Satisfaction with pregnancy and birth services: The quality of maternity care services as experienced by women

Translation and measurement properties of pregnancy and childbirth questionnaire in Iranian postpartum women

BACKGROUND

Perceived care quality and patient satisfaction have been important care quality indicators in recent decades, and healthcare professionals have been influential on women's childbirth experience. This study investigated the measurement properties of the Persian version of the Pregnancy and Childbirth Questionnaire (PCQ), designed to measure mothers' satisfaction with the quality of healthcare services provided during pregnancy and childbirth.

METHODS

This is a cross-sectional methodological study. Instrument translation, face validity, content validity, structural validity, and reliability evaluation were performed to determine the measurement properties of the PCQ's Persian version. A backward-forward approach was employed for the translation process. Impact scores were selected based on the items' importance to measure face validity. Content validity index (CVI) and content validity ratio (CVR) were calculated to measure content validity, and exploratory and confirmatory factor analyses were used to measure structural validity. The cluster random sampling method was used, resulting in a sample of 250 eligible women referred to the health centers of Tabriz, Iran, who were 4 to 6 weeks after giving birth. Cronbach's alpha coefficient and Intraclass Correlation Coefficient (ICC) using a test-retest approach were used to determine the questionnaire's reliability.

RESULTS

The impact scores of all items were above 1.5, which indicates a suitable face validity. The content validity was also favorable (CVR = 0.95, CVI = 0.90). Exploratory factor analysis on 25 items led to the removal of item 2 due to a factor loading of less than 0.3 and the extraction of three factors explaining 65.07% of the variances. The results of the sample adequacy size were significant (< 0.001, and Kaiser-Meyer-Olkin = 0.886). The model's validity was confirmed based on the confirmatory factor analysis fit indicators (i.e., RMSEA = 0.08, SRMR = 0.09, TLI = 0.91, CFI = 0.93, x2/df = 4.65). The tool's reliability was also confirmed (Cronbach's alpha = 0.88, and ICC (95% CI) = 0.93 (0.88 to 0.95)).

CONCLUSION

The validity and reliability of the PCQ's Persian version were suitable to measure the extent to which Iranian women are satisfied with the quality of prenatal and intrapartum care.

Antenatal cardiotocography in primary midwife-led care: Women's satisfaction

BACKGROUND

In the Netherlands, antenatal cardiotocography (aCTG), used to assess fetal well-being, is performed in obstetrician-led care. To improve continuity of care, an innovation project was designed wherein primary care midwives perform aCTGs for specific indications. The aim of this study was to examine the satisfaction and experiences of pregnant women who received an aCTG in primary midwife-led care and explore which factors were associated with high satisfaction.

METHODS

Data were collected through a self-administered questionnaire based on the Consumer Quality Index. The primary outcome was general satisfaction on a 10-point scale, with a score above nine indicating participants were "highly satisfied".

RESULTS

In total, 1227 women were included in the analysis. The study showed a mean general satisfaction score of 9.2. Most women were highly satisfied with receiving an aCTG in primary midwife-led care (77.4%). On the Consumer Quality Index, the mean satisfaction level varied from 3.98 (SD ± 0.11) for the subscale "client satisfaction" to 3.87 (SD ± 0.32) for the subscale "information provision" on a 4-point scale. Women at between 33 and 36 weeks' gestation were more likely to be highly satisfied (adjusted OR [aOR] = 3.35). Compared with a completely comfortable position during the aCTG, a mostly comfortable or somewhat comfortable level had decreased odds of being associated with a ranking of highly satisfied (aOR 0.24 and 0.19, respectively).

CONCLUSIONS

This study shows that pregnant women are satisfied with having an aCTG in midwife-led care. Providing aCTG in midwife-led care can increase access to continuity of care.

Development and Validity of an Intrapartum Self-Assessment Scale Aimed at Instilling Midwife-Led Care Competencies Used at Freestanding Midwifery Units

Building experience in midwife-led care at freestanding midwifery units is needed to enhance assessment, technical, and care competencies specific to midwives. This study aimed to develop a self-assessment scale for midwifery practice competency based on the characteristics of midwife-led care practices in freestanding midwifery units. This study was conducted at 65 childbirth facilities in Japan between September 2017 and March 2018. The items on the scale were developed based on a literature review, discussion at a professional meeting, and a preliminary survey conducted at two timepoints. The validity and reproducibility of the scale were evaluated based on item analysis, compositional concept validity, internal consistency, stability, and criterion-related validity using data from 401 midwives. The final version of the scale consisted of 40 items. Cronbach's α for the overall scale was 0.982. The results for compositional concept validity, internal validity, and criterion-related validity demonstrated that this scale is capable of evaluating a midwife's practice competencies in intrapartum care. Repeated self-assessment using this scale could improve the competencies of midwives from an early stage, maximize the roles of physicians and midwives, and create an environment that provides high-quality assistance to women.

