patients (Monday through Friday) to participate during their postpartum hospitalization. All obstetric clinicians delivering neonates at the participating hospital were obstetricians or midwives.
The key data for this article come from a cross-sectional interview of women that was conducted between 2 and 6 weeks after they had given birth (mean=31.2 days). We reached and completed surveys for 724 women—62% of those eligible for participation. Interviewers collected information about demographics, physical symptoms, emotional symptoms, the extent to which women recalled being prepared to expect common physical and emotional symptoms, perceptions of and satisfaction with their doctor or midwife, and other factors. Data about subsequent health care use come from a second interview conducted approximately 3 months postpartum, for which were able to reach 621 (86%) of those who had previously completed the first interview.
Our survey instrument used validated scales when available and developed new scales based on the results of earlier focus groups with postpartum women and obstetric providers as well as extensive literature searches. The new questions addressed the content and used the language of the focus-group participants. The survey was pilot-tested with 18 women. The baseline survey asked patients to think back to the first 2 weeks after they delivered their newborns and answer a series of questions. The 3-month survey asked patients questions about their postpartum visit.
Our primary variables of interest included the extent to which their obstetric clinicians’ counseling regarding potential symptoms had succeeded in preparing women to experience the symptoms and their satisfaction with the doctor or midwife. We defined preparation for a specific experience (eg, vaginal bleeding) in terms of the woman’s perception and recall that her obstetric clinician had cautioned her that she might experience that sign or symptom. We inferred satisfaction with the clinician on the basis of the response (on a five-point Likert scale) to a question used in hospitals that rates overall care and concern shown by the doctor or midwife.11–13 The distribution of responses was skewed, and we therefore dichotomized the scale into rating the clinician as excellent versus not rating the clinician as excellent.
We assessed patient-centered adequacy of preparation in two ways: symptom specific and global. The symptom-specific assessment included items asking participants whether their obstetric clinician had told them that they might experience 1 of 11 common physical and emotional symptoms postpartum: vaginal bleeding, cesarean delivery or episiotomy site pain, breast pain, hemorrhoids, urinary incontinence, breastfeeding problems, large mood swings, anxiety about taking care of the neonate, bother from their physical appearance, and depression. We considered each question individually and created a simple scale that summed the number of yes responses out of a total of 11 questions. We chose these symptoms based on findings from our focus groups, which suggested that these 11 symptoms were frequent, meaningful to participants, and variably discussed during their obstetric and postpartum care. We assessed a global adequacy of preparation by using responses to the following item: “I wish my doctor (or midwife) would have prepared me more about what I would feel after I had my baby.” Patients answered with a five-point response scale (disagree strongly, disagree, neither disagree nor agree, agree, agree strongly). Patients who agreed or agreed strongly were classified as having a perceived lack of preparation by their clinician.
By interpreting these variables as the construct of patient-centered adequacy of preparation, we avoid the concern about whether the clinician actually said something on the topic to the patient. The question instead becomes whether the clinician’s anticipatory counseling was adequate to meet the needs of the individual patient given the woman’s level of comprehension, stress, and other factors that predictably could affect memory and learning in the clinical encounter.14
Physical symptoms were assessed by the presence or absence of eight physical symptoms (vaginal bleeding, cesarean delivery site or episiotomy site pain, breast pain, urinary incontinence, headache, backache, hemorrhoids, and hair loss). We created a simple scale that summed the number of yes responses out of a total of eight symptoms. Depression was assessed using the Patient Health Questionnaire 2, which has been validated in the primary care, antepartum, and postpartum settings.15,16 We also asked a question on overall self-assessed health.17
We developed three questions on access to the clinician based on work from Safran et al.18 Patients rated their ability to get through to the doctor’s or midwife’s office by phone, ability to speak to their clinician by phone, and ability to see the clinician if the patient thought they needed to. All questions had six-point Likert response scales with a possible range of 0-15 (Cronbach α=0.87). We also measured trust in the obstetric clinician and having a regular doctor.18 Maternal demographics included age, marital status, education, and race. Parity and delivery type were obtained from review of medical records.
All statistical analyses were performed using PC SAS 8.2 (SAS Institute Inc., Cary, NC). Univariable analyses were conducted using χ2 tests to evaluate the association of clinician preparation for common physical and emotional symptoms, overall preparation for the postpartum experience, maternal demographics, presence of physical and emotional symptoms, self-assessed health, access, and having a regular doctor with satisfaction with obstetric clinician. We used the McNemar χ2 test to assess the marginal distribution of women who experienced symptoms compared with that of women who were adequately counseled to expect symptoms.19 We used the κ statistic to assess the extent to which clinicians’ clinical judgment allowed them to prepare specific patients selectively for specific symptoms.19 Multivariable logistic regression models assessed the independent association of maternal demographics, preparation for 11 common physical and emotional symptoms, overall preparation, perceptions of health care, and other factors with satisfaction with the clinician.
The patient sample was racially/ethnically and socioeconomically diverse. Women who rated their clinician as excellent were more likely to be older, to be white, and to have more than a high school education and were less likely to have Medicaid insurance (Table 1).
