Les soins obstétricaux que les femmes attendent de leurs médecins de famille Sue Douglas MD CCFP Catherine Cervin MD FCFP Kelly Nicol Bower MSc RÉSUMÉ OBJECTIF Déterminer ce que les femmes attendent comme soins obstétricaux de la part des médecins de famille et l expérience qu elles en ont TYPE D ÉTUDE Entrevues en profondeur semi-structurées individuelles à 36 semaines de grossesse et 6 semaines postpartum. CONTEXTE Cabinets de médecine familiale à Halifax, Nouvelle-Écosse. PARTICIPANTES Sur les 6 femmes primigestes à faible risque recrutées par 5 médecins de famille féminins, 5 ont complété l entrevue postpartum. MÉTHODE Des entrevues d une à deux heures ont été effectuées à l aide d un guide d entrevue non structuré. Elles ont été enregistrées sur ruban magnétique et transcrites intégralement. On a utilisé la théorie ancrée pour analyser les données. PRINCIPALES OBSERVATIONS Les attentes des femmes tombent dans 4 catégories principales: apport d information, support émotionnel, explications des décisions et soins professionnels adéquats. Concernant le rôle des médecins, les attentes étaient semblables dans certains domaines et diverses dans d autres. Toutes les femmes s attendaient à ce que le médecin fournisse de l information, écoute et respecte leur désir et prodigue des soins médicaux de qualité. Certaines s attendaient à ce que le médecin fournisse un support émotionnel et de l aide aux décisions alors que d autres ne s y attendaient pas. On notait une incertitude évidente quant au rôle du médecin de famille dans la préparation à la naissance. Les participantes ont attribué plusieurs rôles différents au médecin de famille comme dispensateur de soins obstétricaux. Ces rôles correspondaient à un type holistique de soins répondant aussi bien aux besoins psycho-sociaux que biomédicaux des femmes qui vont donner naissance. CONCLUSION D autres études seront nécessaires pour définir les rôles du médecin de famille dans les soins obstétricaux et pour décrire comment ces rôles s intègrent aux rôle analogues joués par les autres intervenant de l équipe obstétricale. Points de repère du rédacteur Cet article a fait l objet d une révision par des pairs. Le texte intégral est aussi accessible en anglais à www.cfpc.ca/cfp. Can Fam Physician 2007;53:874-879 Recherche Ce que les femmes pensent du rôle de plusieurs des intervenants dispensant des soins obstétricaux tels les infirmières, sages-femmes et doulas a déjà fait l objet d études. Les auteurs de cette étude n ont pu trouver aucune étude sur les soins obstétricaux que les femmes attendent des médecins de famille et sur l expérience qu elles en ont. Les résultats montraient que les médecins assument différents rôles comme dispensateurs de soins obstétricaux. On croyait qu ils devaient fournir des informations, un support émotionnel et des soins professionnels en plus d expliquer et de partager les décisions. Toutefois, un réserve s impose: les femmes interrogées étaient toutes désignées par leurs médecins de famille, d où le risque d une partialité dans la sélection. 874 Canadian Family Physician Le Médecin de famille canadien Vol 53: may mai 2007
What women expect of family physicians as maternity care providers Sue Douglas MD CCFP Catherine Cervin MD FCFP Kelly Nicol Bower MSc Research ABSTRACT OBJECTIVE To explore women s expectations and experiences of family physicians as maternity care providers. DESIGN In-depth semistructured one-on-one interviews were conducted at 36 weeks gestation and at 6 weeks postpartum. SETTING Family practices in Halifax, NS. PARTICIPANTS Five female family physicians recruited a total of 6 low-risk primigravida women. Five of the 6 women completed follow-up interviews. METHOD Interviews lasting 1 to 2 hours were conducted using an unstructured interview guide. Interviews were audiotaped and transcribed verbatim. Data were analyzed using a grounded-theory approach. MAIN FINDINGS Women s expectations fell into 4 main categories: informational support, emotional support, advocacy, and competent professional care. Womens expectations of physicians were consistent in some areas and varied in others. All women expected their physicians to communicate information about their medical care, listen to and respect their wishes, and provide them with competent medical care. Some women expected their physicians to provide emotional support and help with decision making, while others did not. Uncertainty about the role of family physicians in helping women prepare for birth was also evident. Women in our study described a range of roles for family physicians as maternity care providers. These roles reflected a holistic style of care that addresses the psychosocial as well as the biomedical needs of women giving birth. CONCLUSION Research is needed to define family physicians roles as maternity care providers and to describe how these roles fit with similar roles filled by other maternity care providers. This article has been peer reviewed. Full text is also available in English at www.cfpc.ca/cfp Can Fam Physician 2007;53:874-879. EDITOR S KEY POINTS Studies have explored how women perceive the roles of various maternity care providers, such as nurses, midwives, and doulas. The authors of this study were unable to find any research on women s expectations and experiences of family physicians as maternity care providers. Results showed that family physicians assumed a range of roles as maternity care providers. They were seen as providing information, advocacy, emotional support, and professional care. Results of this study should be interpreted with caution. The women questioned were all chosen by their family physicians, so selection bias is an issue. Vol 53: may mai 2007 Canadian Family Physician Le Médecin de famille canadien 875
