Single Room Maternity Care and Client Satisfaction

235
BIRTH 27:4 December 2000
Single Room Maternity Care and Client Satisfaction

Patricia A. Janssen, MPH, PhC, Michael C. Klein, MD, CCFP, FCPS, Susan J. Harris, MD, CCFP,
Jetty Soolsma, MA, CNM and Laurie C. Seymour, BSN
ABSTRACT: Background: Single room maternity care is the provision of intrapartum
and postpartum care in a single room. It promotes a philosophy of family centered care
in which one nurse cares for the family consistently throughout the intrapartum and
postpartum periods. At B.C. Womens Hospital, a tertiary level obstetric teaching hospital
in Vancouver, British Columbia, a seven-bed, single room maternity care unit was developed
and opened as a demonstration project. As part of the evaluation of this unit, client
satisfaction was compared between women enrolled in single room maternity care and
those in a traditional setting. Method: The study group included 205 women who were
admitted to the single room maternity care unit after meeting the low-risk criteria. Their
responses on a satisfaction survey were compared with those of a historical comparison
group of 221 women meeting the same eligibility criteria who were identified through chart
audits 3 months before the single room maternity care unit was opened. A second, concurrent
comparison group comprised 104 women who also met eligibility criteria. Results: Study
group women were more satisfied than comparison groups in all areas evaluated, including
provision of information and support, physical environment, nursing care, patient education,
assistance with infant feeding, respect for privacy, and preparation for discharge. Conclusions: Single room maternity care was associated with a significant improvement in client
satisfaction because of many factors, including the physical setting itself, avoidance of
transfers, and improved continuity of nursing care. (BIRTH 27:4 December 2000)
The continued evolution of maternity care toward a
philosophy that is both client centered and acknowledges birth as a normal physiologic and developmental
process has given rise to many changes in the last two
decades. The traditional practice of admitting women
to labor rooms, moving them to delivery rooms, and
then transferring them to postpartum wards was based
on a partitioning of resources, space, equipment, and
nursing staff that was intended to provide an economy
of scale for the institution. This movement of the
childbearing woman to the location of a variety of
Patricia Janssen, Michael Klein, and Susan Harris are from the
Department of Family Practice, University of British Columbia
and B.C. Womens Hospital; Jetty Soolsma and Laurie Seymour
are from B.C. Womens Hospital; and Patricia Janssen is also from
the B.C. Research Institute for Childrens and Womens Health,
Vancouver, British Columbia, Canada.
Address correspondence Patricia Janssen, BC Womens, 4500 Oak
St, Room E414A, Vancouver, British Columbia, Canada, V6H-3N1.
q 2000 Blackwell Science, Inc.
caregivers can result in her experiencing feelings of

disorientation, anxiety about being in the right place
at the right time, a lack of space in any one area, and
a need to meet and adjust to multiple caregivers.
In a system with single room maternity care, when
the parturient woman is in established labor, families
are admitted to one room and stay there throughout
the intrapartum and postpartum periods. The newborn
remains with the family at all times. This type of
care promotes a philosophy of family centered care,
characterized by continuity, a team approach to decision making, respect for privacy and individual choice,
and appreciation of childbirth as a natural and normal
process. The purpose of the study was to compare
womens satisfaction with single room maternity care
with that of clients cared for in the traditional labor
and delivery unit and the postpartum unit.
Background
The concept of single room maternity care was first
introduced in South Africa in 1970 as the Single-
236
Unit Delivery System or SUDS (1). This system

