Abstract
Background
Women's perceptions of satisfaction with maternity care are an integral part of quality assessment in the context of perinatal outcomes in epidemiological data. We present the results of a nationwide project focused on women's satisfaction and experience with standard care covered by public health insurance in the Czech Republic. The aim is to describe the quality of maternity care as perceived by women, focusing on the information provided and the organisation of care. Based on the results, specific steps should be proposed to optimise the maternity care system in the Czech Republic.
Methods
National questionnaire analytical exploratory study (standardised PREMAPEQ instrument); assisted completion of the questionnaire by ten women; its adaptation according to differences in the national system of care and pilot testing; online data collection 2022 (N=1944); satisfaction rating: 5-point Likert scale; satisfaction clusters = average of responses to a given group of questions (converted to a scale 0-100); effect of sociodemographic characteristics on clusters determined by analysis of variance (ANOVA) with p=0.05; followed by Bonferroni correction for multiple testing and Games-Howell post-hoc tests. Effect size was assessed using Eta-squared for ANOVA results.
Results
Place of birth was associated with women's satisfaction in several areas, to the benefit of large obstetric facilities. Satisfaction of first-time mothers is significantly lower in many areas when compared to multiparous women. A high satisfaction level with the attitude of health professionals in labour wards was identified. A lower satisfaction level with the care organization was identified in postpartum wards. Low satisfaction with the information provided to women throughout all maternity care was found. The lowest satisfaction level was identified in the information about the woman's and baby's health status, care of the baby, and breastfeeding support. Key factors influencing women's experience and satisfaction with care in the Czech Republic include the attitude of health professionals, respect for the women's wishes, access to and sufficiency of information, the possibility of co-decision, choice, and the partner's presence during labour.
Conclusions
The overall level of women's satisfaction with the care provided in the Czech Republic is relatively high, but there are areas where satisfaction lags behind expectations. Women's satisfaction with maternity care must be systematically monitored, and the findings of women's priorities must be continuously addressed.
Keywords: Satisfaction, Quality, Care, Maternity, Respect, Experience, Women
Background
Quality of care, respect, and esteem are crucial stones of satisfaction and positive experience in relationships between caregivers and care recipients for all participants and stakeholders. Quality of health care is defined as effective, safe, and in compliance with people’s and the community’s preferences and needs [1]. Respectful care should be part of evidence-based care (EBC), considering the care recipient´s needs and preferences, and, at the same time, ethical, relational, and communicative dimensions beyond clinical evidence [2]. The above-mentioned principles integrate both the biomedical and partnership components of care, which is emphasised in the care of the woman in motherhood. They have become safe, respectful, and have a woman-centred approach.
The Czech Republic has a long tradition of maternity care at a high medical level. The number of births varied around one hundred thousand per year until 2021. Since 2022, a persistent decline in the birth rate has been recorded at 10% year-on-year (89 thousand births/2023). According to existing demographic models, a downward trend is expected in the following years. The average age of women giving birth steadily rises slightly (30.6 years). The frequency of caesarean section births was 26% in 2023 [3]. Maternal mortality has been low for a long time, reaching approximately 10–15 deaths per 100,000 births. Premature births account for about 6.4% of all births. Perinatal mortality in 2022 reached 4.58‰. A well-functioning system of graded differentiated care for premature births and risky or pathological pregnancies contributes to the achieved perinatological results [4]. The high medical level of care does not always correlate with the subjective perception of the quality of care provided to women.
In terms of integrity, a limitation of the current perinatal care system in the Czech Republic is the lack of full-scale monitoring of women’s satisfaction and the quality of care from the women’s perspective by means other than the above-mentioned statistical results. Public health insurance in the Czech Republic covers a gynaecologist’s care throughout the pregnancy. Currently, there is no option to choose a midwife as a standard care provider for low-risk women, nor is there an option to choose continuous care provided by one known provider or a group of providers covered by public health insurance. Care provided by a selected midwife outside a public health facility is almost always at a direct cost to the woman (which means paid out of pocket). The care of a midwife is automatically covered by public insurance only if she is an employee of a health facility, and then mainly on a flat-rate basis as part of a hospital stay [5].
Most births in the Czech Republic (98%) occur in public maternity hospitals. The current legislation leads to a situation where there is no cumulative reliable data on the number and outcomes of home births in the Czech Republic. It is estimated that 1-1.5% of women choose this option on a planned basis. Independent midwifery centres (outside maternity hospitals) or birthing centres don’t exist, and there is no legislative provision for midwives to provide homebirth care.
The professional medical (primarily obstetric and neonatal) societies in the Czech Republic do not support home births. Therefore, women who choose this alternative to childbirth sometimes give birth without professional medical care. The lack of legislation and transparent rules for births outside healthcare facilities has been repeatedly pointed out. The Constitutional Court of the Czech Republic’s 2024 decision represents a significant shift in the protection of midwives assisting with home births. However, it excludes births outside healthcare facilities from healthcare services covered by public health insurance, and with the possibility of regulation by the state [6].
Women who want to limit their stay in a maternity hospital as much as possible can choose the alternative of an outpatient delivery. The birth itself takes place in the maternity hospital, and two hours after the birth, the woman goes home with the newborn. The limitation of this option is the organisation of follow-up care at home. In the Czech Republic, there isn´t a systematically organised system of reimbursed postpartum home visits by midwives. If a woman is interested in such a service, she must arrange and pay for it herself. Many women do not even know about this possibility. The alternative is to visit a gynaecologist in their office or receive treatment at a health facility. The newborn is under the care of a general practitioner for children and adolescents. Standard postpartum care for mother and baby during the first 48–72 h is mainly provided in rooming-in postpartum wards. It is provided by two separate organisational teams, obstetric and neonatology. Communication and competence confusion can result from such separate care, often incomprehensibly organised for the woman. Both teams generally support breastfeeding, but the information given to women can be inconsistent and confusing for the woman [7, 8].
Standard maternity care provided by gynaecologists is mainly based on secondary and tertiary prevention and routine interventions (so-called care packages). That is, its biomedical component predominates. The disadvantage of such care is that, in many cases, there is not enough time for primary preventive, educational, and women-centred care. In particular, the content of standard care may not always sufficiently take into account the psychosomatic and psychosocial needs of women according to current international recommendations [5, 9–10].
The new approach to care is the focus of the newly established Midwifery Centres, formed recently at obstetric facilities across the Czech Republic. This is a new concept with both outpatient and inpatient components, emphasising individualised care provided by midwives. However, these centres are not yet accessible to all women and do not have a uniform concept [11].
Our paper presents the first quantitative analysis of the results of a study focusing on assessing women’s satisfaction with maternity care, which has been lacking in our setting. The primary objective is to describe the quality of maternity care as perceived by women, focusing on the information provided and the organisation of care, and associated satisfaction with caregiving in early motherhood. The secondary objective is to identify areas with the highest and lowest satisfaction levels.
The practical aim is to challenge the strengths, improve the weaknesses, or overcome barriers to the current care system.
Methods
A national cross-sectional survey using the Pregnancy and Maternity Care Patient’s Experiences Questionnaire (PREMAPEQ) [12] was conducted over 2021–2024 in two phases. The first phase was completed at the end of 2022. We present the results of the first phase. This is an analytical, exploratory study to examine our dataset and possibly identify its hidden structures. The goal is to summarise the main characteristics of the data.
