From fragmented levels of care to integrated health care: Framework toward improved maternal and newborn health

Strategies and practices for organizational learning in integrated care

PURPOSE

The purpose of this study is to identify important strategies and practices supporting inter-organizational learning (IOL) in integrated care. The two research questions ask how organizational network architectures can help involved organizations overcome the barriers of IOL in integrated care (RQ1) and what design recommendations can strengthen the processes of IOL in integrated care (RQ2).

DESIGN/METHODOLOGY/APPROACH

This study applies a qualitative design to analyze an improvement initiative in a regional, integrated care service for elderly patients with multiple illnesses in Norway. An inductive thematic analysis for the triangulating of qualitative data from different sources was applied. Patterns within the data were organized into themes, categories and subcategories. No software was applied.

FINDINGS

The identified characteristics of the organizational network architectures supporting IOL in integrated care in the case under study were: equality of the involved parties, shared goals, recognition of expertise and the abilities to coordinate, design IOL processes and make joint decisions (RQ1). The categories of practices supporting the process of IOL were: insight into complex realities, contradictions, iteration, motivation and prototypes (RQ2).

ORIGINALITY/VALUE

This study offers much-needed insight into a successful approach for IOL in integrated care. The results offer strategies to be considered when building organizational networks for the improvement of integrated care and relevant practices useful when designing IOL processes in such care services. We believe such knowledge has important implications for policymakers, frontline personnel, education, research and leaders.

Integrated maternity care: A concept analysis

INTRODUCTION

Integrated maternity care is strongly promoted in the Netherlands. However, the term 'integrated' and its practical meaning is understood differently by professionals and policy makers. This lack of clarity is also visible in other countries and hinders implementation. In this study, we will examine how the concept of 'integrated maternity care' and its defining attributes are presented in the international literature.

METHODS

This study aims to provide a definition and deeper understanding of the concept of integrated maternity care by conducting a concept analysis using Morse's method. We performed a systematic search using Embase and Ebscohost (CINAHL, PsychINFO, SocINDEX, MEDLINE) including records that described integrated maternity care from on organizational perspective. Through a qualitative analysis of the selected research and non-research records, we identified defining attributes, boundaries, antecedents, and consequences of the concept. Subsequently, we constructed a definition of the concept based on the findings.

RESULTS

We included 36 records on integrated maternity care in the period from 1978 to 2022. Our search included 21 research and 15 non-research records (e.g. guidelines and policy records). Only half of these had a definition of integrated maternity care. Over time, the definition became more specific. Our concept analysis resulted in three defining attributes of integrated maternity care: collaboration, organizing collaboration and woman-centeredness. We identified role clarity, a culture of collaboration, and clear and timely communication as antecedents of integrated maternity care. A number of consequences were found: continuity of care, improved outcomes, and efficiency. All consequences were described as expected effects of integrated maternity care and not based on evidence.

CONCLUSION

We propose the following definition: 'Integrated maternity care is woman-centred care provided by (maternity) care professionals collaborating together within and across different levels of healthcare with a specific focus on organizing seamless care.' Addressing the antecedents is important for the successful implementation of integrated maternity care.

Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions

The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.

FIGO good practice recommendations for cesarean delivery: Prep-for-Labor triage to minimize risks and maximize favorable outcomes

Cesarean delivery is an abdominal surgical procedure performed for child delivery when the vaginal route is not feasible or desired due to maternal/fetal indications. All childbirth facilities should be able to safely perform a cesarean, which is not the current reality. For planned cesarean delivery, the facility must be prepared for the patient. In contrast, for unplanned arrivals at the facility, FIGO's Prep-for-Labor triage method allows rapid decision-making on whether cesarean delivery can be safely performed on site or whether transfer to an advanced care center is needed. A checklist of staff/tools for safe on-site cesarean delivery is provided to enable timely decision-making. Maternal complications following cesarean are three-fold higher than vaginal delivery. To prevent nonmedically indicated cesarean by favoring vaginal delivery, up-to-date safe and effective guidance is provided, defining labor, second stage length, and status before an arrested labor is confirmed. Whether cesarean delivery is planned or emergency, the Misgav Ladach simplified procedure is proposed as it is suitable for both low- and high-risk cases, including twins, thereby reducing both operative morbidity and postoperative recovery. A trial of labor after first cesarean (TOLAC) should be pursued when feasible, for which the indications, contraindications, safeguards, and steps of safe labor induction are delineated. Implementation of these good practice recommendations will improve childbirth by reducing excessive nonindicated cesareans, while precisely defining the resources and postoperative care required for safe performance on site. Enabling safe childbirth by cesarean and TOLAC, even at sites with low rates currently, will significantly improve maternal and fetal outcomes.