was developed to address a polarization of attitudes
toward childbirth care, in which home births were
considered to be the only way to have natural deliveries and the hospital was the only way to ensure safe
deliveries. These SUDS rooms were designed to be
able to cope with every obstetric contingency other
than cesarean delivery. Rooms were bright, airy, attractively decorated, and allowed for free movement. They
were designed to instill an atmosphere of positiveness
and cheerfulness. Unlike todays single room maternity care, women were transferred to a postpartum
room 2 hours after delivery.
The Cybele Cluster System evolved from the single
unit delivery system in the United States in the early
1980s. This system allowed for the family to room in
together during the entire hospital stay (2).
Elements that these two systems had in common were
an emphasis on the humanistic, emotional, and social
aspects of childbirth; a family centered birth, continuity
of care through use of midwives, primary care nurses,
or both; attractive and functional furnishings including
an adjustable bed to promote physiologic birth; and an
outside window to provide natural lighting (3). Advantages for clients included an increased opportunity to
establish rapport with their nursing caregivers, no separation of parents from the newborn, and a positive environment conducive to a more physiologic labor and
delivery and sense of well-being (2).
Recent literature continues to report client satisfaction as a major benefit of single room maternity care.
The literature to date, however, has generally been descriptive in nature (4). Satisfaction with single room maternity care among nurses has been measured but not
compared with that of nurses working in other areas (unpublished data, Victoria General Hospital, Winnipeg,
1992). Berkland described the conversion in 1990 of
labor, and delivery rooms to labor, delivery, and postpartum rooms at Clarkson Hospital in Nebraska (5). She
refers to a postcare evaluation indicating that the 12-bed
single room maternity care unit was an overwhelming
success with families. A caring supportive staff was
the first item mentioned by most families, followed by
attention given to family, and positive comments about
the facility itself.
The Birthplace at St. Marys Hospital in Minneapolis
with 18 single maternity care rooms evaluated patient
satisfaction by means of questionnaires completed after
discharge (6). The results were reported anecdotally,
with patients complimenting the nursing staff on their
helpfulness and understanding. One respondent noted
that the many amenities made one feel at home.
The current study was conducted at B.C. Womens
Hospital, an obstetric tertiary level teaching hospital
in Vancouver, British Columbia, where more than 7000
births per year occur, making it the largest such facility

in Canada. Before 1997 all care was provided in 12
labor and delivery rooms and 52 postpartum rooms.
A seven-bed demonstration single room maternity care
unit was constructed in 1997. Before implementing
single room maternity care on a wide scale, we wished
to evaluate its impact on client satisfaction in a large
cohort study that compared low-risk women receiving
the new program with similar women receiving care
in the traditional setting within the same institution.
This evaluation also examined caregiver satisfaction,
pregnancy outcomes, utilization and cost issues, and
a nursing education program, which will be the topics
of future publications.
The Single Room Maternity Care Unit
Our single room maternity care unit consists of seven
spacious rooms, each with outside windows. The units
are decorated with maple furniture, and have bathrooms complete with bathtubs. A sofa chair converts
to a comfortable bed for a labor support person. Soundproofing was installed in the walls throughout the unit.
In the family lounge, families can prepare their own
meals, sit at a table or in comfortable chairs, and make
telephone calls or watch the family television channel.
The low-risk delivery suite comprises eight delivery
rooms built within the inner structure of the building.
B.C. Womens Hospital was built in the early 1980s
when the importance of natural childbirth, including
water therapy and natural daylight, was not understood
as it is today. The rooms, therefore, are dark with
small bathrooms that only have toilets and showers.
In general, the rooms have a high-tech, low-touch
appearance, even though at their inception they represented a dramatic improvement over the operating
room style that was the standard at that time.
The postpartum modules each consist of 14 small
rooms designed for mothers only. Two of the rooms
are doubles; all others are single occupancy, which are
available at no extra charge and filled on a first-come,
first-served basis. It must be pointed out that in the
1990s, with encouragement for the participation of
fathers and family members during childbirth, these
rooms are overcrowded.
Staffing
Single room maternity care nursing staff consists of
a core group of 20 nurses who have completed
perinatal nursing training. Supplementary staff comprise eight casuals who have had comparable
perinatal training. Three perinatal nurses, supported
by a patient services clerk and a patient services
aide, staff the unit around the clock. The nurse-to-
237
patient ratio is the same in the single room maternity