Data collection tool description
The questionnaire design is based on the classic Donabedian structure for assessing care satisfaction and distinguishing between structure, process, and outcomes [13]. The PREMAPEQ consists of four sections that assess women’s satisfaction with care during pregnancy, labour, the postpartum ward, and the home puerperium. The questionnaire was translated into Czech using a double-blind method with a back translation and validation by independent experts, and converted into a digital online form in KoBo Toolbox (safe data collection online platform). A five-point Likert scale ranging from “Not at all” to “To a very large extent” was used to assess women’s satisfaction with most items, with some items having a “Not applicable” option. The target group comprised women who had given birth in the Czech Republic and were 6 weeks to 6 months postpartum. The questionnaire was distributed by designated trained persons in maternity hospitals and the community, and completed online.
As part of the questionnaire adaptation, 10 women were assisted in completing the questionnaire; items they did not understand were identified. The changes in wording reflect the different organisation of the care system in the Czech Republic, especially in the section “perinatal care”, the only supported option in the Czech Republic is labour in a maternity hospital, and “postnatal care” - a different organisation of care in the postnatal period (see above). The authors of the original instrument have granted written consent and agreed upon the changes made. The original instrument was tested for internal consistency across key domains [12]. Each section of the questionnaire has been supplemented with an item identifying women’s use of services and care not covered and reimbursed by public health insurance (e.g., community midwife, doula, lactation consultant, etc.). At the end of the questionnaire, space was left to freely share a woman’s personal story or experience of maternity care, illustrating the questionnaire data. The adapted online questionnaire was piloted from March to May 2022, yielding 497 completed questionnaires.
Data collection process
The first phase of data collection: from May to December 2022, through authorised persons in the postpartum wards of Czech maternity hospitals (from perinatology centres mainly in Brno and Prague, as these two are the facilities with the highest birth rates), through authorised community midwives and social networks of professional organisations. Completing the questionnaire for sensory-disabled women was completed with the assistance of an instructed person. Due to the online form, women from all the health facilities in the Czech Republic could participate without restrictions, for which an information leaflet with a link to the questionnaire in the online form was distributed. To preserve the anonymity of the women and the health facility, the women did not indicate a specific health facility in the questionnaire, but only whether or not they had given birth in a perinatology centre, representing a large maternity hospital with highly specialised care. Non-centralised maternity hospitals include all other maternity hospitals outside of perinatal centres.
Data analysis methodology
We present the exploratory data analysis on questionnaires completed and submitted in 2022. Continuous variables were described using mean and standard deviation, and categorical variables were described using absolute and relative frequencies. In the questionnaire, responses to most questions were linearly transformed from a five-point scale to 0-100 for more sensitive data analysis and presentation. Satisfaction clusters were then calculated as the average responses to a given group of questions. The effect of selected sociodemographic indicators on satisfaction clusters was determined by analysis of variance (ANOVA) using a significance level of 0.05.
The statistical software IBM SPSS Statistics, version 29.0.1, was used. Bonferroni correction was applied to the main ANOVA results to control for multiple testing and reduce the risk of type I error. Subsequently, due to unequal sample sizes, the Games-Howell test was used for post-hoc analysis. Effect size was assessed using Eta-squared (η2) for ANOVA results, with values categorised as small (0.01), medium (0.06), and large (0.14) following Cohen’s benchmarks.
Results
1,944 questionnaires were evaluated, and 607 women reported a story or experience. A qualitative analysis was carried out on the free-text comments, which will be published separately because of the need to describe the findings and a considerable amount of narrative description.
Demographic characteristics of the study population (see Table 1)
Table 1.
Demographic characteristics of the study population (N = 1944)
| N | (%) | ||
|---|---|---|---|
| Age (years) | 24 or less | 165 | 8.5% |
| 25-29 | 652 | 33.5% | |
| 30-35 | 885 | 45.5% | |
| 36 or more | 242 | 12.4% | |
| Parity* | First | 1,046 | 53.8% |
| Second | 630 | 32.4% | |
| Third | 217 | 11.2% | |
| Fourth and more | 51 | 2.6% | |
| Number of foetuses | Singleton pregnancy | 1,920 | 98.8% |
| Twins | 23 | 1.2% | |
| Triplets and more | 1 | 0.1% | |
| Mode of birth | Cephalic vaginal | 1,486 | 76.4% |
| Breech vaginal | 13 | 0.7% | |
| Forceps/ventouse | 85 | 4.4% | |
| Caesarean section | 360 | 18.5% | |
| Birth in perinatology centre | Yes | 849 | 43.7% |
| No | 1,095 | 56.3% | |
| Marital status | Married | 1,205 | 62.00% |
| Cohabiting | 709 | 36.5% | |
| Neither married nor cohabiting | 30 | 1.5% | |
| Education | Primary school/Basic | 22 | 1.1% |
| High school | 634 | 32.6% | |
| Secondary vocational school | 122 | 6.3% | |
| University | 1,166 | 60.00% | |
| Self-rated health | Excellent | 626 | 32.2% |
| Very good | 960 | 49.4% | |
| Good | 303 | 15.6% | |
| Fair | 52 | 2.7% | |
| Poor | 3 | 0.2% |
* Parity the last two categories merged
The most frequent respondents were women aged 26–35 (75.3%) and women with a university degree (60%). The average age of the women in the sample was 30.7 years. Most women (53.8%) were primiparous, 32.4% secundiparous, and 13.8% multiparous; over 80% rated their actual health condition as excellent or very good. 96.4% of the women gave birth in the maternity hospital, 3.1% in the study group gave birth planned at home, and 0.5% gave unplanned birth outside the maternity hospital. 43.7% of the women gave birth in the perinatology centre; 76.4% of the women gave cephalic vaginal birth. In terms of age and parity, the sample group is similar to the general population. The vast majority (73%) of women reported having their chosen birth attendant present, mainly their partners. Some women also reported using services not covered/reimbursed by public health insurance − 39.9% of women during pregnancy, 14.5% during labour, and 33.5% postnatally (on average, about one-third of the women surveyed). The most frequent choices were community midwives, lactation consultants, doulas, or physiotherapists. The results of women’s satisfaction with the care provided are presented in Tables 2, 3 and 4 (Satisfaction with antenatal care, Satisfaction with perinatal care, Satisfaction with postnatal care).
Satisfaction with antenatal care (see Table 2)
Table 2.
