BACKGROUND

Patient-reported experiences and outcomes (PROs) are an important component of health care quality assessment. Current PRO item banks do not include childbirth, the number 1 reason for hospital admission in the United States.

OBJECTIVE

Develop a conceptual framework and preliminary item bank for childbirth-specific PRO domains, limited to the delivery and immediate postpartum period.

METHODS

Using PROMIS® methodology, we conducted a comprehensive literature review to identify self-reported survey items eliciting childbirth patient-reported values and preferences (V&P) measured in pregnancy and associated experiences and outcomes (PROs) measured immediately postpartum. The V&P/PRO domains largely overlapped and were validated and complemented by focus groups. In collaboration with our community partners, we used a modified Delphi approach to select domains and items that were included in the survey. We conducted an observational study using national survey response panels organized through The Nielsen Company to identify women's V&P in childbirth. Eligible participants were US pregnant women (English or Spanish speaking) ≥18 years old, and ≥20 weeks pregnant. We used bivariate analyses to test whether key predisposing conditions (eg, demographics, prior experiences, beliefs) were associated with V&P items using data weighted to reflect the US pregnant population. We also fitted a multivariable logistic regression model to each V&P item to describe “who” wanted each item. Women participated in a postpartum follow-up survey to collect information about their childbirth experiences and outcomes (PROs). In bivariate analyses, we tested whether predisposing conditions, V&P, PROs, and the “gaps” between V&P and PROs were predictors of women's satisfaction with hospital childbirth services, which was measured using an ordinal scale of 1 to 10. Multivariable logistic regression models confirmed the results. We used PROMIS guidelines to finalize the conceptual framework and preliminary item bank for childbirth-specific V&P/PROs and key predisposing conditions.

RESULTS

We identified 5902 PRO items that mapped to 19 domains and 58 subdomains within an empirical conceptual framework. Of 2757 respondents to the antepartum survey, 81.6% (N = 2250) anticipated a vaginal delivery in a hospital and are reported on in detail here. Maternal characteristics that were associated with each V&P item varied (eg, hospital services desired by nulliparas versus multiparas differed, with nulliparas more likely to want to avoid medical interventions and to receive information regarding baby care and feeding). Predisposing conditions, such as maternal confidence and ability to cope well with pain, appeared frequently as predictors in the models. Of 500 laboring women who answered the postpartum survey, key findings included the following: (1) The strongest predictors of women's satisfaction with hospital childbirth services were items in the domains of staff communication, compassion, empathy, and respect; and (2) 23 PROs, including being told about progress in labor and adequate pain relief in labor, appeared especially relevant to women experiencing childbirth. A final model predicting women's satisfaction with hospital childbirth services included a total of 8 items that could be optimized by doctors, midwives, and hospitals. Variables that were eligible for the model were selected in a hierarchical fashion, in the order of predisposing conditions, V&P, PRO, and gap items.

CONCLUSIONS

We developed a conceptual framework and preliminary item bank for childbirth experiences and outcomes. The preliminary item bank consisted of 60 key predisposing conditions and 100 V&P/PRO items, forming the foundation for the Childbirth Experiences and Outcomes Survey and providing a tool for patient-reported data collection and benchmarking efforts.

LIMITATIONS AND SUBPOPULATION CONSIDERATIONS

Detailed results were limited to the subpopulation of women who planned for vaginal birth in a hospital. Additional analyses will need to be conducted for women who planned for cesarean delivery or delivery at home or in a birth center. Further, the use of national online panels included the potential for recruitment bias.