care group and in the comparison groups, that is 1
to 1 in labor and 1 to 4 in postpartum. Nurses and
support staff communicate by way of an in-house
wireless companion telephone system.
In the delivery suite, nurses provide primary nursing
care to the childbearing families in collaboration with
physicians and other health caregivers. Organization
of the delivery suite is centralized and coordinated by
the team leader. The activity level in the delivery suite
is high, and women are transferred to the postpartum
unit as soon as their condition allows. On the postpartum unit a new care team that has not participated in
the birth receives the family, who have to develop a
new set of relationships. This often includes the repetition of a lot of information about the mother, newborn,
and the birth itself.
Methods
Survey Instrument
Satisfaction is a difficult concept to measure (7), and
no tools have been rigorously designed and tested for
evaluating patient satisfaction in single room maternity
care. The evaluation team addressed the task of designing such a tool. Our initial challenge was to determine
from our clients the important components of satisfaction. In collaboration with our Department of Health
Promotion, we held focus groups with approximately
40 mothers and their babies who attended well baby
drop-in clinics in community health units. Members
of the evaluation team also attended patient focus
groups at a recently renovated suburban hospital attended by multiparas who had given birth in both a
traditional setting and in their new single room maternity care setting. We reviewed womens comments
about their hospital stay that had been gathered as part
of a community health care evaluation. Six months
before the development of single room maternity care,
B.C. Womens Hospital had initiated a maternity satisfaction survey, and these data provided insight into
important issues for our clients. We also reviewed the
literature on measurement of satisfaction related to
maternity care.
After identifying several key areas related to satisfaction, we designed a questionnaire that was reviewed
by hospital patients and revised, then piloted and revised further. It was translated into Chinese and Punjabi script and then back-translated into English to
check for accuracy. Additional revision focused on
ensuring that wording was culturally appropriate and
in context. Approval for the final version was given
by the University of British Columbia Behavioral Re-
search Ethics Board and the B.C. Womens Research

Review Committee.
Sample
The first group to be surveyed was composed of all
women who met eligibility requirements for single
room maternity care during the 3 months before the
opening of the new unit. This group was chosen for
comparison in case the introduction of the intervention
of single room maternity care created changes in philosophy related to patient care that would be reflected
throughout the institution, thereby masking the true
influence of the intervention on patient satisfaction.
These women were admitted to the delivery suite in
active labor and stayed there until 2 hours postpartum,
when they were transferred to a postpartum ward. This
is the traditional labor and delivery/postpartum approach. The women were identified through a review
of patient Kardex files in postpartum nursing stations.
All women who would have been eligible for single
room maternity care during the 3-month period were
handed surveys with an explanation by a postpartum
nurse clinician.
A second comparison group was composed of all
women who were eligible for single room maternity
care according to its triage form, but who did not go
there because no room was available at the time or
because their physician did not want them to use that
type of care. Some physicians did not want to care
for women on the single room maternity care module
because they were often concurrently caring for others
in the delivery suite, located on a different floor. Data
from this comparison group were collected concurrently with data from single room maternity care
women.
Responses from these two comparison groups were
compared with the study group, comprising all women
who had received their care in the single room maternity care unit during the first 6 months after the unit
opened. These eligible women were in active labor,
as defined by the presence of regular contractions and
cervical dilation of at least 3 cm and less than 0.5 cm
in length. They were experiencing a normal pregnancy
(3742 weeks gestational age, single fetus, cephalic
presentation, normal fetal health assessment). Exclusion factors included anticipated imminent delivery on
admission (within 15 min); planned cesarean section;
elevated blood pressure (> 140/90 or evidence of pregnancy-induced hypertension); intrauterine growth restriction (estimated to be < 10th percentile for
gestational age and gender); oligohydramnios (amniotic fluid index < 5%); presence of thick meconium;
or insulin-dependent diabetes. In addition, exclusions
included any indications for intensive monitoring in
238
labor or postpartum or prolonged postpartum stay