Research What women expect of family physicians as maternity care providers Giving birth is one of the most profound experiences in women s lives. The birth experience itself is etched into women s memories and shapes their identity as mothers. 1 The quality of the relationships women have with their care providers is a key determinant of whether they have positive birth experiences; these relationships seem more important than medical aspects of care, such as pain control. 2 Family medicine is a holistic style of care that addresses the medical, emotional, psychological, and spiritual needs of patients. 3 Family physicians maternity care should address the psychosocial as well as the medical needs of women during pregnancy and childbirth. Studies have explored how women perceive the roles of various maternity care providers, such as nurses, midwives, and doulas. 4-6 These studies have identified a range of roles for these providers that includes emotional support, advocacy, informational support, tangible support, and professional or medical care. We were unable to find any research on women s expectations and experiences of family physicians as maternity care providers. The purpose of this study was to begin to explore women s expectations and experiences of family physicians as maternity care providers, particularly what family physicians do to assist women during birth. This information could help define the roles of family physicians as maternity care providers. METHODS Design In-depth interviews were conducted with low-risk women at 36 weeks gestation and at 6 weeks postpartum to obtain qualitative information on their birth experiences and on their relationships with and expectations of their physicians. Interviews were scheduled at 36 weeks because this is a time when care providers commonly discuss upcoming labour and delivery with women. We thought women would be reflecting on the upcoming birth experience and on who would be Dr Douglas is currently a Senior Lecturer in General Practice in the Academic Unit of General Practice and Community Health at the Australian National University in Canberra. She was formerly Acting Head of Family Medicine at the IWK Health Centre in Halifax, NS. Dr Cervin is a family physician and an Associate Professor in the Department of Family Medicine at Dalhousie University in Halifax. She was formerly Residency Program Director. Ms Bower is the Regional Epidemiologist at First Nations and Inuit Health, Atlantic Region, for Health Canada in Halifax, NS. She was formerly a research associate with the Department of Family Medicine at Dalhousie University. assisting them during delivery. Interviews were scheduled at 6 weeks postpartum to allow for sufficient recovery time from the birth and to ensure memories of the birth experience were still relatively fresh in women s minds. The Research Ethics Board of the IWK Health Centre in Halifax, NS, approved the study. Participants and setting Participants were recruited by 5 female family physicians providing obstetric care in the municipality of Halifax, which has a population of approximately 500 000. The physicians used purposive sampling to select patients who met the study criteria, specifically women who were healthy, pregnant with their first babies, and being followed by family physicians for obstetric care. These physicians provided eligible patients with information on the study and got interested patients to complete consent forms. All interested participants were contacted by the project interviewer, and all agreed to participate. Women who had been seen by obstetricians or had had serious pregnancy-related complications were excluded from the study. Women from various cultural and demographic backgrounds were not specifically sought, although a range of sociodemographic backgrounds was represented in the sample. Women were in their late 20s to early 30s and lived in urban areas. Six participants were involved in the first interview; five completed the follow-up interview. While only 6 women were interviewed, the interviews lasted 1 to 2 hours in an effort to capture the depth and richness of each individual experience. Data collection Women were contacted by telephone to arrange the interviews. A young woman who had never been pregnant conducted all the interviews. Women were interviewed at the location of their choice. An unstructured interview guide was used, and detailed field notes were taken. All interviews were audiotaped and transcribed within 48 hours of the interview. Transcripts were checked against tapes for accuracy by the interviewer. Member checking was inherent in the postpartum interview, and clarification was sought on missing or conflicting information. Data analysis Analysis was conducted iteratively during the data collection process and was guided by the grounded-theory approach that seeks to develop and understand connections between and among theoretical categories. At least 2 members of the research team independently reviewed each transcript before the next interview took place. Then the team collaborated on refining the interview guide to test emerging theories and to seek alternative views from subsequent participants. After the 876 Canadian Family Physician Le Médecin de famille canadien Vol 53: may mai 2007