Quality improvement of childbirth care (Adequate Birth Project) and the assessment of women's birth experience in Brazil: a structural equation modelling of a cross-sectional research

BACKGROUND

Brazil's maternity care is highly medicalized, and obstetric interventions in labour and birth are high, mainly in private health system. The Adequate Birth Project (PPA-Projeto Parto Adequado) is quality improvement project designed to reduce unnecessary caesarian section rates in private hospitals in Brazil. This study evaluated the association between the participation of the PPA and the birth experience assessed by the women.

METHODS

It was carried out in 2017/2018 a hospital-based research with a convenience sample of 12 private hospitals among the 23 participants of the project. In this article, a sub-sample of 2348 mothers of 4878 postpartum women, including only women who desired vaginal birth at the ending of pregnancy was analyzed. Multigroup structural equation modelling was used for data analysis to compare vaginal birth and caesarean section. The latent variable was constructed from four items: participation in decisions, respectful treatment during labour and birth, satisfaction with the care during childbirth, satisfaction with care of the baby.

RESULTS

In the vaginal birth group, women who participated in PPA rated the birth experience better than women who did not participate (standardized coefficient: 0.388, p-value: 0.028). On the other hand, this effect was not observed (standardized coefficient: - 0.271, p-value: 0.085) in the caesarean section. Besides, the explicative models for a good birth experience varied to the type of childbirth. Among women with vaginal birth, complication during pregnancy and younger age were associated with a more positive birth experience. In contrast, for women with a caesarean section, access to information and participation in the pregnant group was associated with a better evaluation of the birth experience.

CONCLUSIONS

The childbirth care model that encourages vaginal delivery and reduces unnecessary caesarean modulates the birth experience according to the type of birth. This study also highlights the importance of perceived control, support, and relationship with the health team shaping women's experience with labour and delivery. These factors may affect policy, practice, and research on childbirth care.

The experience of giving birth in a hospital in Spain: Humanization versus technification

AIM

To explore and describe the experiences of women giving birth in a tertiary public hospital, with special focus on experiences related to humanized care and women's participation in decision making.

METHOD

This is a qualitative phenomenological study through semi-structured interviews to postpartum women giving birth in a tertiary hospital between January and May 2017. Data were analysed through content analysis.

RESULTS

The two overarching themes emerged were the professional-information dyad and privacy. Subthemes of the first main theme were the therapeutic relationship, decision-making, feeding the baby, procedures, and the time factor. Subthemes of the second topic were the feelings generated by the hospital environment, the delivery room, and the maternity ward.

CONCLUSIONS

If the therapeutic relationship is good, technology is not seen as dehumanising but rather as necessary to ensure continuing safety. "Humanising" material resources are not a priority for women in the birth process and are little used. Privacy was experienced as being a particularly intense need, which women called for throughout the healthcare process.

Assessing Perception of Prenatal Care Quality Among Black Women in the United States

INTRODUCTION

There has been little attention to measuring quality of prenatal care from a Black person's perspective. We examined validity and reliability of the Quality of Prenatal Care Questionnaire (QPCQ) and perceptions of the quality of prenatal care among pregnant Black women.

METHODS

A total of 190 women had complete data on the postpartum questionnaire containing the QPCQ within 8 weeks after birth. Internal consistency reliability was assessed using Cronbach's α. Construct validity was assessed through hypothesis testing using select questions from the Pregnancy Risk Assessment Monitoring System (PRAMS) and Pearson's r correlation.

RESULTS

The mean (SD) maternal age was 26.5 (5.5) years, and 85.3% of births were term (>37 weeks' 0 days' gestation). The total mean (SD) QPCQ score was 191.3 (27.9) points (range 46-230), and the mean (SD) item score for the subscales ranged from 3.88 (0.80) points to 4.27 (0.64). The Cronbach's α for the overall QPCQ score was .97 and ranged from .72 to .96 for the 6 subscale scores, which indicated acceptable internal consistency reliability. All but one subscale had a Cronbach's α higher than .80. The Approachability subscale had a Cronbach's α of .72. Construct validity demonstrated a moderate and significant positive correlation between the PRAMS items and the QPCQ (r = .273, P < .001).

