New research into women’s experiences of treatment for hyperemesis gravidarum across the UK has found a worrying lack of informed consent to treatment, significant problems accessing treatment and high levels of dissatisfaction with care. However, the development of new Day Units showed promising improvements in care satisfaction and a 50% reduction in hospital days. Such units could have a positive financial impact for maternity units as well as a beneficial psychosocial impact on pregnant women and their families.
Hyperemesis Gravidarum (HG) is a complication of pregnancy characterised by extreme levels of nausea and vomiting starting in early pregnancy and persisting for many month. HG can lead to a host of physical and psychological complications such as dehydration and malnutrition, oesophageal trauma, deep vein thrombosis, Wernicke’s encephalopathy, depression, anxiety and post-traumatic stress disorder. Until recently women requiring rehydration have been admitted to hospitals for IV fluids and medication. Recently, HG Day Units (HGDUs) have been established within early pregnancy units or Gynecology wards where women can attend for rapid IV rehydration and return home the same day. Such services have been supported by the publication of the RCOG Greentop guidelines for nausea and vomiting in pregnancy and HG last year.
The survey published today explored and compare women’s experiences of treatment in the two different settings; hospital ward admission and HGDUs. The online survey conducted last year by the charity Pregnancy Sickness Support and researchers at Plymouth University received in depth responses from 394 women from across the UK. All participants were either currently pregnant or had received treatment in the previous two years for HG. The survey assessed satisfaction with the following areas: medic al treatment; care received from staff; information provision about the condition and it’s treatments to make informed decisions; staff knowledge of HG; treated with dignity and respect; continuity of care between staff; and feeling better on discharge. Additionally the survey explored access to treatment and relapse following discharge.
Overall treatment in HGDUs was associated with higher levels of satisfaction but not in all areas. Satisfaction with medical treatment was similar in both groups however significantly more women in the HGDUs group felt better on discharge. Nearly 40% of hospital admitted women did not feel better on discharge and many women reported feeling mentally worse following admission. Despite more women in the HGDUs feeling better on discharge deterioration post discharge was almost identical in both groups; 13% continued to improve, 20% stayed the same and 67% deteriorated post discharge.
Dissatisfaction with information provision was worryingly high across both groups but significantly more so in the hospital admission group. Across both groups only 34% of women felt they were given the information needed to make informed decisions and many women reported being given incorrect or false information such as certain drugs causing birth defects or that there were no other medication options, which resulted in a termination of an otherwise wanted foetus.
A quarter of all women felt that they were not treated with dignity and respect half of the participants reported dissatisfaction with staff knowledge. Many women reported having to find information out for themselves or explaining the condition to staff. Over 50% of women found access to treatment in the first place was difficult and reported that they were “not believed” when presenting for help with symptoms.
Were care was considered good the reports are glowing with women thanking staff for saving their baby’s life and helping them through the most difficult times of their lives. However, where care was deemed unsatisfactory the impacts were huge with women reporting they no longer trusted healthcare professionals and a number of women terminating pregnancies due to the lack of forthcoming treatment.
On exploration of the reasons for preference, most women reported that they would prefer to return home to their families and did not find the hospital environment conducive to rest. However, there were exceptions and some women welcomed admission for respite from their responsibilities at home which exacerbated symptoms. Many women with HG feel under pressure to continue their roles as mothers, home managers, employees and so on despite being acutely and severely ill; admission to hospital enabled them to rest which they felt helped to manage symptoms. Additionally, some women treated in HGDUs reported that rather than a specific unit they were given IV fluids in a public waiting room or a hard chair in an office, received no food or oral fluids and were discharged at inappropriate times such as two o’clock in the morning. They claimed this was for staff to avoid completing admission paperwork. Furthermore, a number of women recognised that while they would have liked to go home at night they were too unwell by the time they were admitted and needed multiple bags of fluid before discharge, which could not have been achieved as an outpatient.
While outpatient treatments appear to be cost effective for the NHS and preferable to most women the most important fact for either setting appears to be staff knowledge and understanding and information provision to enable informed consent. Access to either setting should be forthcoming for sick women and the setting most appropriate for individual women should be considered.
To learn more about HG research, care and treatment and how to establish an effective service in your area come to the International Colloquium on Hyperemesis Gravidarum this October here in the UK. For details go to www.ICHG2017.org
Read the full article here:
Dean C, Marsden J. MIDIRS Midwifery Digest, vol 27, no 1, March 2017, pp 11-20
© MIDIRS 2017
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