What women expect of family physicians as maternity care providers Research initial 6 interviews, emerging themes had been repeated often enough that a second wave of participant recruitment was not initiated. After all the data were collected, each team member again read the transcripts independently to identify key words or phrases. The team met and collectively grouped key words and phrases into conceptual categories. FINDINGS Four broad themes emerged regarding women s expectations and experiences of their family physicians as maternity care providers: informational support, emotional support, advocacy, and professional medical care. Informational support Women expected their family physicians to provide them with information about their clinical status and care. Discussion of management options was of particular importance. One said, My doctor was brilliant! She would always sit down and actually say what was going through her mind. Another said her doctor would explain to me what is going on as it s going on and, I don t know, talk about the different opinions. One woman thought family physicians should be more forthcoming with information: I think [physicians] need to be more forthcoming with details and ask very specific questions. There was uncertainty about the family physician s role in preparing women for labour and delivery: I don t know if she would have offered [a birth plan] or not but I really like that [birth plan] because everything is kind of written down. One commented, I said, Should I draw up a birth plan? She looks at me and says, Your plan is to give birth. Emotional support Women described several ways in which their family physicians provided them with emotional support. They appreciated the verbal praise and encouragement they received from their physicians. One said, The most encouraging was her saying what a great job I was doing. She also commented, You know, to hear that, the encouragement or the praise, is really valued and I kept hearing [how well she was doing], and I remember thinking I m great at this! I guess I could put it on my resume. Some women also commented on the comforting effect of their physicians presence. One said, I think just her presence just because I was comfortable with her anyway I really think that helped a lot, and I was really comforted that she was there each time [during checks] because I did feel like I had seen her quite a bit throughout the day. Some women described their family physicians as people they trusted and who trusted them in return, people with whom they had a special bond. Comments included the following. She s a friend; she s someone that you can call any time, and she trusts my judgment. I was confident that I was going to be able to [give birth], that I did get along well with my doctor, and that I trusted her. I d be a lot more comfortable with her than probably any other doctors or nurses or anything. She s been there from day 1. She knows the ins and outs and everything. And I ve known her for a long time, so yeah, it s pretty important for her to be there. Not all the women expected their family physicians would be a source of emotional support. One said, I think she is every bit as capable [as a regular family physician] but is not so much concerned with my feelings or thoughts or emotions, and I see the nurse and my husband offering the words of encouragement and support. I see her more getting down to business and getting this baby out. Physicians ability to anticipate and respond to women s medical and emotional needs was important. One woman said, Knowing me well enough, being able to perceive [what] I needed, was just wonderful. Another said, She actually got me up on the table and we heard the heartbeat that day, which was mega-important to me, and She s not chatty. I wouldn t describe her as necessarily a warm person, but I felt the support when I needed it, and really have the confidence that she ll be there when I need her and in the ways that I need her. Advocacy Advocacy was another universal theme. All participants expected their family physicians to facilitate meeting their needs and wishes in some manner. They expected their physicians to listen to and respect their wishes and concerns. One said, She listens to me and respects what I say, and she responds to my questions. Another said, No, there was nothing she could have done better because she was going by our wishes. Other comments included, And she s really great because she listens to you and is also very good at explaining things, and I need to have them listen to me, [to know that] if my gut instinct goes against what they are saying, they will listen to that. Women also commented on the importance of their physicians taking proactive steps to facilitate their needs and wishes. I brought my dream birth and she went through it there and then. She was really good about that and really supportive, and she was saying to make sure we had enough of these to give to all the nurses and whoever doctor would be there. Vol 53: may mai 2007 Canadian Family Physician Le Médecin de famille canadien 877