Satisfaction with antenatal care
| N (%) | Check-ups by a midwife (SD) | N (% in the category) | Check-ups by a gynecologist (SD) | N (% in the category) | Information during pregnancy care (gynecologist) | N (% in the category) | Information during pregnancy care (midwife) | N (% in the category) | |
|---|---|---|---|---|---|---|---|---|---|
| Where did you give birth? | p = 1,000 | p < 0,001, η² = 0,021 | p < 0,001, η² = 0,021 | p = 0,043, η² = 0,010 | |||||
| Delivery ward at a hospital | 1811 (93,2 %) | 92,9 (13,0) | 209 (11,5 %) | 84,8 (20,0)a | 1766 (97,5 %) | 52,1 (22,5)a | 1782 (98,4 %) | 60,1 (29,9)b | 1065 (58,8 %) |
| Birth centre/without gynaecologist | 64 (3,3 %) | 94,1 (13,3) | 35 (54,7 %) | 80,7 (20,9)ab | 62 (96,9 %) | 40,9 (19,2)b | 64 (100,0 %) | 61,4 (25,4)ab | 52 (81,3 %) |
| Planned home birth | 60 (3,1 %) | 95,8 (8,8) | 33 (55,0 %) | 66,8 (27,5)b | 50 (83,3 %) | 37,3 (24,2)b | 55 (91,7 %) | 75,7 (32,6)a | 41 (68,3 %) |
| Birth outside the hospital (not planned) | 9 (0,5 %) | 100,0 (-) | 1 (11,1 %) | 86,3 (14,3)ab | 8 (88,9 %) | 37,9 (20,2)ab | 9 (100,0 %) | 71,9 (45,8)ab | 4 (44,4 %) |
| How did you give birth? | p = 1,000 | p = 1,000 | p = 0,364 | p = 1,000 | |||||
| Normal birth (cephalic) | 1486 (76,4 %) | 93,2 (13,2) | 227 (15,3 %) | 84,1 (20,5) | 1441 (97,0 %) | 50,8 (22,7) | 1460 (98,3 %) | 61,2 (29,9) | 903 (60,8 %) |
| Forceps/ventouse | 85 (4,4 %) | 94,1 (12,2) | 11 (12,9 %) | 83,8 (17,7) | 82 (96,5 %) | 50,0 (19,2) | 82 (96,5 %) | 57,1 (27,3) | 52 (61,2 %) |
| Breech birth | 13 (0,7 %) | 100,0 (-) | 1 (7,7 %) | 80,8 (26,7) | 12 (92,3 %) | 42,0 (29,4) | 12 (92,3 %) | 47,6 (30,7) | 7 (53,8 %) |
| Caesarean section | 360 (18,5 %) | 94,4 (9,1) | 39 (10,8 %) | 84,8 (20,6) | 351 (97,5 %) | 53,5 (22,8) | 356 (98,9 %) | 60,2 (31,1) | 200 (55,6 %) |
| What is your age? | p = 1,000 | 0.429 | 0.984 | 0.639 | |||||
| 24 or less | 165 (8,5 %) | 95,0 (15,3) | 13 (7,9 %) | 81,1 (21,0) | 162 (98,2 %) | 48,7 (20,6) | 163 (98,8 %) | 55,7 (29,6) | 111 (67,3 %) |
| 25-29 | 652 (33,5 %) | 92,2 (13,5) | 87 (13,3 %) | 83,6 (21,1) | 625 (95,9 %) | 51,0 (21,9) | 636 (97,5 %) | 60,4 (28,1) | 395 (60,6 %) |
| 30-35 | 885 (45,5 %) | 94,0 (11,8) | 140 (15,8 %) | 85,1 (19,9) | 867 (98,0 %) | 51,3 (23,2) | 876 (99,0 %) | 61,2 (31,1) | 519 (58,6 %) |
| 36 or more | 242 (12,4 %) | 93,4 (12,4) | 38 (15,7 %) | 85,0 (20,4) | 232 (95,9 %) | 53,3 (23,6) | 235 (97,1 %) | 64,2 (31,1) | 137 (56,6 %) |
| What is your highest completed level of education? | p = 1,000 | p = 1,000 | p = 0,008, η² = 0,008 | p = 0,243 | |||||
| Primary school/basic | 22 (1,1 %) | 95,0 (0,0) | 1 (4,5 %) | 82,4 (24,4) | 19 (86,4 %) | 49,5 (18,9)a | 21 (95,5 %) | 42,4 (27,6) | 12 (54,5 %) |
| High school | 634 (32,6 %) | 95,3 (9,2) | 54 (8,5 %) | 83,8 (20,3) | 613 (96,7 %) | 53,8 (24,1)a | 621 (97,9 %) | 58,9 (30,7) | 388 (61,2 %) |
| Secondary vocational school | 122 (6,3 %) | 92,9 (12,4) | 21 (17,2 %) | 85,8 (19,6) | 118 (96,7 %) | 53,3 (25,8)a | 121 (99,2 %) | 62,5 (31,2) | 80 (65,6 %) |
| University | 1166 (60,0 %) | 92,9 (13,4) | 202 (17,3 %) | 84,3 (20,6) | 1136 (97,4 %) | 49,7 (21,3)a | 1147 (98,4 %) | 62,0 (29,4) | 682 (58,5 %) |
| Overall, would you say your health is… | p = 1,000 | p = 0,021, η² = 0,008 | p = 1,000 | p = 0,173 | |||||
| Excellent | 626 (32,2 %) | 94,0 (13,1) | 105 (16,8 %) | 86,1 (19,6)a | 609 (97,3 %) | 50,6 (23,1) | 618 (98,7 %) | 63,7 (31,1) | 371 (59,3 %) |
| Very good | 960 (49,4 %) | 93,0 (12,8) | 130 (13,5 %) | 84,0 (20,3)ab | 933 (97,2 %) | 51,7 (22,5) | 943 (98,2 %) | 60,9 (29,2) | 551 (57,4 %) |
| Good | 303 (15,6 %) | 93,4 (10,3) | 38 (12,5 %) | 82,0 (21,8)b | 291 (96,0 %) | 51,4 (22,3) | 296 (97,7 %) | 55,6 (29,6) | 201 (66,3 %) |
| Fair | 52 (2,7 %) | 88,8 (16,0) | 4 (7,7 %) | 79,5 (22,4)ab | 50 (96,2 %) | 51,2 (21,6) | 50 (96,2 %) | 58,6 (31,4) | 38 (73,1 %) |
| Poor | 3 (0,2 %) | 100,0 (0,0) | 1 (33,3 %) | 63,3 (35,1)ab | 3 (100,0 %) | 34,5 (4,1) | 3 (100,0 %) | 68,8 (0,0) | 1 (33,3 %) |
| How many times have you given birth in the past? | p = 1,000 | p = 1,000 | p = 0,041, η² = 0,007 | p = 0,538 | |||||
| Never | 1046 (53,8 %) | 92,6 (13,2) | 155 (14,8 %) | 83,5 (20,4) | 1023 (97,8 %) | 49,6 (22,0)b | 1032 (98,7 %) | 58,9 (29,4) | 618 (59,1 %) |
| 1 | 630 (32,4 %) | 94,8 (11,5) | 74 (11,7 %) | 84,8 (20,6) | 608 (96,5 %) | 53,3 (23,0)a | 614 (97,5 %) | 63,2 (30,3) | 374 (59,4 %) |
| 2 | 217 (11,2 %) | 94,5 (10,4) | 39 (18,0 %) | 86,4 (20,2) | 209 (96,3 %) | 52,3 (23,1)ab | 214 (98,6 %) | 62,1 (30,2) | 144 (66,4 %) |
| 3 | 45 (2,3 %) | 91,5 (18,1) | 10 (22,2 %) | 82,4 (22,8) | 40 (88,9 %) | 55,4 (26,0)ab | 44 (97,8 %) | 65,6 (36,6) | 24 (53,3 %) |
| 4 or more | 6 (0,3 %) | - | 0 (0,0 %) | 80,0 (19,2) | 6 (100,0 %) | 60,1 (22,4)ab | 6 (100,0 %) | 37,5 (53,0) | 2 (33,3 %) |
| Did you give your last birth in a perinatology centre? | p = 1,000 | p < 0,001, η² = 0,011 | p = 0,005, η² = 0,005 | p = 0,380 | |||||
| Yes | 849 (43,7 %) | 94,3 (11,4) | 124 (14,6 %) | 86,6 (19,1) | 830 (97,8 %) | 53,1 (22,1) | 838 (98,7 %) | 62,4 (29,3) | 527 (62,1 %) |
| No | 1095 (56,3 %) | 92,7 (13,5) | 154 (14,1 %) | 82,3 (21,3) | 1056 (96,4 %) | 49,8 (22,9) | 1072 (97,9 %) | 59,4 (30,5) | 635 (58,0 %) |
The p-values of the ANOVA statistical test are listed in the question title line, and statistical significance < 0.05 is highlighted
The category description rows describe the absolute and relative frequency, the value of the satisfaction cluster in mean (SD) format and the number of women who responded to a given set of questions and their relative frequency within that category
a,bPost-hoc Games-Howell test. Groups sharing the same letter do not differ statistically from each other. If they have different letters (e.g., one has a and the other has b), there is a statistically significant difference between them (p < 0.05)
Note: η² represents the effect size (Eta-squared) reported for statistically significant results (p < 0.05)
Pregnancy satisfaction with antenatal care provided by midwives reached a high level (91.5–100). None of the assessed parameters (place of birth, mode of birth, age, education, health status, number of previous births, size of the delivery room) had a statistically significant impact on the rating. Satisfaction with antenatal care provided by the gynaecologist was lower (66.8–86.6). However, this was a significantly larger group of women. In this category, there was an association of place of birth on satisfaction scores, with the highest level of satisfaction among women who gave birth at the maternity hospital (84.8). For a complete description of the situation, we report that the satisfaction level was 86.3 among women who gave unplanned home birth (n = 9) and 66.8 among women who gave planned home birth (n = 60), but the samples were too small for statistical verification. A correlation (p = 0,021, η² = 0,008) was observed between women’s satisfaction with prenatal care provided by a gynaecologist and their overall health status, with satisfaction level clearly associated with better health (86.1–63.3). A difference (p < 0,001, η² = 0,011) was also observed among women who gave birth in a perinatology centre, concentrating complications and pathologies compared to non-centralised maternity hospitals (86.6 and 82.3).