Prep-for-Labor: Overview of FIGO's labor and delivery triage bundles of care to optimize maternal and newborn outcomes

Childbirth is an intense event in which decisions may need to be made in seconds to guarantee the health of both mother and newborn. Despite health systems and care approaches varying widely according to real-life scenarios, availability of facilities, beliefs, resources, staff, and geography, among others, optimal outcomes should be ensured worldwide. Triaging low-risk pregnancies from high-risk pregnancies is the first step to ensure proper allocation of resources. From this need, we developed FIGO's Prep-For-Labor triage methods, a series of 2-minute labor and delivery bundles of care, with special regard given to low- and middle-income countries and rural settings. Around 80% of women, once properly triaged, can pursue vaginal delivery with minimal intervention, while those at risk can either be managed on site or transferred promptly to an advanced care site. FIGO's bundles of care and good practice recommendations for labor and delivery and immediate newborn triage cover four clinical scenarios: (1) preterm labor; (2) induced or spontaneous labor at term; (3) cesarean delivery; and (4) newborn care. From rapid triage of the mother (low vs high risk) to the list of required equipment, description of skilled staff, and coordination of resources, the recommendations for care are introduced across these four areas in this overview article. Implementing the proposed management steps described in each summary can improve maternal and neonatal outcomes.

Optimizing the childbirth experience: A pragmatic approach

In our efforts to optimize the labor experience and mitigate childbirth‐associated disability and mortality, we offer a call to action to identify drivers of and provide solutions to rising cesarean delivery rates, provide equitable care to mothers requesting elective cesarean, improve the operative safety of indicated cesarean deliveries, and provide guidance on acute care decision‐making in the labor suite and referral to levels of care.

Critical Interpretive Synthesis of Qualitative Data on the Health Care Ecosystem for Vulnerable Newborns in Low- to Middle-Income Countries

OBJECTIVE

To critically assess and synthesize qualitative findings regarding the health care ecosystem for vulnerable (low-birth-weight or sick) neonates in low- to middle-income countries (LMICs).

DATA SOURCES

Between May 4 and June 2, 2020, we searched four databases (Medline [PubMed], SCOPUS, PsycINFO, and Web of Science) for articles published from 2010 to 2020. Inclusion criteria were peer-reviewed reports of original studies focused on the health care ecosystem for vulnerable neonates in LMICs. We also searched the websites of several international development agencies and included findings from primary data collected between May and July 2019 at a tertiary hospital in Kenya. We excluded studies and reports if the focus was on healthy neonates or high-income countries and if they contained only quantitative data, were written in a language other than English, or were published before 2010.

STUDY SELECTION

One of the primary authors conducted an initial review of titles and abstracts (n = 102) and excluded studies that were not consistent with the purpose of the review (n = 60). The two primary authors used a qualitative appraisal checklist to assess the validity of the remaining studies (n = 42) and reached agreement on the final 13 articles.

DATA EXTRACTION

The two primary authors independently conducted open and axial coding of the data. We incorporated data from studies with different units of analysis, types of methodology, research topics, participant types, and analytical frameworks in an emergent conceptual development process according to the critical interpretive synthesis methodology.

DATA SYNTHESIS

We synthesized our findings into one overarching theme, Pervasive Turbulence Is a Defining Characteristic of the Health Care Ecosystem in LMICs, and two subthemes: Pervasive Turbulence May Cause Tension Between the Setting and the Caregiver and Pervasive Turbulence May Result in a Loss of Synergy in the Caregiver-Parent Relationship.

CONCLUSION

Because pervasive turbulence characterizes the health care ecosystems in LMICs, interventions are needed to support the caregiver-parent interaction to mitigate the effects of tension in the setting.