(> 48 hr). Women were evaluated for eligibility when
they presented to the admission/triage desk at the
entrance to the delivery suite. Nurses used prenatal
records to assist them in the triage process.
The research nurse gave women in the two comparison groups the surveys, together with an explanation
of how to complete them in a value-neutral fashion,
that is, stating that completing the form would help
us to provide better care for our clients. Surveys were
given on the day of delivery, to be completed after
delivery and before discharge. Surveys were anonymous, and participants returned them to their nurse in
sealed envelopes. The envelopes were then placed in
a basket in the nursing station for the research nurse
to pick up. This nurse tracked the numbers of surveys
handed out each day on each module, and returned 2
or 3 times to encourage women to complete the surveys
if they had not yet done so.
Our research team chose not to assign women to
groups randomly. We believed that such a comparison
would be confounded by womens preferences. Those
who were randomized to a care model different from
what they had asked for might be disappointed, which
could be reflected in their responses. All women who
went to single room maternity care either wanted to
go there or had no preference. In contrast, 40.2 percent
of women receiving care in the postpartum modules
did not receive their preference; that is, they had asked
for single room maternity care. Women were asked
about their preference at the time they presented at the
hospital admitting/triage desk. To avoid selection bias,
the data presented for the comparison group represent
only those women who either had no preference for
either single room maternity care or traditional labor
and delivery/postpartum care, or who stated before
triage that they preferred the traditional care.
The comparison group represented in Tables 2 to 9
is the concurrent comparison group, since it was thought
to be the group most relevant for comparison. Data for

the historical comparison group are available on request.
Data Analysis
Categorical variables were analyzed using the chisquare statistic. Data from 5-point Likert scales were
analyzed using a nonparametric statistic, the MannWhitney U test, because the responses on surveys
were not normally distributed. The type I (alpha) error
was set at 0.05. Comments from open-ended questions in the caregiver surveys were categorized and
summarized. No adjustment was made for multiple
comparisons.
Results
Survey return rates were 99 percent from the single
room maternity care group, 55 percent from the historical comparison group, and 50 percent from the concurrent comparison group. In total, 205, 221, and 193
subjects were in the three groups, respectively. When
women who had not obtained their preferred place of
care were eliminated from the concurrent comparison
group, 104 participants remained. The study group
women were similar to comparison groups in both
language spoken at home (a measure of acculturation)
and in parity (Table 1).
Participants were asked about information and support they received: specifically, if their opinions were
sought and choices valued, if they were given adequate
information for decision making, and if they were satisfied with comfort measures. Although both groups
scored their care very positively (> 4 on a scale of 15,
where 1 4 very dissatisfied and 5 4 very satisfied), the
study group responded significantly more positively on
all items in this category ( p < 0.001) (Table 2).
Time spent with family and friends was evaluated.
More women in the study group thought that they
Table 1. Characteristics of Participants and Comparison of Groups
Characteristic
Parity
Nulliparas
Language spoken
English
Cantonese
Mandarin
Punjabi
Comparison Group
Pre-SRMC
(n 4 221)
No. (%)
SRMC Group
(n 4 205)
No. (%)
Comparison Group
Concurrent*
(n 4 104)
No. (%)
105 (47.5)
96 (46.8)
45 (43.3)
0.15
71
22
8
7
0.21
0.20
0.06
0.33
165
29
9
10
(77.5)
(13.6)
(4.2)
(4.7)
150
34
4
6
(76.9)
(17.4)
(2.1)
(3.1)
(68.9)
(21.4)
(7.8)
(6.8)
* Data refer only to those women who preferred either the traditional labor-delivery-recovery and postpartum service, or who had no
preference.
SRMC 4 Single room maternity care.
239
spent the right amount of time with their support person

( p 4 0.005) and their baby ( p 4 0.007) (Table 3).
The amount of rest that each group received was insufficient for approximately one-third of each group.
Study women experienced less exposure to multiple
caregivers and thought that more respect was shown
for their privacy ( p < 0.001) (Table 4).
Noise was an issue for both groups, but less so for
the study group, in which 14.9 percent of women were
bothered by noise compared with 34 percent in the
comparison group ( p < 0.001 (Table 5). Sources of
noise that were less troublesome to the study group
were hospital neighbors and crying babies. The physical layout of the single room maternity care room was
found to be superior by the study group with respect
to spaciousness, availability of supplies, comfort of the
support person, and lighting (Table 5) (1 4 strongly
disagree, 5 4 strongly agree). Ratings of quantity and
quality of food were not different and, in fact, the same
dietary department served all areas.
Perceptions of the time that nurses could spend
with families were assessed in relation to physical,
emotional, and spiritual needs during both labor and
the postpartum period. Although most mean scores
Table 2. Information and Support
Question
Comparison
(n 4 104)
Mean
SRMC
(n 4 205)
Mean
4.32
4.07
4.19
4.29
4.15
4.25
4.46
4.73
4.58
4.61
4.66
4.71
4.61
4.71
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
Caregivers helped you view birth as a natural process