When assessing the sufficiency of information and the availability of information during antenatal care, a relatively low level of satisfaction was recorded in the information provided by registering gynaecologists (34.5–60.1) and midwives (37.5–75.7). The place of birth had an association on satisfaction ratings (p < 0,001, η² = 0,021) within the category of information provision by the gynaecologist, with the highest satisfaction among women who delivered at the maternity hospital (52.1). For a complete description, we report that the lowest satisfaction was among women who gave planned (n = 60) and unplanned (n = 9) home births. For the category of information provided by midwives, the situation was reversed, with the highest satisfaction among women who gave birth, both planned and unplanned, at home, and the lowest satisfaction among women who gave birth in a maternity hospital and midwifery centre. For the category of provision of information in antenatal care by the gynaecologist, there was a relationship between women’s satisfaction and the increasing number of previous births (49.6–60.1) and a difference between women who gave birth in a perinatology centre and women who gave birth in a non-centralised maternity hospital (53.1 and 49.8).
The most valued aspects of midwives’ care in pregnancy were sufficient time given for care (89.7) and a respectful approach (96). For the gynaecologist, women most valued respectful behaviour (89.4) and showing concern for the woman (80.3). Women received the least information from the gynaecologist (e.g., the lowest satisfaction) about breastfeeding and childcare (24.4), mood changes (34.4), pain management options (34.8), and the postnatal period (43.2); the average satisfaction was 51.2. The least information from the midwife (e.g., lowest satisfaction) was about mood changes (39.9), breastfeeding and childcare (52.5), postnatal period (62.6), and pain management options (64.7); mean satisfaction was 60.8.
Satisfaction with care during labour and birth (see Table 3)
Table 3.
Satisfaction with perinatal care
| N (%) | Personal relationships in the delivery ward | N (% in the category) | Resources and organization in the delivery ward | N (% in the category) | Attention to partner in the delivery ward | N (% in the category) | |
|---|---|---|---|---|---|---|---|
| Where did you give birth? | p = 0,031, η² = 0,007 | p = 0,054 | p = 1,000 | ||||
| Delivery ward at a hospital | 1811 (93,2 %) | 82,3 (21,3)a | 1503 (83,0 %) | 79,1 (20,3) | 1503 (83,0 %) | 87,7 (22,0) | 1482 (81,8 %) |
| Birth centre/without gynaecologist | 64 (3,3 %) | 78,1 (21,6)a | 46 (71,9 %) | 78,5 (19,9) | 46 (71,9 %) | 92,1 (15,0) | 46 (71,9 %) |
| Planned home birth | 60 (3,1 %) | 84,7 (16,8)a | 3 (5,0 %) | 79,2 (18,8) | 3 (5,0 %) | 87,5 (17,7) | 2 (3,3 %) |
| Birth outside the hospital (not planned) | 9 (0,5 %) | 35,4 (50,1)a | 2 (22,2 %) | 33,5 (43,0) | 2 (22,2 %) | 100,0 (-) | 1 (11,1 %) |
| How did you give birth? | p = 1,000 | p = 0,860 | p < 0,001, η² = 0,083 | ||||
| Normal birth (cephalic) | 1486 (76,4 %) | 82,3 (21,2) | 1136 (76,4 %) | 79,5 (19,9) | 1136 (76,4 %) | 91,2 (16,3)a | 1119 (75,3 %) |
| Forceps/ventouse | 85 (4,4 %) | 77,8 (23,2) | 71 (83,5 %) | 75,6 (22,8) | 71 (83,5 %) | 90,5 (12,9)ab | 71 (83,5 %) |
| Breech birth | 13 (0,7 %) | 84,5 (15,1) | 11 (84,6 %) | 83,0 (14,7) | 11 (84,6 %) | 94,3 (11,7)ab | 11 (84,6 %) |
| Caesarian section | 360 (18,5 %) | 82,2 (21,7) | 336 (93,3 %) | 78,0 (21,3) | 336 (93,3 %) | 75,9 (33,1)b | 330 (91,7 %) |
| What is your age? | p < 0,001, η² = 0,014 | p < 0,001, η² = 0,017 | p = 0,127 | ||||
| 24 or less | 165 (8,5 %) | 74,4 (26,5)b | 136 (82,4 %) | 71,0 (24,5)b | 136 (82,4 %) | 82,7 (27,1) | 131 (79,4 %) |
| 25-29 | 652 (33,5 %) | 83,3 (19,5)a | 543 (83,3 %) | 80,5 (18,5)a | 543 (83,3 %) | 88,3 (21,7) | 540 (82,8 %) |
| 30-35 | 885 (45,5 %) | 82,9 (21,0)a | 691 (78,1 %) | 79,8 (20,1)a | 691 (78,1 %) | 88,5 (20,2) | 681 (76,9 %) |
| 36 or more | 242 (12,4 %) | 80,7 (22,5)ab | 184 (76,0 %) | 77,3 (21,7)ab | 184 (76,0 %) | 87,6 (23,5) | 179 (74,0 %) |
| What is your highest completed level of education? | 0.440 | 0.417 | 1.000 | ||||
| Primary school/basic | 22 (1,1 %) | 83,1 (17,6) | 19 (86,4 %) | 78,4 (16,1) | 19 (86,4 %) | 93,8 (11,5) | 18 (81,8 %) |
| High school | 634 (32,6 %) | 80,4 (23,7) | 513 (80,9 %) | 77,5 (22,4) | 513 (80,9 %) | 87,5 (23,0) | 501 (79,0 %) |
| Secondary vocational school | 122 (6,3 %) | 85,6 (21,6) | 97 (79,5 %) | 82,8 (19,3) | 97 (79,5 %) | 86,8 (22,8) | 96 (78,7 %) |
| University | 1166 (60,0 %) | 82,6 (20,0) | 925 (79,3 %) | 79,4 (19,2) | 925 (79,3 %) | 88,0 (21,2) | 916 (78,6 %) |
| Overall, would you say your health is… | p < 0,001, η² = 0,021 | p < 0,001, η² = 0,021 | p < 0,001, η² = 0,017 | ||||
| Excellent | 626 (32,2 %) | 84,9 (20,0)a | 486 (77,6 %) | 82,2 (19,0)b | 486 (77,6 %) | 91,6 (16,7)a | 478 (76,4 %) |
| Very good | 960 (49,4 %) | 81,9 (21,5)ab | 771 (80,3 %) | 78,1 (20,6)a | 771 (80,3 %) | 86,4 (23,2)b | 763 (79,5 %) |
| Good | 303 (15,6 %) | 79,3 (21,7)b | 246 (81,2 %) | 77,3 (20,0)a | 246 (81,2 %) | 86,9 (23,2)b | 239 (78,9 %) |
| Fair | 52 (2,7 %) | 74,2 (25,4)ab | 48 (92,3 %) | 70,3 (23,2)a | 48 (92,3 %) | 78,6 (31,7)ab | 48 (92,3 %) |
| Poor | 3 (0,2 %) | 37,5 (22,0)ab | 3 (100,0 %) | 45,0 (33,1)ab | 3 (100,0 %) | 91,7 (14,4)ab | 3 (100,0 %) |
| How many times have you given birth in the past? | p = 0,819 | p = 0,852 | p = 1,000 | ||||
| Never | 1046 (53,8 %) | 81,8 (21,4) | 859 (82,1 %) | 78,4 (20,5) | 859 (82,1 %) | 88,1 (21,3) | 845 (80,8 %) |
| 1 | 630 (32,4 %) | 81,4 (22,0) | 498 (79,0 %) | 78,8 (20,6) | 498 (79,0 %) | 86,8 (23,0) | 492 (78,1 %) |
| 2 | 217 (11,2 %) | 85,4 (18,9) | 166 (76,5 %) | 82,1 (18,6) | 166 (76,5 %) | 89,8 (21,4) | 163 (75,1 %) |
| 3 | 45 (2,3 %) | 84,6 (24,2) | 26 (57,8 %) | 80,6 (20,5) | 26 (57,8 %) | 90,9 (21,1) | 26 (57,8 %) |
