Evaluating multi-dimensional aspects of postnatal hospital care

Childbirth as Fault Lines: Justifications in Physician-Patient Interactions About Postnatal Rehabilitation

Research on justifications has shown their significance in advice-giving, decision-making and children disputes. However, the majority of studies gloss over practical functions of justifications in patient-physician interactions as they are often expected and pursued by patients and in turn, are adopted by physicians to support their stance and authority. This study, through conversation analysis (CA), aims to explore a) what are pragmatic functions of justifications in patient-physician interaction? b) how and when do physicians unfold their justifications for treatment recommendations? c) how do physicians deal with different responses based on their epistemic and deontic domains?. A total of 32 video-recordings between postpartum women and physicians are collected and studied. Four pragmatic functions of justifications drawn upon by physicians are explored: justifications as face-saving, reassurance, risk discussion and clarification-seeking. Despite physicians' attempts to justify their positions as less challenged by patients, this is not the entire picture as they demonstrate their desire to resolve patients' concerns and coordinate their viewpoints to achieve the best practice that facilitates patients' well-being.

Validating a framework of women's experience of the perinatal period; a scoping review

OBJECTIVE

The aim of this paper is to identify and explain the factors that make up a woman's experience of the perinatal period. We accomplish this by validating a framework, described in an earlier study, that identifies the distinct dimensions of the perinatal experience.

DESIGN

We conducted a scoping review, using five online databases, to identify and categorize studies that investigate women's experience of the perinatal period.

FINDINGS

We found 251 publications that focused on the experience of the perinatal period. Our review confirmed the seven dimensions of our framework describing women's experiences of the perinatal period - the woman as unique individual, the woman as active participant in care, the responsiveness of maternity care and health services, the lived experience of being pregnant, giving birth and the postpartum period, communication and relationships with care providers, information and childbirth education, and support from social environment. One new dimension emerged from the studies we identified: societal influence. The resulting eight dimensions provide a comprehensive overview of the important aspects of women's experience of the perinatal period. While each dimension is distinct, there are significant overlaps and close relationships between them.

CONCLUSION

The framework is a useful guide for healthcare providers, researchers, and policy makers who wish to improve the experience of the perinatal period. It is important to remember, however, that the current framework is dynamic, open to new insights and further development and refinement.

The perception of youth health centres' friendliness: does it differ between immigrant and Swedish-Scandinavian youths?

BACKGROUND

Ensuring a good quality service and equal access according to need for all young people is a key objective of the Swedish health system. The aim of this study was to explore youths' perception of youth health centres' (YHCs') friendliness and to assess the differences in perception between immigrant and Swedish-Scandinavian youths.

METHODS

All YHCs in the four northern counties in Sweden were invited (22 centres), and 20 agreed to participate. Overall, 1089 youths aged 16-25 years answered the youth-friendly health services-Sweden questionnaire between September 2016 and February 2017. Thirteen sub-domains of friendliness were identified and their scores were calculated. Multilevel analysis was used to examine the differences in perception between immigrant and Swedish-Scandinavian youths.

RESULTS

Our sample consisted of 971 Swedish-Scandinavian youths (89.2%) and 118 immigrants (10.8%). Generally, both groups perceived the services to be very friendly. All 13 sub-domains were rated more than three in a four-point scale except for fear of exposure and parental support of psychosocial services. However, immigrant youths perceived YHCs less friendly than their counterparts, particularly regarding the domains of equity, respect, quality and parental support.

CONCLUSIONS

Our study suggests that even though youths perceived YHCs as highly friendly, there is a space for improvement regarding access to health care. Our findings highlight the importance of an open and culturally sensitive attitude of the staff and the need to engage parents and community as a key to improve immigrant youths' accessibility to health care.

Patients' Perceptions Of The Quality Of Palliative Care And Satisfaction - A Cluster Analysis

PURPOSE

Palliative care services are multidisciplinary, and the quality needs to be evaluated from the patients' perspectives. The aim was to explore the patient profiles in palliative care with respect to patients' perception of the quality of palliative care received and patient satisfaction, and to describe and compare person-related and organization-related conditions that characterize the patient profiles.