Caregivers asked for your feelings/opinions in planning care
Caregivers gave information needed to make informed choices
Caregivers supported your choices
Assistance given to support person
Comfort measures to deal with pain of labor
Comfort measures to deal with pain after the baby was born
Table 3. Being with Your Family and Friends

Question
Amount of time spent with your support person was:
Not enough
Just right
Too much
The amount of time spent with your baby was:
Not enough
Just right
Too much
The amount of rest you had was:
Not enough
Just right
Too much
Comparison
No. (%)
SRMC
No. (%)
3 (2.9)
95 (91.3)
6 (5.8)
0
202 (98.5)
3 (1.5)
0.005
3 (2.9)
89 (86.4)
11 (10.7)
1 (0.5)
197 (96.1)
7 (3.4)
0.007
33 (37.1)
66 (66.7)
0
58 (28.3)
141 (71.6)
1 (0.5)
0.39
Table 4. Privacy Needs

Question
Respect shown by caregivers for your privacy
Number of different nurses who cared for you during your labor, delivery,
and postpartum stay
Number of different doctors (including students, residents) who looked after
you during labor, delivery, and postpartum stay
Number of hospital staff who came into your room during labor period
Number of hospital staff who came into your room during postpartum stay
Comparison
Mean
SRMC
Mean
4.27
4.26
4.71
4.66
<0.001
<0.001
4.33
4.62
0.001
4.24
4.15
4.60
4.57
<0.001
<0.001
240
were 4.0 or higher for both groups, the single room

maternity care women consistently scored their nursing
care significantly higher ( p < 0.001) (Table 6) (1 4
not enough, 5 4 ample). Similarly, time spent teaching
the family about care of the mother and baby was
perceived to be greater and information given to be
more consistent by the study group ( p < 0.001) (Table
7) (1 4 strongly disagree, 5 4 strongly agree).
Breastfeeding practice differed between the two
groups (Table 8). Study group mothers thought that
caregivers spent more time assisting with feeding ( p
< 0.001). Significantly fewer babies in single room
maternity care received supplementation with formula
(18.4% vs. 48.4%, p < 0.001). No differences were
found in proportions of women putting the baby to
breast immediately after birth.
Discharge instructions and review of written information were more consistently carried out in single
room maternity care (Table 9). Specific areas of knowl-
edge in relation to baby care were assessed and found

to be similar between the groups, with the exception of
positioning the baby for feeding and sleeping, bathing,
caring for the umbilical cord, and finding sources of
help in the community, which were items that study
group parents felt better able to cope with than comparison group parents.
Families were invited to write comments in relation
to each of the areas assessed by the questions. Both
study and comparison women viewed nursing staff as
being very supportive to them. Single room maternity
care mothers made most of the comments about staff
support, enjoying the experience of rooming-in, and
receiving the opportunity to rest by nurses who cared
for their baby. Some women in comparison groups
expressed a wish to have stayed in a single room.
Some women in the study group felt pressure to go
home before they felt comfortable leaving.
All groups provided positive feedback on the quality
Table 5. Physical Environment

Question
Bothered by noise at any time
Talking/visiting by hospital staff
Talking/visiting by hospital neighbors
Staff talking at the nursing station
Crying babies
Women in labor
Room was spacious and adequate for my needs

I was able to find the supplies I needed
My support person was comfortable
Lighting was adequate
Food was acceptable in quantity
Food was acceptable in quality
Housekeeping staff respected my privacy
Comparison
No. (%)
35
8
17
10
22
3
(34.0)
(7.8)
(16.5)
(9.7)
(21.4)
(2.9)
SRMC
No. (%)
30
9
8
9
13
13
(14.9)
(4.5)
(4.0)
(4.5)
(6.5)
(6.5)
Mean
Mean
4.05
4.25
3.88
4.29
3.95
3.44
4.28
4.87
4.54
4.68
4.62
4.17
3.66
4.65
p
<0.001
0.30
<0.001
0.08
<0.001
0.28
<0.001
<0.001
<0.001
0.001
0.06
0.09
<0.001
Table 6. Nursing Care