| 4 or more | 6 (0,3 %) | 85,0 (16,3) | 5 (83,3 %) | 83,0 (12,4) | 5 (83,3 %) | 85,0 (16,3) | 5 (83,3 %) |
| Did you give your last birth in a perinatology centre? | p < 0,001, η² = 0,012 | p < 0,001, η² = 0,019 | p = 0,015, η² = 0,005 | ||||
| Yes | 849 (43,7 %) | 84,6 (19,0) | 701 (82,6 %) | 82,1 (18,3) | 701 (82,6 %) | 89,6 (20,8) | 693 (81,6 %) |
| No | 1095 (56,3 %) | 80,0 (23,0) | 853 (77,9 %) | 76,5 (21,6) | 853 (77,9 %) | 86,4 (22,5) | 838 (76,5 %) |
The p-values of the ANOVA statistical test are listed in the question title line, and statistical significance < 0.05 is highlighted.
The category description rows describe the absolute and relative frequency, the value of the satisfaction cluster in mean (SD) format and the number of women who responded to a given set of questions and their relative frequency within that category
a,bPost-hoc Games-Howell test. Groups sharing the same letter do not differ statistically from each other. If they have different letters (e.g., one has a and the other has b), there is a statistically significant difference between them (p < 0.05).
Note: η² represents the effect size (Eta-squared) reported for statistically significant results (p < 0.05)
A high level of satisfaction was achieved in assessing the attitude and behaviour of the staff in the labour ward (74.2–85.6), except for unplanned home births (n = 9) and poor health status of women (35.4 and 37.5). Association with the satisfaction rating was shown for the place of birth, age of the woman, health status, and type of maternity hospital (in terms of peri or non-perinatology centre). The highest satisfaction was reported by women who gave birth in a maternity hospital (82.3), were aged 25–29 years (83.3), had an excellent subjectively evaluated health status (84.9), and gave birth in a perinatology centre (84.6). Women’s satisfaction in planned home births (n = 60) could not be assessed due to the low numbers.
A relatively high level of satisfaction was recorded among women with the organisation of care and facilities in labour wards (70.3–83.0). Cases of unplanned home births could not be taken into account due to the low number (33.5). Factors that influenced the satisfaction rating in this category were the age of the women with the lowest satisfaction in the group of women 24 years and below (71.0), the general subjectively evaluated health status of the women, where a correlation was observed with the highest satisfaction level in women with excellent health status (82.2) and birth in a perinatology centre, when compared to births given in a non-centralised maternity hospital (82.1 vs. 76.5).
A high level of women’s satisfaction with the care provided was reported in the category of the approach to the woman’s partner in the labour ward (75.9–94.3). The mode of birth had a significant association on the satisfaction rating, with the highest level of satisfaction in the case of cephalic vaginal birth and vaginal breech birth (91.2 and 91.2). The woman’s age was reflected in the lowest satisfaction rate in the 24 years and below age group (82.7). Higher satisfaction was observed among women with excellent health (91.6) and among women who gave birth in a perinatal centre (89.6).
Women were most satisfied with allowing their partner to be present during the birth (93). The lowest level of satisfaction for these items was in the areas of organisation of labour in the labour ward - who is responsible for care (65.8), the welcome on arrival in the labour ward (70.8), and information given by the obstetrician (73.2) and midwife (50.7). For a more complete picture, we report that the highest levels of satisfaction with the behaviour of healthcare professionals during labour were reported by women who had planned a home birth (84.7); women who gave birth in a labour ward (82.3) were similarly satisfied with the behaviour of the midwife only (78.1). The lowest satisfaction with the behaviour of health professionals was expressed by women who gave birth unplanned outside a maternity hospital (n = 9). However, these cases could not be assessed due to the small number.
Satisfaction with care during the early postnatal period (see Table 4)
Table 4.
Satisfaction with postnatal care
| N (%) | Personal relationships during your postnatal stay | N (% in the category) | Resources and organization during your postnatal stay | N (% in the category) | Attention to partner during your postnatal stay | N (% in the category) | Information about women’s health during your postnatal stay | N (% in the category) | Information and guidance about your child during your postnatal stay | N (% in the category) | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Where did you give birth? | 1.000 | 0.439 | 1.000 | 0.363 | 0.364 | ||||||
| Delivery ward at a hospital | 1811 (93,2 %) | 79,3 (21,8) | 1769 (97,7 %) | 68,1 (21,8) | 1769 (97,7 %) | 58,9 (33,5) | 1684 (93,0 %) | 49,5 (27,0) | 1756 (97,0 %) | 66,0 (28,0) | 1768 (97,6 %) |
| Birth centre/without gynaecologist | 64 (3,3 %) | 78,0 (22,1) | 59 (92,2 %) | 61,7 (22,0) | 59 (92,2 %) | 60,0 (32,3) | 55 (85,9 %) | 40,5 (23,9) | 58 (90,6 %) | 57,9 (31,0) | 59 (92,2 %) |
| Planned home birth | 60 (3,1 %) | 79,2 (29,5) | 2 (3,3 %) | 50,9 (18,9) | 2 (3,3 %) | 75,0 (0,0) | 1 (1,7 %) | 43,8 (8,8) | 2 (3,3 %) | 40,6 (30,9) | 2 (3,3 %) |
| Birth outside the hospital (not planned) | 9 (0,5 %) | 73,3 (22,2) | 5 (55,6 %) | 61,9 (22,1) | 5 (55,6 %) | 70,0 (22,7) | 5 (55,6 %) | 40,0 (20,5) | 5 (55,6 %) | 55,0 (40,8) | 5 (55,6 %) |
| How did you give birth? | 1.000 | 1.000 | 1.000 | 1.000 | 1.000 | ||||||
| Normal birth (cephalic) | 1486 (76,4 %) | 79,3 (21,5) | 1385 (93,2 %) | 67,7 (21,6) | 1385 (93,2 %) | 59,3 (33,1) | 1315 (88,5 %) | 49,3 (26,7) | 1375 (92,5 %) | 65,8 (27,9) | 1384 (93,1 %) |