DISCUSSION

To our knowledge, this is the first study to examine the validity and reliability of the QPCQ and perceptions of quality of prenatal care among Black women from the United States. The results indicate that participants rate the quality of their prenatal care highly and that the QPCQ is a reliable and valid measure of the quality of prenatal care. Use of a convenient and reliable instrument to measure the quality of prenatal care rather than prenatal care satisfaction or utilization may help to elucidate the factors of prenatal care that are protective specifically among Black women.

Developing an Evaluation Model for Maternity Care: A Mixed-Method Study from Iran

Background:

Maternity care is an integral part of primary health care (PHC) systems worldwide. This study aimed to develop a new model for evaluating the maternity health program (MHP) in Iran.

Methods:

In this mixed-methods study, first, the challenges of MHP were surveyed through systematic review and expert interviews. Next, to identify the existing shortcomings in MHP evaluation system, the SWOT technique, cross-sectional study and comparative analyses were used. Finally, the Delphi technique was used to reach consensus on developed evaluation standards.

Results:

The final developed evaluation model contains five dimensions including reproductive health/family planning, maternity health, health records, evaluation, and resources management. Overall, this model has 32 standards and 289 measures. The scores obtained for the sum of the measures in two importance and applicability criteria were 8.24 and 7.85, which these scores are estimated to be equal to 91.55 and 87.22 percent of the highest possible scores, respectively.

Conclusion:

Considering the comprehensiveness of the obtained model, it is hoped that it could lead to performance improvement of the PHC centers in the area of maternity health.

Hospital Childbirth: Perspectives of Women and Professionals for a Positive Experience-A Qualitative Study

The perception and interpretation of childbirth are changing as values change. This requires women and professionals to adapt to new circumstances. The objective of this study was to analyze the perspectives of women and professionals on hospital birth and to identify improvement areas in order to achieve a positive perinatal experience. A qualitative prospective study with a phenomenological approach was conducted using semi-structured interviews with women, two and eight months after childbirth, participant observation, and professional focus groups. The analysis of the transcribed texts involved a thematic inductive approach. Four improvement areas emerged from the analysis: (a) strengthening communication and the therapeutic relationship; (b) unifying criteria between hospitals and primary care centers to provide coordinated and coherent information; (c) involvement of the partner in the whole process of pregnancy-childbirth-puerperium; (d) improvement of the spaces used in prenatal care and births. The need for a continuity of care from the beginning of pregnancy to the postpartum period is emphasized, which requires an improvement in information, participation, and the promotion of shared decision-making. To this end, coordinated interdisciplinary work, involvement of the partner and the improvement of the spaces used in prenatal care and births are essential.

Patient Perspectives of Rural Kansas Maternity Care

Introduction

Pregnant women in rural areas face a unique set of challenges due to geographic maldistribution of obstetric services. The perspectives of rural Kansas women were sought regarding experience of birth and satisfaction with maternity care.

Methods

Medical student research assistants facilitated discussion groups and structured interviews in rural Kansas communities distributed throughout the state with women who had an uncomplicated delivery in the last 24 months. Participants were recruited via convenience sampling from clinic medical records and appointments over a two-to-three-week period. Guiding questions were used to facilitate discussion. Survey instruments were used to gather information about satisfaction with maternity care. Data for qualitative and quantitative analysis was aggregated using Rural Urban Commuting Area (RUCA) codes.

Results

Fourteen groups with 47 total participants completed the survey and discussion. Participants came from large rural, small rural, and isolated areas in Kansas as described by RUCA Code Four Category Classification. Survey results indicated that satisfaction with maternity care in participants' home county was significantly higher in small rural and isolated compared to large Rural RUCAs. Qualitative analysis results showed positive experiences related to doctor characteristics, relationship with doctor, doctor's involvement with care, alternative labor options, and distance convenience. Negative experiences were related to doctor bedside manner, doctor not there until delivery, and staff related complaints.

Conclusions

Kansas women in small rural and isolated RUCA codes appeared to be more satisfied with care.

Methods of induction of labor and women's experience: a population-based cohort study with mediation analyses

BACKGROUND

Negative childbirth experience may affect mother wellbeing and health. However, it is rarely evaluated in studies comparing methods of induction of labor (IoL).