Question
Amount of time nurse was able to spend with you was
adequate to take care of your physical needs
Labor
Postpartum
Amount of timeemotional needs
Labor
Postpartum
Amount of timespiritual needs
Labor
Postpartum
Nurse responded to your needs in a timely manner
Labor
Postpartum
Comparison
Mean
SRMC
Mean
4.41
4.38
4.78
4.65
<0.001
0.002
4.27
4.26
4.71
4.64
<0.001
<0.001
3.94
4.10
4.57
4.53
<0.001
<0.001
4.50
4.41
4.80
4.75
<0.001
<0.001
241
Table 7. Teaching
Question
Comparison
Mean
SRMC
Mean
4.13
4.51
<0.001
4.10
3.81
4.57
4.42
<0.001
<0.001
3.98
4.40
<0.001
Amount of time your caregivers were able to spend with you

to teach you to care for yourself
Care for your baby
Spend with your support person to teach them about caring for
you and your baby
Information you received from different caregivers was
1 4 very inconsistent 5 4 consistent
Table 8. Feeding Your Baby

Question
Amount of time caregivers spent helping you to feed
your baby (1 4 not enough, 5 4 ample)
If breastfeeding, fed baby within 12 hr after birth
If breastfeeding, baby received supplementation with
formula
If breastfeeding, baby received supplementation with
water
How are you feeding your baby
Breast
Formula
Both
Comparison
No. (%)
SRMC
No. (%)
4.47
<0.001
79 (79.0)
44 (48.4)
160 (84.2)
34 (18.4)
0.044
<0.001
10 (13.3)
12 (6.9)
0.10
63 (60.6)
8 (7.7)
33 (31.7)
166 (85.1)
15 (7.7)
14 (7.2)
<0.001
Comparison
No. (%)
SRMC
No. (%)
71 (85.5)
66 (81.5)
159 (90.3)
155 (90.1)
0.25
0.05
76 (90.5)
172 (97.7)
0.01
57 (68.7)
55 (64.7)
143 (87.2)
149 (83.7)
<0.001
<0.001
Mean
Mean
4.25
Table 9. Discharge Planning

Question
Before going home, did your nurse give clear
instructions about:
When to call the doctor
When to make an appointment for your doctor to
see the baby
When to expect a call from the community health
nurse
How to use a car seat
Did the nurse review handouts in your information
package
When you get home, you will be able to cope with:

Knowing when the baby is hungry/full
Knowing that the baby is getting enough milk
Positioning your baby to feed
Positioning your baby to sleep
Knowing when your baby is ill
Knowing what to do if your baby gags or chokes
Giving your baby a bath
Caring for your babys cord
Knowing some ways to cope with your crying baby
Finding sources of help in the community
4.15
4.00
4.25
4.31
3.80
3.69
4.21
4.30
4.05
3.95
4.29
4.17
4.39
4.52
3.92
3.82
4.47
4.53
4.14
4.30
0.07
0.06
0.04
0.001
0.33
0.19
0.008
0.009
0.25
0.001
242
of nursing care. Most respondents addressing the quality