| Forceps/ventouse | 85 (4,4 %) | 78,0 (22,3) | 83 (97,6 %) | 67,7 (21,2) | 83 (97,6 %) | 60,9 (30,7) | 78 (91,8 %) | 45,4 (24,4) | 82 (96,5 %) | 67,3 (25,4) | 83 (97,6 %) |
| Breech birth | 13 (0,7 %) | 79,5 (23,8) | 11 (84,6 %) | 66,2 (20,0) | 11 (84,6 %) | 43,2 (30,3) | 11 (84,6 %) | 48,9 (37,7) | 11 (84,6 %) | 62,5 (30,6) | 11 (84,6 %) |
| Caesarean section | 360 (18,5 %) | 79,2 (22,6) | 356 (98,9 %) | 68,4 (22,8) | 356 (98,9 %) | 57,9 (35,3) | 341 (94,7 %) | 49,8 (28,0) | 353 (98,1 %) | 64,9 (29,5) | 356 (98,9 %) |
| What is your age? | 0.122 | 0.935 | 1.000 | 1.000 | 1.000 | ||||||
| 24 or less | 165 (8,5 %) | 75,3 (23,5) | 156 (94,5 %) | 65,5 (22,8) | 156 (94,5 %) | 56,8 (33,0) | 150 (90,9 %) | 48,5 (27,9) | 155 (93,9 %) | 62,6 (28,6) | 156 (94,5 %) |
| 25-29 | 652 (33,5 %) | 80,9 (20,4) | 622 (95,4 %) | 69,1 (21,0) | 622 (95,4 %) | 58,5 (33,9) | 591 (90,6 %) | 49,9 (26,0) | 618 (94,8 %) | 66,9 (27,3) | 622 (95,4 %) |
| 30-35 | 885 (45,5 %) | 78,9 (21,9) | 842 (95,1 %) | 67,2 (22,0) | 842 (95,1 %) | 59,1 (33,3) | 803 (90,7 %) | 48,5 (27,5) | 835 (94,4 %) | 65,0 (28,5) | 841 (95,0 %) |
| 36 or more | 242 (12,4 %) | 78,4 (23,5) | 215 (88,8 %) | 68,3 (22,3) | 215 (88,8 %) | 61,7 (33,3) | 201 (83,1 %) | 50,5 (26,6) | 213 (88,0 %) | 66,9 (28,6) | 215 (88,8 %) |
| What is your highest completed level of education? | 1.000 | 1.000 | 1.000 | 0.072 | 1.000 | ||||||
| Primary school/basic | 22 (1,1 %) | 70,8 (23,9) | 21 (95,5 %) | 64,7 (22,6) | 21 (95,5 %) | 56,0 (26,7) | 21 (95,5 %) | 42,5 (32,8) | 20 (90,9 %) | 66,4 (28,3) | 21 (95,5 %) |
| High school | 634 (32,6 %) | 79,6 (21,8) | 594 (93,7 %) | 68,7 (22,3) | 594 (93,7 %) | 60,1 (33,1) | 553 (87,2 %) | 51,2 (29,5) | 589 (92,9 %) | 66,5 (27,9) | 594 (93,7 %) |
| Secondary vocational school | 122 (6,3 %) | 78,3 (25,2) | 117 (95,9 %) | 67,8 (25,1) | 117 (95,9 %) | 61,5 (33,9) | 113 (92,6 %) | 53,5 (29,5) | 117 (95,9 %) | 66,3 (31,7) | 117 (95,9 %) |
| University | 1166 (60,0 %) | 79,3 (21,3) | 1103 (94,6 %) | 67,4 (21,1) | 1103 (94,6 %) | 58,2 (33,7) | 1058 (90,7 %) | 47,8 (24,9) | 1095 (93,9 %) | 65,1 (27,8) | 1102 (94,5 %) |
| Overall, would you say your health is… | p < 0,001, η² = 0,013 | p = 0,001, η² = 0,012 | p = 1,000 | p = 0,042, η² = 0,007 | p = 0,237 | ||||||
| Excellent | 626 (32,2 %) | 81,8 (21,9)a | 589 (94,1 %) | 70,4 (21,9)a | 589 (94,1 %) | 60,8 (34,2) | 565 (90,3 %) | 51,5 (27,2)a | 582 (93,0 %) | 67,2 (28,9) | 589 (94,1 %) |
| Very good | 960 (49,4 %) | 79,3 (20,9)ab | 907 (94,5 %) | 67,6 (21,0)ab | 907 (94,5 %) | 58,8 (33,1) | 867 (90,3 %) | 49,4 (26,3)ab | 901 (93,9 %) | 65,5 (27,2) | 906 (94,4 %) |
| Good | 303 (15,6 %) | 75,4 (22,8)b | 288 (95,0 %) | 64,6 (23,2)b | 288 (95,0 %) | 56,0 (32,5) | 265 (87,5 %) | 45,4 (27,4)b | 288 (95,0 %) | 65,0 (28,8) | 288 (95,0 %) |
| Fair | 52 (2,7 %) | 71,2 (23,7)b | 48 (92,3 %) | 60,4 (21,7)b | 48 (92,3 %) | 58,6 (34,3) | 45 (86,5 %) | 41,8 (30,5)ab | 47 (90,4 %) | 55,4 (28,6) | 48 (92,3 %) |
| Poor | 3 (0,2 %) | 69,4 (27,7)ab | 3 (100,0 %) | 51,0 (34,8)ab | 3 (100,0 %) | 54,2 (50,5) | 3 (100,0 %) | 41,7 (26,0)ab | 3 (100,0 %) | 47,9 (40,2) | 3 (100,0 %) |
| How many times have you given birth in the past? | p = 0,807 | p = 0,006, η² = 0,008 | p = 1,000 | p = 1,000 | p = 0,001, η² = 0,012 | ||||||
| Never | 1046 (53,8 %) | 78,3 (22,4) | 1015 (97,0 %) | 66,1 (22,5)b | 1015 (97,0 %) | 57,9 (33,6) | 973 (93,0 %) | 48,4 (26,4) | 1010 (96,6 %) | 63,1 (28,6)b | 1015 (97,0 %) |
| 1 | 630 (32,4 %) | 80,3 (21,0) | 591 (93,8 %) | 69,6 (21,0)a | 591 (93,8 %) | 60,0 (33,4) | 555 (88,1 %) | 49,4 (27,7) | 584 (92,7 %) | 68,6 (27,1)a | 590 (93,7 %) |
| 2 | 217 (11,2 %) | 80,1 (21,3) | 192 (88,5 %) | 70,1 (20,1)ab | 192 (88,5 %) | 59,8 (32,9) | 182 (83,9 %) | 51,9 (26,8) | 190 (87,6 %) | 68,7 (28,0)ab | 192 (88,5 %) |
| 3 | 45 (2,3 %) | 83,9 (16,5) | 32 (71,1 %) | 74,6 (18,8)ab | 32 (71,1 %) | 68,3 (31,4) | 30 (66,7 %) | 55,5 (28,2) | 32 (71,1 %) | 72,5 (24,8)ab | 32 (71,1 %) |
| 4 or more | 6 (0,3 %) | 90,8 (18,3) | 5 (83,3 %) | 82,5 (20,6)ab | 5 (83,3 %) | 77,5 (22,4) | 5 (83,3 %) | 57,5 (24,4) | 5 (83,3 %) | 82,5 (12,0)ab | 5 (83,3 %) |
| Did you give your last birth in a perinatology centre? | p = 0,001, η² = 0,007 | p = 0,006, η² = 0,006 | p = 1,000 | p = 0,085 | p = 0,029, η² = 0,004 | ||||||
| Yes | 849 (43,7 %) | 81,3 (20,8) | 833 (98,1 %) | 69,6 (20,8) | 833 (98,1 %) | 59,5 (32,8) | 787 (92,7 %) | 50,9 (26,4) | 826 (97,3 %) | 67,6 (27,5) | 833 (98,1 %) |
| No | 1095 (56,3 %) | 77,5 (22,4) | 1002 (91,5 %) | 66,3 (22,5) | 1002 (91,5 %) | 58,6 (34,0) | 958 (87,5 %) | 47,9 (27,3) | 995 (90,9 %) | 64,0 (28,5) | 1001 (91,4 %) |
The p-values of the ANOVA statistical test are listed in the question title line, and statistical significance < 0.05 is highlighted
The category description rows describe the absolute and relative frequency, the value of the satisfaction cluster in mean (SD) format and the number of women who responded to a given set of questions and their relative frequency within that category
a,b Post-hoc Games-Howell test. Groups sharing the same letter do not differ statistically from each other. If they have different letters (e.g., one has a and the other has b), there is a statistically significant difference between them (p < 0.05)
Note: η² represents the effect size (Eta-squared) reported for statistically significant results (p < 0.05)
Satisfaction ratings regarding staff attitude in the postpartum ward ranged from 69.4 to 90.8. Association on satisfaction ratings was observed in the case of the age of the woman, with the lowest satisfaction ratings for women aged 24 years and below. There was a correlation between women’s satisfaction with their health status and women who subjectively assessed excellent health status, who showed the highest satisfaction (81.8). Birth in a perinatology centre was associated with higher satisfaction among women in this category than in a non-centralised maternity hospital (81.3 vs. 77.5).