AIM

To compare women's experience of IoL according to the method, considering the mediating role of interventions and complications of delivery.

METHODS

We used data from the MEDIP prospective population-based cohort, including all women with IoL during one month in seven French perinatal networks. The experience of IoL, assessed at 2 months postpartum, was first compared between cervical ripening and oxytocin, and secondarily between different cervical ripening methods. Mediation analyses were used to measure the direct and indirect effects of cervical ripening on maternal experience, through delivery with interventions or complications.

FINDINGS

The response rate was 47.8% (n = 1453/3042). Compared with oxytocin (n = 541), cervical ripening (n = 910) was associated less often with feelings that labor went 'as expected' (adjusted risk ratio for the direct effect 0.78, 95%CI [0.70-0.88]), length of labor was 'acceptable' (0.76[0.71-0.82]), 'vaginal discomfort' was absent (0.77[0.69-0.85]) and with lower global satisfaction (0.90[0.84-0.96]). Interventions and complications mediated between 6 and 35% of the total effect of cervical ripening on maternal experience. Compared to the dinoprostone insert, maternal experience was not significantly different with the other prostaglandins. The balloon catheter was associated with less pain.

DISCUSSION

Cervical ripening was associated with a less positive experience of childbirth, whatever the method, only partly explained by interventions and complications of delivery.

CONCLUSION

Counselling and support of women requiring cervical ripening might be enhanced to improve the experience of IoL.

A meta-synthesis of the perspectives and experiences of healthcare professionals on the humanisation of childbirth using a meta-ethnographic approach

PROBLEM

The humanisation of childbirth has been identified as a practice of care focusing on the physical, psychological, and emotional wellbeing of women. Healthcare professionals (HCPs) are expected to understand and embed humanised practice when supporting women in childbirth.

AIM

The aim of this paper is to present a meta-synthesis of the experiences and perspectives of HCPs who undertake care for women at the time of birth regarding the humanisation of childbirth.

METHODS

A systematic search of the electronic databases CINAHL, Medline, PsycINFO, and SocINDEX were conducted in July 2020. Qualitative studies exploring HCPs' experiences and perspectives of humanisation in childbirth were eligible. Studies were synthesised using a meta-ethnographic approach.

FINDINGS

Fourteen studies involving 197 participants were included. Two themes were identified: 'Women at the centre' and 'Professional dissonance'. Two line of argument synthesis were identified: 'invisible boundaries' and 'unconscious undermining'.

DISCUSSION

HCPs recognised that women required positive interactions which met both their emotional and physical needs. Human touch supported bonding between HCPs and women. HCPs understood humanisation as the reduction of unnecessary intervention and/or technology but had difficulties enacting this and often used disempowering language when discussing women's choices. The management of pain and the presence of a companion were considered important by HCPs.

CONCLUSION

This synthesis revealed that HCPs do understand the humanisation of childbirth but have difficulties in enacting it in practice. Women classified as high risk were identified as having specific needs such as increased emotional support. Further research is required for women classified as high risk who may require technology and/or interventions to maintain a safe birth.

"I fought my entire way": Experiences of declining maternity care services in British Columbia

BACKGROUND

The 2016 WHO Standards for improving quality of maternal and newborn care in health facilities established patient experience of care as a core indicator of quality. Global health experts have described loss of autonomy and disrespect as mistreatment. Risk of disrespect and abuse is higher when patient and care provider opinions differ, but little is known about service users experiences when declining aspects of their maternity care.

METHODS

To address this gap, we present a qualitative content analysis of 1540 written accounts from 892 service users declining or refusing care options throughout childbearing with a large, geographically representative sample (2900) of childbearing women in British Columbia who participated in an online survey with open-ended questions eliciting care experiences.

FINDINGS

Four themes are presented: 1) Contentious interactions: "I fought my entire way", describing interactions as fraught with tension and recounting stories of "fighting" for the right to refuse a procedure/intervention; 2) Knowledge as control or as power: "like I was a dim girl", both for providers as keepers of medical knowledge and for clients when they felt knowledgeable about procedures/interventions; 3) Morbid threats: "do you want your baby to die?", coercion or extreme pressure from providers when clients declined interventions; 4) Compliance as valued: "to be a 'good client'", recounting compliance or obedience to medical staff recommendations as valuable social capital but suppressing desire to ask questions or decline care.