PATIENTS AND METHODS

A cross-sectional study, including 140 patients from four different multidisciplinary palliative care contexts in Norway, was conducted in 2014. The Quality from the Patient's Perspective questionnaire for Palliative Care, which is based upon a person-centered theoretical model, was used. Satisfaction was measured by the Emotional Stress Reaction questionnaire. Person- and organization-related conditions were measured. Hierarchical cluster analysis, ANOVA, Pearson Chi-Square Test and ANCOVA were used.

RESULTS

Three unique patient clusters with different patterns of perceptions of quality of care and satisfaction were identified; Cluster 1 (41%) had the best perception of care quality and were more satisfied, Cluster 2 (34%) had better perceptions of care quality and were most satisfied and Cluster 3 (25%) had worst perceptions of care quality and were less satisfied. The clusters were characterized by person-related conditions (eg, patients' sense of coherence and perceptions of subjective importance of the quality) as well as organization-related conditions (eg, physicians' competence and type of care services).

CONCLUSION

The results can be used by multidisciplinary healthcare personnel to tailor quality work and improve person-centered care in palliative care contexts. Improvement initiatives should focus on implementing a person-centered approach, increasing the palliative care competence of the personnel and facilitate specialized palliative care services in the homecare context.

The evolution of birth medicalisation: A systematic review

First described at the beginning of the 1970s, the concept of birth medicalisation has experienced a theoretical and ideological evolution influenced by the lines of research that have been associated with it. This evolution has given rise to different schools of thought concerning medicalisation, but also various methodologies used in different scientific fields. It seems relevant to propose a global synthesis of the various lines of thought related to birth medicalisation. To do this, the authors conducted a systematic literature review based on the PRISMA method. With a total of 38 occurrences in French and English, the authors scrutinised 17 databases with a publication period between 1995 and 2018. A total of 112 documents (107 articles, 3 book chapters, 2 books) has been identified, grouped and categorised into five main themes in the results section (1) the theoretical evolution of the concept of medicalisation, (2) factors related to the birth medicalisation, (3) the impact of the birth medicalisation, (4) the humanisation of birth and (5) experiences related to childbirth. A reasoned synthesis of the literature is therefore carried out in each part and then discussed according to the selected lines of research that require development in order to guarantee the best possible accompaniment to women who give birth.

Prevalence and risk of mental disorders in the perinatal period among migrant women: a systematic review and meta-analysis

This study was conducted in order to evaluate the prevalence and risk of mental disorders in the perinatal period among migrant women. Six databases (including MEDLINE) were searched from inception to October 19th, 2015, in addition to citation tracking. Studies were eligible if mental disorders were assessed with validated tools during pregnancy and up to 1 year postpartum among women born outside of the study country. Of 3241 abstracts screened, 53 met the inclusion criteria for the review. Only three studies investigated a mental disorder other than depression. Unadjusted odds ratios were pooled using random effects meta-analysis for elevated depression symptoms during pregnancy (n = 12) and the postpartum (n = 24), stratified by study country due to heterogeneity. Studies from Canada found an increased risk for antenatal (OR = 1.86, 95% CIs 1.32-2.62) and postnatal elevated depression symptoms (OR = 1.98, 95% CIs 1.57-2.49) associated with migrant status. Studies from the USA found a decreased risk of antenatal elevated depression symptoms (OR = 0.71, 95% CIs 0.51-0.99), and studies from the USA and Australia found no association between migrant status and postnatal elevated depression symptoms. Low social support, minority ethnicity, low socioeconomic status, lack of proficiency in host country language and refugee or asylum-seeking status all put migrant populations at increased risk of perinatal mental disorders.

Comparative study analysing women's childbirth satisfaction and obstetric outcomes across two different models of maternity care

OBJECTIVES

To describe the differences in obstetrical results and women's childbirth satisfaction across 2 different models of maternity care (biomedical model and humanised birth).