The lowest level of women’s satisfaction scores was achieved in the organisation of care and facilities in postnatal wards (50.9–82.5). There was a correlation between women’s satisfaction with their health status and the highest level of satisfaction in the group of women with excellent health status (70.4). The number of previous births is also associated with satisfaction scores, with satisfaction increasing with the number of births and reaching the highest level among women who had given birth four or more times (82.5). Women who gave birth in a perinatology centre showed higher satisfaction levels with care organisation and facilities in the postpartum wards than women giving birth in a non-centralised maternity hospital (69.6 vs. 66.3).
Satisfaction with the staff attitude towards the woman’s partner in the postpartum wards was relatively low (43.2–77.5). There was no statistically significant association of any of the evaluated factors.
The low level of women’s satisfaction with the information about their health status in the postpartum ward (41.7–57.5) was influenced by education, with the lowest level of satisfaction in the group of women with primary education (42.5) and health status, with the highest level of satisfaction reported by women with excellent health status (51.5).
Births in a perinatology centre were associated with higher satisfaction rates in this assessed category than births in a non-centralised maternity hospital (50.9 vs. 47.9).
Women’s satisfaction with the level of information about the baby’s condition and education on childcare in postpartum wards ranged from 40.6 to 82.5. Health status was associated with satisfaction ratings, decreasing satisfaction from excellent health status (67.2) to subjectively assessed poor health status of women (47.9). The number of previous births was also associated with satisfaction ratings, with the lowest satisfaction rate among first-time mothers (63.1).
The lowest level of satisfaction among women in the postpartum ward was in the areas of information about women’s health (49.2), especially mood changes (25.8), information about breastfeeding (59.6), and satisfaction with breastfeeding support (62.4). Satisfaction was relatively low with the organisation of care (67.8), and women often did not know who to reach in case of need (37.5). Regarding parity, first-time mothers were the least satisfied with the organisation of care; women with the lowest and highest levels of education were the least satisfied with the information given.
Satisfaction ratings for the attitude of health care professionals in providing health care after discharge from the hospital and during the six-week postpartum period were high (75.2–100). Place of birth was associated with satisfaction ratings, with the highest level of satisfaction reported by women who gave birth in the hospital (90.6). Higher satisfaction rates were reported by women who gave birth electively at home; the low number of cases does not allow for a valid assessment.
The mode of birth was associated with satisfaction ratings. The highest satisfaction rates were reported for women who experienced vaginal extraction and caesarean section (85.0 and 91.4, respectively). Labour in a perinatology centre was associated with higher satisfaction rates in this assessed category than in a non-centralised maternity hospital (91.0 vs. 88.7).
Satisfaction ratings with the health care organisation after discharge and during the six-week postpartum period were high (73.4–93.8). The place of birth was associated with satisfaction ratings, with the highest satisfaction reported by women who gave birth in a perinatology centre compared to a non-centralised maternity hospital (88.8 vs. 85.6).
Satisfaction ratings for the availability of information and information about the woman’s health status after discharge and during the six-week postpartum period were low (4.2–59.4). Place of birth was again associated with satisfaction. Women who gave birth in a perinatology centre were more satisfied than those who gave birth in a non-centralised maternity hospital (51.9 vs. 46.4). Women’s satisfaction with the availability of information and information provided about the child’s health status after discharge from the hospital was higher (52.8–93.8). Again, the place of birth was associated with women’s satisfaction (p < 0,001). Women who gave birth at the perinatology centre were more satisfied than those at a non-centralised maternity hospital (76.8 vs. 70.6).
Discussion
The organisation of maternity care in the Czech Republic differs in several aspects from neighbouring countries. Cases in which a midwife takes over the central part of antenatal care are rare. Obstetricians still assist a large number of physiological births (among low-risk mothers) in Czech maternity hospitals. Although the number of maternity hospitals where midwives take over physiological births has increased recently, these facilities are still in the minority [11, 14]. Community-based midwifery care in the postpartum period does not yet have the support of professional medical societies. It is generally not organised in any way [15, 16]. The model of care described above offers many benefits but can also pose pitfalls. The professional level of health care is very high. However, the disadvantage is the lack of an individualised approach to women, for which there is often insufficient space in such organised care. Sufficient time for thorough education, consideration of individual needs and wishes, and establishing a relationship between the pregnant woman or her family and the health professional is becoming increasingly important, especially nowadays, and women rightly demand these values [17, 18]. Appropriate tools are being sought to objectively map women’s views and satisfaction with the care system. Such information can be used in efforts to optimise care not only from a professional perspective but also from the women’s perspective [19–21].
The evaluation of women’s satisfaction with antenatal care shows a relatively high level of satisfaction overall. In line with international studies, higher satisfaction rates in some aspects are achieved through midwifery care [16, 22, 23]. However, it should be emphasised that this is a significantly smaller and specific group of women who actively seek midwifery care. This fact is very likely to influence the final satisfaction rating. On the other hand, there is no disputing that, for this specific group of women, community midwifery care is the optimal option for maximum individual attention and a positive experience. The need to shift care from the hospital to the community has been discussed for a long time to offer women a continuity-of-care model [24]. Still, there is much to do to bring about real changes in the Czech Republic.
The low level of women’s satisfaction with the assessment of information and availability of information during antenatal care, both by registering gynaecologists and midwives, suggests that this segment of care is not optimally set up. Women planning a home birth are probably met with incomprehension or inappropriate communication from their gynaecologist regarding their choice. It’s not just about the place of birth, but about the relationship between the gynaecologist and the woman. There is a need to find better ways of communicating relevant information to women during antenatal care [25]. The association of parity with women’s satisfaction with information during antenatal care may reflect prior experience. Therefore, our results show that the target group that needs to be primarily aimed at is nulliparous women, the youngest women (≤ 24 years), women with lower education levels, or poorer health status, to ensure equal access to care, which corresponds with other studies [26, 27]. Although the overall effect of educational level appeared significant in our sample, post hoc analysis did not reveal statistically significant differences among specific groups after correction.