Research What women expect of family physicians as maternity care providers I felt like she was really understanding what we wanted and respecting that and trying to get that through to everyone. One woman described how her family physician helped her to realize her wish to spend some quiet time with her baby following an instrumental delivery. She was giving me that moment I wished for, even though there had been no room for it earlier. She gave me that special moment, and I thought that was really nice. Women expected their family physicians to aid them in decision making. There was variability, however, in the degree to which women wanted their family physicians to take on the decision-making role. One said, I think the doctor should decide what, explain to you what you might need and what (will) happen. I need my doctor to say, Here s what I need to do and why I ve made that decision, added another. Yet another said, I don t want anyone else mandating the way this is going to be. Most women described a shared decision-making process in which their physicians were more like guides or coaches: This time [first birth] I would very much want to be guided throughout. Professional medical care Not surprisingly, women expected their physicians to have the requisite knowledge and skills to ensure they had a safe pregnancy and delivery and to be the physicians doing the actual delivery. One said, I m hoping her role is to monitor my health and the baby s health and [take] whatever decision makes the most sense to get the baby out safely. Another added, Well I hope that she is the one that delivers the baby. DISCUSSION Roles in relation to others roles The roles women described for their family physicians greatly overlapped with those described for other maternity care providers. Of particular importance to family physicians were activities that overlapped with the activities of labour and delivery nurses because these two professional groups often work closely together as part of childbirth care teams. Informational support and emotional support have been identified as key domains of nurses maternity care in the literature. 5,6 Bowers says that caring and emotional support are conveyed through presence, words of encouragement, and continuity of caregiver. 6 The women in our study highly valued the emotional support they received from their family physicians in all 3 of these areas. Expectations of support varied, however, with some women clearly identifying their physicians as support people and others consciously excluding them from this role. Another area of variability was in women s expectations of their family physicians with regard to decision making. Such differences in women s expectations of nurses with regard to support, comfort, and decision making have also been described in the literature. 7 Mackey and Lock concluded that, given these variations, it is important to explore women s preferences and expectations before birth to avoid miscommunication and conflict. 7 It would logically follow that this would also apply to women s expectations of their family physicians. It might, therefore, be prudent for family physicians to discuss their patients expectations of them as maternity care providers to facilitate good communication and high-quality patient care. Advocacy, another role described for family physicians in our study, has also been described in the nursing literature. 4 Specifically, the women in our study described the importance of physicians listening to them, respecting their wishes, and discussing management options with them. They also described how their physicians seemed to sense what was important to them and how they took proactive steps to ensure that women s wishes were respected. Further questions The results of our study raise some further questions. First, how are family physicians roles related to those described for other maternity care providers? Are they complementary, additive, or redundant? Are different professional groups aware of their respective roles? For example, how does a woman s expectation of her family physician as a source of emotional support differ from her expectation of her nurse? These are practical questions, and it is important for members of the childbirth care team to be aware of the scope of care that each provides in order to facilitate high-quality, efficient, comprehensive care. Another question is how do physicians characteristics influence their roles as maternity care providers? Recent studies indicate that physicians providing maternity care have a range of practice styles from a midwifery type of style to an obstetricianlike style. 8 Family physicians whose practice has a predominantly midwiferylike style might provide more personalized emotional support. In contrast, family physicians who have a more obstetricianlike style might see emotional support as primarily a role for nurses. This would suggest that family physicians need to be aware of their own styles and clearly communicate them to their patients to avoid misunderstandings and mismatches in patient-physician values and expectations. Limitations First, as a qualitative study, this work was designed to generate, not prove, hypotheses. Consequently, further studies are needed to clearly outline the nature and 878 Canadian Family Physician Le Médecin de famille canadien Vol 53: may mai 2007