SETTING

2 university hospitals in south-eastern Spain from April to October 2013.

DESIGN

A correlational descriptive study.

PARTICIPANTS

A convenience sample of 406 women participated in the study, 204 of the biomedical model and 202 of the humanised model.

RESULTS

The differences in obstetrical results were (biomedical model/humanised model): onset of labour (spontaneous 66/137, augmentation 70/1, p=0.0005), pain relief (epidural 172/132, no pain relief 9/40, p=0.0005), mode of delivery (normal vaginal 140/165, instrumental 48/23, p=0.004), length of labour (0-4 hours 69/93, >4 hours 133/108, p=0.011), condition of perineum (intact perineum or tear 94/178, episiotomy 100/24, p=0.0005). The total questionnaire score (100) gave a mean (M) of 78.33 and SD of 8.46 in the biomedical model of care and an M of 82.01 and SD of 7.97 in the humanised model of care (p=0.0005). In the analysis of the results per items, statistical differences were found in 8 of the 9 subscales. The highest scores were reached in the humanised model of maternity care.

CONCLUSIONS

The humanised model of maternity care offers better obstetrical outcomes and women's satisfaction scores during the labour, birth and immediate postnatal period than does the biomedical model.

A systematic review of the relationship factor between women and health professionals within the multivariant analysis of maternal satisfaction

INTRODUCTION

personalised support provided to women by health professionals is one of the prime factors attaining women's satisfaction during pregnancy and childbirth. However the multifactorial nature of 'satisfaction' makes difficult to assess it. Statistical multivariate analysis may be an effective technique to obtain in depth quantitative evidence of the importance of this factor and its interaction with the other factors involved. This technique allows us to estimate the importance of overall satisfaction in its context and suggest actions for healthcare services.

METHODS

systematic review of studies that quantitatively measure the personal relationship between women and healthcare professionals (gynecologists, obstetricians, nurse, midwifes, etc.) regarding maternity care satisfaction. The literature search focused on studies carried out between 1970 and 2014 that used multivariate analyses and included the woman-caregiver relationship as a factor of their analysis.

RESULTS

twenty-four studies which applied various multivariate analysis tools to different periods of maternity care (antenatal, perinatal, post partum) were selected. The studies included discrete scale scores and questionnaires from women with low-risk pregnancies. The "personal relationship" factor appeared under various names: care received, personalised treatment, professional support, amongst others. The most common multivariate techniques used to assess the percentage of variance explained and the odds ratio of each factor were principal component analysis and logistic regression.

DISCUSSION

the data, variables and factor analysis suggest that continuous, personalised care provided by the usual midwife and delivered within a family or a specialised setting, generates the highest level of satisfaction. In addition, these factors foster the woman's psychological and physiological recovery, often surpassing clinical action (e.g. medicalization and hospital organization) and/or physiological determinants (e.g. pain, pathologies, etc.).

Successful early postpartum support linked to management, informational, and relational continuity

OBJECTIVE

to explore ways in which parents experience support from health professionals in the early postpartum period and understand how parenting support is related to management, informational, and relational continuity.

DESIGN

a qualitative study consisting of focus group interviews followed by deductive content analysis.

SETTING AND PARTICIPANTS

a large city in Sweden; 18 women and 16 men.

FINDINGS

study participants reported that parenting support occurs by providing consistent advice; indicating who to ask when care questions arise; enabling access to the care system when needs surface; providing sufficient information about self-management for mother or baby; involving parents in discharge planning; distributing information that empowers parents; enabling team/clinical care consistency; and appointing persons in the care system who can foster parents׳ feelings of trust--in short: by enabling management, informational, and relational continuity.

KEY CONCLUSIONS

care continuity experiences lead to perceived parenting support in the early postpartum period. Effective health care organisations within the postpartum care system must embody these types of continuity: management, informational, and relational. There is a need for researchers to design tools for measuring continuity and for policymakers to enable coherence and co-ordination among professionals.