CONCLUSION

We conclude that in situations where a pregnant person declines recommended treatment, or requests treatment that a care provider does not support, tension and strife may ensue. These situations deprioritize and decenter a woman's autonomy and preferences, leading care providers and the culture of care away from the principles of respect and person-centred care.

Maternity care through the eyes of Southern European immigrant parents in Norway

OBJECTIVE

To explore Southern European immigrant mothers and fathers' experiences of reproductive health services in Norway, and their perceptions of health providers' beliefs and attitudes regarding pregnancy and childbirth.

METHOD

We employed a qualitative research methodology with two focus group discussions and 11 in-depth interviews with 4 fathers and 11 mothers from Italy, Spain, Portugal, and Greece, whose children were born in Norway. Thematic Analysis was conducted to identify and analyze patterns across the data.

RESULTS

We identified three themes as key elements in parents' experiences: experiences with the coverage and organization of the Reproductive Health Services; relational experiences with health providers; and pregnancy and delivery as a culturally-shaped event. The immigrant parents experienced a clash between their expectations and the procedures and health facility environment encountered in Norway regarding check-ups, diagnosis tests, childbirth preparation courses, and health facilities. Informants perceived that the maternity care practices of the host country were underpinned by the health care providers' cultural understandings of labor and pregnancy. Particularly, they experienced a less interventionist approach towards pregnancy and childbirth.

CONCLUSIONS

The experiences of immigrant parents provide relevant information to improve reproductive health services in a cross-cultural context. Inmigration brings new challenges that must be addressed from a perspective of cultural competence. These services should acknowledge diversity in cultural beliefs around childrearing and involve both fathers and mothers in decision-making.

Women's agenda for the improvement of childbirth care: Evaluation of the Babies Born Better survey data set in Spain

BACKGROUND

Public patient involvement (PPI) generates knowledge about the health-illness process through the incorporation of people's experiences and priorities. The Babies Born Better (BBB) survey is a pan-European online questionnaire that can be used as a PPI tool for preliminary and consultative forms of citizens' involvement. The purpose of this research was to identify which practices support positive birth experiences and which ones women want changed.

METHODS

The BBB survey was distributed in virtual communities of practice and through social networks. The version launched in Spain was used to collect data in 2014 and 2015 from women who had given birth in the previous 5 years. A descriptive, quantitative analysis was applied to the sociodemographic data. Two open-ended questions were analyzed by qualitative content analysis using a deductive and inductive codification process.

RESULTS

A total of 2841 women participated. 41.1% of the responses concerned the category "Care received and experienced," followed by "Specific interventions and procedures" (26.6%), "Involved members of care team" (14.2%), and "Environmental conditions" (9%). Best practices were related to how care is provided and received, and the main areas for improvement referred to specific interventions and procedures.

CONCLUSIONS

This survey proved a useful tool to map the best and poorest practices reported. The results suggest a need for improvement in some areas of childbirth care. Women's reports on negative experiences included a wide range of routine clinical interventions, avoidable procedures, and the influence exerted by professionals on their decision-making.

Satisfaction with maternal and birth services: a survey in public hospitals in Turkey

PURPOSE

The purpose of this study was to determine the satisfaction of women who underwent normal delivery and cesarean section (or C-section) with maternal care in five state-run hospitals in Northwestern Turkey.

DESIGN/METHODOLOGY/APPROACH

This was a cross-sectional study. The sample consisted of 580 women who underwent normal delivery (ND) and 392 who had a C-section (CS). Data were collected using two maternal satisfaction questionnaires, which participants completed right before they were discharged.

FINDINGS

More than half of ND (61.7%) and CS (56.9%) participants were satisfied with maternal care. ND participants who had received antenatal training were more satisfied with maternal care than CS participants who had not received antenatal training. Higher income was a significant predictor for reduced satisfaction with maternal care among CS participants (p = 0.031).

PRACTICAL IMPLICATIONS

Hospital administrators and decision-makers should meet women's expectations, provide them with comfort, encourage them for skin-to-skin contact and respect their right to privacy in order to increase their satisfaction with maternal care. Pregnant women should also be encouraged to receive antenatal training offered by hospitals before delivery.

ORIGINALITY/VALUE

The evidence-based results of the study will help hospital administrators to improve healthcare quality and focus on increasing women's satisfaction with maternal care.