What women expect of family physicians as maternity care providers Research importance of women s expectations of their family physicians, including the expectations of women from different social and cultural backgrounds. The relatively small number of participants might limit the breadth of the data. While we believe that saturation occurred in our sample, it is possible that a larger study would generate additional information about physicians roles. Also, our study does not explore physicians own perceptions of their roles as maternity care providers. It is possible that physicians perceive their roles quite differently from the way women perceive them. Regional and institutional resources might also affect the type of maternity care provided by family physicians. Our study is the first to explicitly explore and describe women s expectations and experiences of family physicians as maternity care providers. While the number of participants was small, the information generated was rich in content. The similarity of our findings to those described for other maternity care providers supports the validity of our findings with respect to women s expectations and experiences. What is not clear is how family physicians roles differ from those of other maternity care providers. The changing face of maternity care is a factor to consider in trying to generalize these results. All the women in this study were attended by the same family physicians who provided their antenatal care. There is a move toward development of alternative models of maternity care in which the delivering physician is often different from the physician who provides antenatal care. 9 Women s expectations of an unknown physician might be quite different from their expectations of a physician with whom they have an existing relationship. Conclusion The results of our study suggest that, from patients perspective, family physicians assume a range of roles as maternity care providers. The major themes identified included informational support, advocacy, emotional support, and professional competence. Women consistently expected their family physicians to communicate information about their medical care, listen to and respect their wishes, and provide them with competent medical care. In contrast, women had different expectations of their physicians with regard to emotional support, decision making, and preparing them for labour and delivery. Similar roles have been described for other maternity care providers, particularly labour and delivery nurses. Research is needed to better define how these roles are related and how they interface during patient care. Research on family physicians own perceptions of their roles as maternity care providers is also needed. This is a critical time in family physician maternity care. Maternity care gives us a unique opportunity to connect with our patients and their families. Loss of this opportunity through the further decline of family physician maternity care will undoubtedly have a negative effect on our profession, on women, and on communities. We hope family physicians will find a way to continue to be involved in this important and rewarding aspect of family medicine. By continuing to help women navigate through the journey of birth, we can continue to contribute to the health of this and future generations. Contributors Drs Douglas and Cervin contributed to design of the study, data analysis and interpretation, and preparing the article for submission. Ms Bower contributed to data collection, transcription, and analysis, wrote the methods section, and reviewed the final drafts of the article. Competing interests None declared Correspondence to: Dr Sue Douglas, Academic Unit of General Practice and Community Health, Australian National University, Bldg 4, Level 2, Canberra Hospital, Woden ACT, Australia; telephone 02 6244-4950; fax 02 6244-4105; e-mail susan.douglas@anu.edu.au References 1. Simkin P. Just another day in a woman s life? Women s long-term perceptions of their first birth experience. Part 1. Birth 1991;15:203-10. 2. Hodnett ED. Pain and women s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002;186(5 Suppl Nature):S160-72. 3. McWhinney IR. A textbook of family medicine. 2nd ed. New York, NY: Oxford University Press; 1997. 4. Tumblin A, Simkin P. Pregnant women s perceptions of their nurse s role during labour and delivery. Birth 2001;28:52-6. 5. Callister LC. The role of the nurse in childbirth: perceptions of the childbearing woman. Clin Nurse Spec 1993;7(6):288-317. 6. Bowers B. Mother s experiences of labour support: exploration of the qualitative research. J Obstet Gynecol Neonatal Nurs 2002;31(6):742-52. 7. Mackey MC, Lock SE. Women s expectations of the labour and delivery nurse. J Obstet Gynecol Neonatal Nurs 1989;18(6):505-11. 8. Reime B, Klein MC, Kelly A, Duxbury N, Saxell L, Liston R, et al. Do maternity care provider groups have different attitudes toward birth? BJOG 2004;111(12):1388-93. 9. Price DJ, Lane C, Klein MC. Maternity care by family physicians: characteristics of successful and sustainable models. J Obstet Gynaecol Can 2005;27(5):460-6. Vol 53: may mai 2007 Canadian Family Physician Le Médecin de famille canadien 879