IMPLICATIONS FOR PRACTICE

identify parents׳ needs so that health professionals can plan for parents׳ first few weeks at home and ensure that parents get access to appropriate care.

International migration and caesarean birth: a systematic review and meta-analysis

Background

Perinatal health disparities including disparities in caesarean births have been observed between migrant and non-migrant women and some literature suggests that non-medical factors may be implicated. A systematic review was conducted to determine if migrants in Western industrialized countries consistently have different rates of caesarean than receiving-country-born women and to identify the reasons that explain these differences.

Methods

Reports were identified by searching 12 literature databases (from inception to January 2012; no language limits) and the web, by bibliographic citation hand-searches and through key informants. Studies that compared caesarean rates between international migrants and non-migrants living in industrialized countries and that did not have a ‘fatal flaw’ according to the US Preventative Services Task Force criteria were included. Studies were summarized, analyzed descriptively and where possible, meta-analyzed.

Results

Seventy-six studies met inclusion criteria. Caesarean rates between migrants and non-migrants differed in 69% of studies. Meta-analyses revealed consistently higher overall caesarean rates for Sub-Saharan African, Somali and South Asian women; higher emergency rates for North African/West Asian and Latin American women; and lower overall rates for Eastern European and Vietnamese women. Evidence to explain the consistently different rates was limited. Frequently postulated risk factors for caesarean included: language/communication barriers, low SES, poor maternal health, GDM/high BMI, feto-pelvic disproportion, and inadequate prenatal care. Suggested protective factors included: a healthy immigrant effect, preference for a vaginal birth, a healthier lifestyle, younger mothers and the use of fewer interventions during childbirth.

Conclusion

Certain groups of international migrants consistently have different caesarean rates than receiving-country-born women. There is insufficient evidence to explain the observed differences.

The assessment of satisfaction with care in the perinatal period

Patient satisfaction is frequently used to evaluate the quality of medical care and to guide the development of health care services. Improved satisfaction is a goal recommended by the Institute of Medicine and the government of the United Kingdom for health care reform. During the perinatal period, dynamic changes in physical and psychological state impose unique challenges in the assessment of satisfaction. This article reviews the measurement of satisfaction with care, together with factors that may influence satisfaction and its measurement during the perinatal period. Recommendations are also provided for further research and development of satisfaction instruments and potential interventions to improve satisfaction with perinatal care.

Postnatal care: development of a psychometric multidimensional satisfaction questionnaire (the WOMBPNSQ) to assess women's views

BACKGROUND

Postnatal care is the neglected area of pregnancy care, despite repeated calls to improve it. Changes would require assessment, which should include women's views. No suitable satisfaction questionnaire exists to enable this.

AIM

To develop a multidimensional psychometric postnatal satisfaction self-completion instrument.

SETTING

Ten maternity services in south west England from 2006-2009.

METHOD

Sources for questions were literature review, fieldwork, and related published instruments. Principal components analysis with varimax rotation was used to develop the final WOMen's views of Birth Postnatal Satisfaction Questionnaire (WOMBPNSQ) version. Validity and internal reliability were assessed. Questionnaires were mailed 6-8 weeks postnatally (with one reminder).

RESULTS

The WOMBPNSQ comprises 36 seven-point Likert questions (13 dimensions including general satisfaction). Of 300 women, 166 (55.3%) replied; of these 155 (95.1 %) were white, 152 (93.8%) were married or cohabiting, 135 (81.3%) gave birth in a consultant unit, 129 (78.6%) had a vaginal delivery; and 100 (60.6%) were multiparous. The 12 specific dimensions were: support from professionals or partner, or social support; care from GP and health visitor; advice on contraception, feeding baby, the mother's health; continuity of care; duration of inpatient stay; home visiting; pain after birth. These have internal reliability (Cronbach's alpha varying from 0.624 to 0.902). Various demographic and clinical characteristics were significantly associated with specific dimensions.