The attitude and behaviour of the staff in the labour wards were rated quite positively by the women, as were the facilities in the labour wards and the team’s attitude towards the women’s partners [28]. Women’s satisfaction levels are associated with age, health status, and place of birth. The lowest level of satisfaction with the health professionals towards the woman’s partner was reported by women in the case of caesarean section, and it can be considered a moderately strong effect (η2 = 0.083). This suggests that during operative deliveries (caesarean sections), partners may be neglected by staff more than during spontaneous deliveries. One possible interpretation is that, in many Czech maternity hospitals, the presence of a partner in the operating theatre is still not the norm. The possibility of accompanying the woman after the end of the operation and the subsequent presence of the partner in the postpartum ward is still rather exceptional. The results show that women perceive this fact very critically. There is room for change in established practices [29].
A clear weak point was identified in the assessment of women’s satisfaction with the organisation of care and facilities in the postpartum wards, and similarly with the provision of information on women’s and babies’ health. The fact that women and physiological newborns are cared for two separately organised teams, e.g., neonatologists and neonatal nurses, obstetricians, and midwives pose many pitfalls. The information conveyed often diverges, and women may perceive the care provided as organisationally complicated and uncoordinated, which does not correspond with the World Health Organisation (WHO) and The International Childbirth Initiative (ICI) recommendations [1, 9]. The most vulnerable group is first-time mothers who have no experience of previous births [26]. They need the most support, but our data show that they are not receiving it to the extent that they feel confident. The system is set up to operate routinely and is unable to devote adequate attention to them.
The staff’s attitude towards the woman’s partner in the postpartum wards was also rated unfavourably, which is probably related to the wards’ care organisation, which often does not allow the partner’s continuous presence. A solution could be to reduce the length of hospital stay in postpartum wards in the future. Before that, we need to build a robust and easily accessible network of providers for follow-up care. The average length of time a woman stays in the hospital after birth in the Czech Republic is around 3 days, mainly related to the organisation of newborn care, where the aim is to perform the maximum number of necessary examinations of the newborn after birth.
A positive finding is a high level of women’s satisfaction with the attitude of health professionals in providing health care after discharge from the hospital and during the six-week postpartum period, and with the organisation of this care [30]. The higher level of satisfaction of women who gave birth by vaginal extraction operation and caesarean section may be influenced by more intensive follow-up care for these women, where a higher number of outpatient check-ups are already planned at discharge. Conversely, the availability of information on the health status of the woman after discharge from the hospital and during the six-week postpartum period is an obvious problem. Similarly, there is a lack of information and education about the baby’s health status after discharge from the hospital.
Across most categories, higher satisfaction is evident among women who gave birth in a perinatology centre compared to smaller, non-centralised maternity hospitals. This finding may be due, in addition to the introduction of the latest medical practices, to the efforts of some perinatology centres to copy current trends and to bring contemporary obstetrics as close as possible to the needs and wishes of women. Many smaller maternity centres, in particular, are currently facing resource constraints, which may also affect the quality of care provided. Satisfaction with midwifery care is also evident in the group of women (albeit small in number) who have given birth in a home setting [31].
In many cases, their age and health status also influenced women’s satisfaction ratings. In this sample, younger women reported lower satisfaction. The highest satisfaction across categories was observed among women with excellent health status. These women have minimal associated health problems and do not require a specific type of care beyond standard care. Women’s perceptions of maternity services are an essential indicator of the quality of care and a source of information on critical indicators of the systemic service organisation [32]. Without identifying gaps, changes in the system cannot be made to improve women’s resulting experiences of public health services and care from pregnancy to the first weeks at home with a new baby.
Strengths and limitations of the study
Strengths
This is a cross-sectional nationwide systematic research focused on the satisfaction of Czech women with the functioning of the healthcare system during motherhood (including the antenatal period, during and after childbirth). Similar data on a comparable scale have not been analysed and published before. The results will be used to develop tools to optimise maternity care nationally in the Czech Republic. Based on this nationwide survey, the national strategy for Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) of pregnant women will be incorporated into the national patient satisfaction survey under the Ministry of Health. Interest in the research results has already been expressed by the Government Council for Gender Equality, the Czech Women’s Lobby, professional organisations of midwives, other women’s reproductive rights organisations, and some Czech maternity hospitals.
Limitations
The results may be influenced by the heterogeneity of individual care providers and healthcare facilities, the COVID-19 period was burdened by epidemiological measures, the level of education attained and the associated motivation to complete the questionnaire, with a predominance of university graduates, as well as the possible recollective optimism or pessimism of women. The electronic form of the questionnaire may have been a limitation for some women, potentially introducing selection bias. Any other psychometric evaluation of the Czech-adapted version was not performed. The online version introduces the risk of multiple submissions, but this was not expected given the questionnaire’s length. Completing the questionnaire carries the risk of women’s trauma reactivating without the opportunity to respond adequately and support women. Difficulties in interpreting the data may be caused by the disproportion in sample size between women who gave birth in the hospital (the majority of women) and women who gave planned or unplanned home births. Key variables (age, number of births, education, health status, and level of facilities) are likely interrelated, making it difficult to clearly distinguish independent effects, which limits the causal interpretation of differences across subgroups. Although we have many statistically significant results, their practical significance (η2) is generally low, which reflects the high statistical power of our large sample.
Conclusions
The results of the study suggest that attention should be focused on the needs of specific groups of women who reported the lowest levels of satisfaction with care, particularly regarding the lack of the information provided. Specifically, these are women in the lowest age group (≤ 24 years), with lower education, first-time mothers, and women with subjectively assessed poorer health.
The lowest women’s satisfaction with care, specifically its organisation, information, and support, is reported by women in the early postpartum period. One of the most important issues to address is the inconsistency in information provided by different healthcare professionals in postnatal care, particularly regarding breastfeeding support, mood changes, and points of contact. This inconsistency in information can lead to a negative experience in motherhood.
The aim of the changes based on the study results is to create an environment that fosters a positive experience of pregnancy and childbirth. Attention should also be paid to strengthening midwives’ roles and positions within the standard maternity care system. It is still necessary to monitor and document women’s opinions and experiences regarding the care provided.
Acknowledgements
The authors thank all the women who shared their experiences and gave their time to complete the questionnaire. The authors also thank all the institutions, organisations, and midwives who participated in the data collection.The authors gratefully acknowledge the statistician MSc. Lenka Szczuková for her expert methodological guidance and valuable contributions that enhanced the rigor of the data analysis and interpretation.This work was supported by the Ministry of Health of the Czech Republic under grant no. NU21-09-00564 " The quality of provided prenatal and perinatal care from the Czech woman perspective.” All rights reserved.
Abbreviations
- EBC
Evidence-Based Care
- PREMAPEQ
Pregnancy and Maternity Care Patient’s Experiences Questionnaire
- WHO
World Health Organisation
- ICI
The International Childbirth Initiative
- PROMs
Patient-Reported Outcome Measures
- PREMs
Patient-Reported Experience Measures
Authors’ contributions
**RW: ** Conceptualisation, Methodology, Investigation, Formal analysis, Validation, Writing - Original Draft**LV: ** Conceptualisation, Methodology, Investigation, Formal analysis, Validation, Writing - Original Draft**LH: ** Methodology, Formal analysis, Validation, Writing - Original Draft**MP: ** **Formal analysis, Validation****PB: ** Writing - Review & Editing**MK: ** Investigation, clinical context exerts consultations**AP: ** Supervision Conceptualisation, Methodology, Writing - Review & Editing and Supervision.
Funding
This work was supported by the Ministry of Health of the Czech Republic under grant no. NU21-09-00564 " The quality of provided prenatal and perinatal care from the Czech woman perspective.” All rights reserved.
Data availability
The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This work is a part of the project supported by the Ministry of Health of the Czech Republic under grant no. NU21-09-00564, " The quality of provided prenatal and perinatal care from the Czech woman’s perspective”. We have done our study following the Declaration of Helsinki. The study has been approved by the Ethical Committee of the Medical Faculty of Masaryk University under the registration no. 50/2020 on the 17th of June 2020.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.