We found variability among the sample in all the relevant variables: symptom experience, extent of preparation, and satisfaction. Although many women experienced postpartum symptoms, many also frequently reported feeling unprepared by their clinicians for these experiences (Table 2). The prevalence of symptoms ranged from 18% for hair loss to 98% for vaginal bleeding. Many women had no recollection of being prepared to experience many of these symptoms, with only 24% reporting having been prepared to expect urinary incontinence, and less than half were prepared to expect breastfeeding problems, hair loss, hemorrhoids, large mood swings, or anxiety. For 9 of the 11 symptoms, the proportion of women who experienced the symptom significantly differed from the proportion of women who were prepared for those symptoms (P<.001). The κ statistic for all 11 comparisons was less than 0.15, revealing poor agreement between these patients’ experience of symptoms and their sense of having been cautioned in advance to expect them.
Twenty-three percent of patients reported overall inadequate preparation by their clinician (Table 3). Nearly three quarters of patients had a regular doctor or midwife, and the majority of patients had complete trust in their clinician. Sixty-one percent of patients rated their clinician as excellent. Rating a clinician as excellent was more common in women who did not report poor self-assessed health, had a regular doctor, had more access to care, and were better prepared for the postpartum experience in univariable analyses (Table 4). Physical symptom burden and positive depression screen were not associated with rating of the clinician in univariable analyses.
After adjusting for maternal demographics, self-assessed health, access, and having a regular doctor in a multivariable model, the odds of rating the clinician as excellent were higher for women with better access to care (adjusted odds ratio [OR] 1.22, 95% confidence interval [CI] 0.81-1.84) and adequate preparation for common physical and emotional postpartum symptoms (OR 1.08, 95% CI 1.01-1.6). In adjusted analyses, women who reported being unprepared were less likely to rate their clinician as excellent (OR 0.40, 95% CI 0.26-0.62).
Eighty-six percent of women (621) were interviewed at 3 months postpartum. Rating a clinician as excellent was strongly associated with completing a postpartum visit within 3 months postpartum (P<.001).
One critical part of care during the obstetric period is helping to prepare the pregnant women to function as a mother. The American Academy of Pediatrics recommends at least one prenatal pediatric visit and close health supervision postpartum.20 Anticipatory guidance is the pediatric term for preparing families for things that may be expected to occur during growth and development.20 There is an obstetric analog. Postpartum women may predictably experience a range of physical and emotional symptoms after giving birth: Although one never knows what any given woman will experience, clinical experience and epidemiologic data are available to inform practice.
This study finds that postpartum women are not prepared adequately for specific, common postpartum physical and emotional symptoms and that nearly a quarter of postpartum women report not having been adequately prepared in general. Obstetric anticipatory counseling did not prepare this population of women for these symptoms, did not match counseling with those women who would experience specific symptoms, and was delivered at rates that systematically varied from the rates that the women experienced symptoms. This lack of preparation was consequential both in terms of patient satisfaction and in terms of returning to the obstetric clinician for timely receipt of follow-up care. The pattern of findings suggests that adequate counseling of all women for all common or highly consequential symptoms (rather than targeted counseling) is likely to be the most desirable strategy.
Our patient-centered approach to assessing adequate preparation by clinicians integrates both clinician behavior and the effectiveness of their behavior. We cannot comment on whether the clinician said anything on the topic to the patient; instead, we find that, at best, things are not said in a way that the patients in our study understood. Counseling needs to penetrate a level of stress, competing priorities, and uncertainties experienced by most patients. It can also be threatened by retroactive inhibition, the human tendency to only remember the latter part of a list or any series of similar items.21 Perhaps the use of a checklist of symptoms may be ineffective at informing or preparing patients, compared with a conversation that engages the patient in a context meaningful to the topic.21
Receipt of information can improve the experiences of women during childbirth, and information is thought to be an important predictor of overall obstetric satisfaction.9,22 Although other areas of medicine have demonstrated that adequate preparation through discharge instructions are helpful for pain control and recovery, there is limited prior evidence about whether preparing women to experience specific, common postpartum physical and emotional symptoms is consequential.23,24 Consistent with the general theme of the literature, we find that it is.18,25,26
Women who do not feel adequately prepared are less satisfied with their clinicians and are less likely to go to their postpartum visit. It takes time to counsel patients well and to engage them in meaningful dialogue about their experiences and what they may expect. Some clinicians may prefer not to counsel women about symptoms they will not expect because they do not want to worry them. Viewing our study participants as experts on themselves suggests that the net effect of helping patients to feel prepared has a positive effect both on their experience and on their behavior. Our study participants experienced a range of physical and emotional symptoms postpartum consistent with those in other studies.27
Our findings are limited by the predominantly cross-sectional design, which required women to recall their experiences. The study design does not allow us to conclude that lack of preparation for postpartum physical and emotional symptoms caused lower patient satisfaction with the clinician or diminished follow-up. We cannot distinguish whether unsatisfied women are less likely to recall adequate preparation or whether women without adequate preparation later report reduced satisfaction with their clinician. In addition, we infer satisfaction with the clinician based on the response to a question that is not a comprehensive measure of satisfaction. However, responses to this question were associated with health care-seeking behavior.
This article provides evidence that effective anticipatory counseling in obstetric practice can make a difference in terms of satisfaction and patient adherence. Women who perceived themselves as adequately prepared had higher satisfaction, and satisfied women were more likely to return for postpartum follow-up. Anticipatory counseling that is universal and of higher quality may improve both patient satisfaction and adherence even further. The literature suggests that such counseling may be more effective when it engages the patient in a dialogue that is meaningful in the context of the visit. Perhaps better preparation for such counseling by obstetric clinicians can improve the quality and experience of postpartum care.
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© 2010 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.