CONCLUSION

WOMBPNSQ could be used to assess existing or planned changes to maternity services or as a screening instrument, which would then enable in-depth qualitative assessment of areas of dissatisfaction. Its convergent validity and test-retest reliability are still to be assessed but are an improvement upon existing postnatal satisfaction questionnaires.

Addressing the midwifery workforce crisis: evaluating an employment model for undergraduate midwifery students at a tertiary maternity hospital in Melbourne, Australia

BACKGROUND AND AIMS

In Victoria, maternity services are under significant strain due to increased numbers of women giving birth and critical workforce shortages. Hospitals have experienced challenges in adequately staffing maternity units, particularly on postnatal wards. In 2008, a tertiary maternity hospital in Melbourne introduced a model where undergraduate midwifery students were employed as Division 2 nurses (SMW_Div2) (enrolled nurses), to work in the postnatal area only. This study explored the pilot employment model from the perspective of the SMW_Div2 and hospital midwives.

METHODS

A web-based survey was administered to hospital midwives and the SMW_Div2s in the employment model in January 2010. The survey explored the views of midwives and SMW_Div2s regarding the perceived impact of the model on workforce readiness, recruitment and retention, and clinical competence and confidence.

FINDINGS

Forty-seven of 158 midwives (30%) and five of nine SMW_Div2s employed in the model responded to the survey. Both groups considered the model to have benefits for the organisation, including increased: student workforce readiness; clinical confidence and competence; and organisational loyalty. Both groups also considered that the model would facilitate: workforce recruitment; a teaching and learning culture within the organisation; and enhanced partnerships between students, hospitals and universities. Caution was expressed regarding workload and the need for ongoing support for SMW_Div2s working in the model.

DISCUSSION AND CONCLUSION

SMW_Div2s and midwives were positive about the introduction of the paid employment model at the Women's. The findings are consistent with evaluations of similar programs in the nursing setting. The employment model has potential short and long term individual and organisational advantages, which is important in the context of increasing births and workforce shortages. Progression of such models will be contingent on the collaboration and cooperation of the various stakeholders involved in maternity workforce and education.

The early postnatal period: exploring women's views, expectations and experiences of care using focus groups in Victoria, Australia

BACKGROUND

There is growing evidence from Australia and overseas that the care provided in hospital in the early postnatal period is less than ideal for both women and care providers. Many health services face increasing pressure on hospital beds and have limited physical space available to care for mothers and their babies. We aimed to gain a more in-depth understanding of women's views, expectations and experiences of early postnatal care.

METHODS

We conducted focus groups in rural and metropolitan Victoria, Australia in 2006. Fifty-two people participated in eight focus groups and four interviews. Participants included eight pregnant women, of whom seven were pregnant with their first baby; 42 women who were in the postpartum period (some up to twelve months after the birth of their baby); and two partners. All participants were fluent in English. Focus group guides were developed specifically for the study and explored participants' experiences and/or expectations of early postnatal care in hospital and at home, with an emphasis on length of hospital stay, professional and social support, continuity of care, and rest. Discussions were audio-taped and transcribed verbatim. A thematic network was constructed to describe and connect categories with emerging basic, organizing, and global themes.

RESULTS

Global themes that emerged were: anxiety and/or fear; and the transition to motherhood and parenting. The needs of first time mothers were considered to be different to the needs of women who had already experienced motherhood. The women in this study were generally concerned about the safety of their new baby, and lacked confidence in themselves as new mothers regarding their ability to care for their baby. There was a consistent view that the physical presence and availability of professional support helped alleviate these concerns, and this was especially the case for women having a first baby.

CONCLUSION

Women have anxieties and fears around early parenting and their changing role, and may consider that the physical availability of professional care providers will help during this time. Care providers should be cognisant of these potential issues. It is crucial that women's concerns and needs be considered when service delivery changes are planned. If anxiety around new parenting is a predominant view then care providers need to recognise this and ensure care is individualised to address each woman's/families particular concerns.