issue were from the study group. Comments with respect
to availability of nurses varied among the comparison
groups. In the delivery suite and postpartum areas, respondents observed that the nurses were too busy and
too fewan observation that also extended to the postpartum period in the single room maternity care unit.
Women praised nurses in all areas for their knowledge and willingness to teach. Again, most such comments came from study group women. Impediments
to teaching and learning were a lack of sufficient nurses
in the comparison groups and too short a stay in the
single room maternity care unit. Another concern related to a lack of rest and time to assimilate information
because of too many visitors.
The two comparison groups differed little from each
other in their responses to the questions, with a few
exceptions. The historical group was more often bothered by noise (49.8%) than the concurrent group
(35.9%), indicating that the noise level in the institution
may have been decreasing over time. Nurses in the
historical comparison group were perceived to spend
less time providing emotional support ( p 4 0.02) and
teaching baby care ( p 4 0.04) compared with the
concurrent comparison group. Fewer women in the
historical group (76.3%) versus the concurrent group
(86.7%) knew when to call their doctor ( p 4 0.02).
Discussion
Improved overall client satisfaction appeared to be the
most likely outcome resulting from the implementation
of single room maternity care. This expectation was
met in every study category, including information and
support; time spent with baby, friends, and family;
privacy and noise levels; and availability of nursing
care and teaching. New mothers in single room maternity care indicated that they felt more competent in
some aspects of baby care, and they were more likely
to be exclusively breastfeeding. Supplies were easier
to find in their rooms, doubtless because traditional
postpartum rooms used centrally located carts for supplies whereas in single room maternity care all supplies
were kept in individual rooms in cupboards.
One objective in undertaking a cohort study, that
is, allowing women to choose their birth setting as
opposed to randomly assigning it, was to measure
preference. Few women, only 16 among 548 eligible
women, chose not to go to single room maternity care
at the time of triage. The comparison group contained
a large proportion of women (40%) who indicated on
their survey form an initial preference for single room
maternity care. Disappointment related to not receiving
the setting of their choice could have biased satisfaction results in favor of single room maternity care.
This analysis was, therefore, limited to comparing responses of women in single room maternity care only
with those women in the comparison group who either
preferred the traditional labor and delivery/postpartum
model or had no preference. When the study group
was compared with the entire comparison group, study
participants continued to be significantly more satisfied with their care in relation to the same aspects as
in the first analysis, with the exception that differences
between the groups became nonsignificant with respect
to knowing when to call the doctor.
Responses among the concurrent comparison group
and the historical comparison group did not differ substantively. We can conclude therefore that the investigation was not simply measuring two groups who were
cared for in the units of their choice. The pre-single
room maternity care comparison group did not have
the choice to be cared for in single room maternity care.
Rather, the changes observed reflect a true difference in
levels of satisfaction.
This study is limited because response rates among
comparison group participants differed from those
among study group participants, which may be because
single room maternity care nurses may have had more
time and more enthusiasm to encourage their clients
to complete the survey forms. In addition, families
who felt very positively about their care may have
been more strongly motivated to complete the surveys,
and comparison group families may have been less
motivated to do so because they were not in a new
setting. Reduced participation from comparison groups
may not have biased the study if families who felt
strongly either positively or negatively took the time
to complete the survey forms.
The study is also limited because of the lack of
outcome data linked to individuals who completed
the satisfaction forms, since disappointment with the
management or outcome of labor and birth might have
influenced their survey responses. In a larger study at
B.C. Womens Hospital conducted at the same time
as this study and extending an additional 3 months,
which examined 583 women in the single room maternity care group and 393 in the comparison group,
findings showed no differences in augmentation of
labor, use of epidural or narcotic analgesia, rates of
cesarean section or forceps use, use of episiotomy,
incidence of postpartum hemorrhage or fever, 5-minute
Apgar scores, or admissions to a secondary or tertiary
nursery among newborns. Therefore it is unlikely that
outcomes negatively influenced satisfaction in the
comparison group. In this longer study, participants in
the comparison groups did not differ with respect to
age or marital status.
We did not restrict the analysis of comparison participants in the postpartum wards to women who were
243
in single rooms. Four of the 16 beds in postpartum

