Abstract
This survey study assesses patients’ self-reported communication experiences with their maternity care clinicians and examines the association of these experiences with women’s reports of feeling pressure to have interventions during delivery.
Introduction
Shared decision-making, when executed properly, is associated with increased patient satisfaction, improved health outcomes, and reduced health care costs.1 Health care lacking patient input may be associated with unwarranted practice variation and both overuse and underuse of health care. Effective clinician-patient communication may be associated with improved outcomes, but it requires patients to have an active and participatory role. One area that, to our knowledge, has not been explored is maternity care. We assessed patients’ self-reported communication experiences with their maternity care clinicians and examined associations of these experiences with women’s reports of feeling pressure to have interventions during delivery.
Methods
This survey study used nationally representative data from Listening to Mothers III (LTM III),2 an online survey of 2400 English-speaking women (aged 18-45 years) who delivered a single infant in a US hospital between July 1, 2011, and Jun 30, 2012. Data analyses were conducted in June 2019. The Indiana University School of Medicine deemed this study to be exempt from institutional review board review because the data are publicly available. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline.
We examined a series of questions, including, “During a prenatal visit in your most recent pregnancy, did you ever hold back from asking questions or discussing your concerns because…?” We compared women’s responses to with their report of feeling pressured from the clinician to accept an epidural, labor induction, or cesarean delivery.
We examined women’s report of holding back from asking questions by sociodemographic and prenatal characteristics using χ2 tests. Statistical significance was set at 2-sided P < .05. We evaluated associations of holding back with feeling pressure to have an intervention using logistic regression adjusting for clinician type and sex, maternal age, educational level, race/ethnicity, payer source, nativity, marital status, parity, and childbirth education class attendance. Analyses were weighted to be nationally representative and were conducted using survey procedures in SAS, version 9.4 (SAS Institute).2
Results
Of the 2400 women in the sample, most were non-Hispanic white (1458 [55.0%]), US born (2233 [93.0%]), and married (1607 [60.4%]), and most received care from obstetrics and gynecology specialists (1734 [70.9%]) (Table). More than 41.0% of women (n = 984) reported that they held back from asking their clinician questions. Their perceived reasons included the clinician seemed rushed (29.6%), they wanted care that differed from the clinician’s preference (20.5%), and fear of being perceived as difficult (23.3%). Younger, nulliparous women receiving care from health care workers who were not obstetrics and gynecology specialists or from female clinicians were the most likely to hold back from asking question (Table). These women also frequently reported feeling discriminated against for various reasons. After adjustment, women who held back from asking questions were more than 5 times more likely to report feeling pressure to have an intervention (adjusted odds ratio, 5.3; 95% CI, 4.0-7.1).
Table. Characteristics of Women Who Reported Holding Back From Asking Questions.
| Characteristic | Women, No. (%)a | P value | |
|---|---|---|---|
| Total (N = 2400) | Held back from asking questions (n = 984) | ||
| Type of maternity care clinician | |||
| Obstetrics and gynecology specialist | 1734 (70.9) | 663 (37.1) | .001 |
| Family medicine doctor | 298 (13.4) | 152 (50.8) | |
| Midwife | 221 (9.9) | 90 (46.0) | |
| Other | 147 (5.7) | 79 (55.2) | |
| Clinician sex | |||
| Female | 1490 (61.0) | 650 (44.7) | .001 |
| Male | 910 (39.0) | 334 (35.0) | |
| Age, y | |||
| 18-24 | 601 (31.8) | 302 (50.1) | <.001 |
| 25-34 | 1336 (53.1) | 553 (39.3) | |
| ≥35 | 463 (15.1) | 129 (27.1) | |
| Education al level | |||
| High school or GED | 466 (42.3) | 180 (38.0) | .14 |
| Some college or associate's degree | 581 (18.4) | 240 (41.2) | |
| College degree or greater | 1353 (39.3) | 564 (43.8) | |
| Race/ethnicity | |||
| Non-Hispanic white | 1458 (55.0) | 557 (38.7) | .047 |
| Non-Hispanic black | 309 (15.3) | 129 (39.1) | |
| Non-Hispanic other race | 181 (6.5) | 91 (54.4) | |
| Hispanic/Latina | 452 (23.1) | 207 (43.4) | |
| Payer source | |||
| Private | 1317 (46.9) | 498 (39.4) | .52 |
| Public or Medicaid | 1018 (53.1) | 455 (41.2) | |
| Nativity | |||
| US born | 2233 (93.0) | 904 (40.4) | .29 |
| Foreign born | 167 (7.1) | 80 (46.9) | |
| Married at the time of birth | |||
| Yes | 1607 (60.4) | 613 (39.1) | .14 |
| No | 793 (39.6) | 371 (43.5) | |
| Prior deliveries | |||
| None | 1144 (40.7) | 469 (47.1) | <.001 |
| ≥1 | 1256 (59.3) | 515 (36.3) | |
| Attended childbirth education classes | |||
| Yes | 919 (34.2) | 451 (50.8) | <.001 |
| No | 1481 (65.8) | 533 (35.7) | |
| Felt discrimination owing to race/ethnicity, culture, or language | |||
| Never or sometimes | 2270 (94.0) | 879 (38.2) | <.001 |
| Usually or always | 130 (6.1) | 105 (82.4) | |
| Felt discrimination owing to health insurance | |||
| Never or sometimes | 2252 (91.8) | 868 (37.4) | <.001 |
| Usually or always | 148 (8.2) | 116 (80.4) | |
| Felt discrimination owing to a difference of opinion | |||
| Never or sometimes | 2230 (90.8) | 845 (36.5) | <.001 |
| Usually or always | 170 (9.3) | 139 (83.7) | |
| Clinician used medical words you did not understand | |||
| Never or sometimes | 2098 (85.3) | 802 (37.4) | <.001 |
| Usually or always | 302 (14.7) | 182 (60.9) | |
| Clinician spent enough time with you | |||
| Never or sometimes | 446 (20.3) | 340 (71.5) | <.001 |
| Usually or always | 1954 (79.7) | 644 (33.1) | |
| Clinician answered questions | |||
| Never or sometimes | 323 (15.5) | 250 (73.9) | <.001 |
| Usually or always | 2077 (84.5) | 734 (34.8) | |
| Clinician encouraged discussion about health questions or concerns | |||
| Never or sometimes | 482 (23.3) | 342 (67.4) | <.001 |
| Usually or always | 1918 (78.7) | 642 (33.7) | |
Sample sizes are unweighted. Percentages are weighted estimates.
Discussion
Patients need authority to make choices about their care without feeling coerced.3 Similar to the situation in nonmaternity settings,4 we found that many pregnant women may be reluctant to engage in the decision-making process. A total of 41.0% of women reported holding back from asking their maternity care clinician questions, and that reluctance was associated with greater odds of reporting feeling pressured to have an intervention. In other work, women who perceived pressure from clinicians for labor induction or cesarean delivery were more likely to undergo these procedures regardless of medical indication.5
These cross-sectional data could not determine directionality of these associations and are subject to recall bias. Nevertheless, this was the first study, to our knowledge, to examine patient-held fears of voicing disagreement and being perceived as difficult as barriers affecting maternity care. Findings suggest a breakdown in communication that is associated with women not fully participating in their maternity care. This presents an opportunity for interventions focused on patient activation.6 Such efforts should encourage women to ask questions and also help clinicians create an environment for open communication. We believe that both are needed to make sure the preferences of women are considered.
References
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