rooms have double occupancy. Although such a restriction may have reduced differences between groups,
part of the reason for introducing single room maternity
care was to ensure that families were in private rooms
throughout their hospital stay. Increased satisfaction
related to the privacy of a single room is part of the
experience the study wished to measure.
It is impossible to know from this evaluation exactly
what contributed to the increase in client satisfaction
in single room maternity care. An obstetric program
in a Florida teaching hospital reported a 126-percent
increase in private maternity patients after the introduction of this type of care, but the author did not comment
on specifically which factors attracted the new clients
(8). Certainly it is not surprising to find that families
are happier in new rooms where the windows open,
lighting is natural, and bathtubs are availableoptions
not available in traditional delivery suite rooms. However, indications are that the improvement was multifactorial. Many families responded that the amount of
contact they had with single room maternity care
nurses was reassuring. This finding speaks to the continuity-of-care issue. Experience in other settings has
shown that mothers receive more education and support in newborn care, which in turn, leads to improved
confidence in parenting skills (9). Clients in our setting
talked about the ease of having family members stay
together and learn together in this environment.
It is known that the workload for individual nurses
in the single room maternity care unit at times may
have been less than that for nurses in other areas because the unit was not running at full occupancy during
the time of the evaluation. Comparison group nurses
may have had other women assigned to them who had
more complex nursing care needs than those assigned
to study group nurses, which may have decreased their
opportunity for as much personal contact with the comparison group women as study group nurses.
It is important to recognize that, in general, women
in all groups were highly satisfied with their care.
Differences, although statistically significant, remained small, and may not represent a difference that
is truly important to families. Most differences between
means scores were in the order of 0.5 on a scale of 1
to 10. In an institution where the overall satisfaction
was lower, differences in the two settings within the
institution may have been more pronounced.
The consistency of findings in favor of the single
room maternity care group in almost all of the parameters measured raises the question of systematic bias. The
one aspect of client care that did not differ between the
groups was with respect to the food service. A concern
raised by staff in single room maternity care units visited
before the construction of our unit was the increased
ability to hear other women in labor, since the rooms

were adjacent. Although soundproofing was installed in
the walls of the single room maternity care units, 6.5
percent of women in the single room maternity care unit
versus 2.9 percent in the comparison groups were bothered by the noise of other women in labor. Our consistent
findings in favor of single room maternity care are supported by the comments of clients in response to the
open-ended questions in the survey.
The participants in this study were selected because
of their low-risk status. We have no reason to suspect
that these results would not be generalizable to other
settings that care for women of variable-risk status. It
is possible that some of the issues perceived by women
to be better addressed in the single room maternity
care setting might be even more important to women
of higher risk status, such as patient teaching and preparation for discharge.
These findings supported the hypothesis that single
room maternity care for eligible low-risk patients significantly improved client satisfaction. Components of
this improvement included satisfaction with the physical environment, emphasis on family centered care,
and increased access to nursing time for education and
direct care. Improvement in satisfaction was sustained
despite a shorter hospital stay, whether or not the comparison group consisted of women who had received
their first choice of setting (labor and delivery/postpartum), and whether or not the comparison group was
surveyed concurrently with or before the initiation of
the single room maternity care unit.
References
1. Notelovitz M. The single-unit delivery systemA safe alternative to home deliveries. Am J Obstet Gynecol 1978;132:
889894.
2. Fenwick L, Dearing R. The Cybele Cluster: A Single Room
Maternity Care System for High- and Low-Risk Families. Spokane: Cybele Society, 1981.
3. Young D. Single-room care for low- and high-risk families. In:
Young D, ed. Changing Childbirth. Rochester, NY: Childbirth
Graphics Ltd, 1982: 315328.
4. McKay S, Phillips C. Family-Centered Maternity Care: Implementation Strategies. Rockville, MD: Aspen Systems, 1984.
5. Berkland C. Small- to Medium-Birth Hospitals: Bishop
Clarkson Memorial Hospital, Omaha. Report of the Fifth Ross
Planning Associates Symposium, Columbus, OH: Ross Laboratories, 1991:6065.
6. Reed G, Schmid M. Nursing implementation of single-room
maternity care. J Obstet Gynecol Neonat Nurs 1986;15:
386389.
7. Bramadat IJ, Driedger M. Satisfaction with childbirth: Theories
and methods of measurement. Birth 1993;21:2229.
8. Phillips C. Single-room maternity care for maximum costefficiency. Perinatol Neonatol 1988;12:2224, 2831.
9. Williams J, Mervis R. Use of the labor-delivery-recovery room
in an urban tertiary care hospital. Am J Obstet Gynecol 1990;
162:2324.

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BIRTH 27:4 December 2000