The characteristics of compassionate care during childbirth according to midwives: a qualitative descriptive inquiry

BACKGROUND

Although compassion is considered to be of prime importance in nursing and midwifery, there is no clear understanding of what compassionate care in childbirth entails, and how midwives perceive compassionate care is largely unknown. This study accordingly seeks to describe the characteristics, of compassionate care during childbirth as perceived by midwives.

METHODS

A qualitative descriptive inquiry was undertaken with a voluntary online survey, where participants were recruited via snowball sampling on the social networking site, Facebook. The participants were midwives, and the unit of analysis was the received responses. Participants reported on instances of compassionate care during childbirth. The data was thematically analysed using Tesch's eight steps to identify common themes.

RESULTS

Ninety-eight responses were analysed and three themes with eight sub-themes emerged as dominant characteristics. Themes and sub-themes were as follows: making meaningful connections with women (displaying good interpersonal skills, conduct based on dignity and respect, establishing trust); initiating individualised understanding of each woman (showing empathy, permitting maternal choice) and action through care and support (providing emotional support, assistance through instrumental care, continuous informational support).

CONCLUSIONS

In seeking to determine what characterises compassionate care in childbirth, the findings reveal a process of making meaningful connections with women through recognising their needs, initiating individualised understanding of each woman's needs and desiring to ease it, which is subsequently manifested in action through emotional, instrumental and informational care and support. A better understanding of how midwives perceive compassionate care could potentially improve the quality of care midwives offer during childbirth.

Women's experiences of midwifery care immediately before and after caesarean section deliveries at a public Hospital in the Western Region of Ghana

Background

Childbirth remains a uniquely multifaceted, mental-cognitive and a major life experience to women. It is composed of a variety of psycho social and emotional aspects and creates memories, sometimes bad experiences and unmet expectations which leaves the mother with lasting scars. Therefore, this study aimed at exploring post-caesarean section delivered mothers experiences of midwifery care in a public hospital in Ghana.

Methods

This descriptive exploratory qualitative research used an interpretative approach to explore mothers’ experiences of midwifery care immediately before and after caesarean section (CS). The study employed a purposive sampling technique in recruiting 22 participants who had knowledge of the phenomenon under study. Data collection was guided by an interview guide, which involved face to face individual interviews and focus group discussion at the postnatal ward and clinic. All interviews were audio-recorded and lasted 30–40 min. Audio recordings were transcribed verbatim and inductive thematic data analysis employed.

Results

Four major themes emerged from the analysis of participants’ transcripts: Support by Midwives (physical and psychological, and attitude towards patients’ pain management); Protection of mothers (provision of privacy, confidentiality and physical environment); Provision of information/communication (before caesarean section, and before a minor task) and midwives’ attitude (attitude towards delivery care).

Conclusion

Mothers delivered by caesarean section had varied experiences of midwifery care which were both positive and negative ones. Provision of psychological support and adequate pain management were positive experiences. The challenges experienced were related to provision of information, privacy, and physical support. Participants, who underwent emergency CS in particular, were dissatisfied with the provision of information concerning the surgical procedure. Provision of privacy and physical support were also issues of great concern. We therefore, recommend supportive and sensitive midwifery care particularly for mothers undergoing emergency CS. Documenting women’s diverse experiences of midwifery care before and after CS delivery is important to healthcare providers, hospital managers and policy makers as the feedback garnered can be used to improve maternity services and inform decisions on midwifery care.

A qualitative study of hospital birth perceptions: The helix of priority needs

OBJECTIVE

To understand which needs are considered priorities in the hospital birth experience from the perspectives of postpartum women.

DESIGN

This qualitative prospective study used a phenomenological approach. Data were collected through participant observations and semi-structured interviews recorded at eight weeks and eight months after childbirth. The data were analysed using a thematic approach.

PARTICIPANTS

The study cohort consisted of 43 participants at eight weeks after childbirth and 33 participants eight months after childbirth.

SETTING

Donostia University Hospital, San Sebastián, Spain, in 2016-2017.

FINDINGS

Through the analysis, the following four main themes emerged, each in different categories: (a) Professional care: symbiosis between the woman and the professional: (a.1) professional treatment and its characteristics, (a.2) professional competence, and (a.3) professional information and listening: pillars in the support relationship. (b) Control and hospital safety: (b.1) hospital environment: external control. (c) Presence of the partner: (c.1) support, guidance, and participation. (d) Perception of observed feelings: (d.1) fear of complications or separation from the child, (d.2) fear of internal lack of control, and (d.3) fear of an instrumental delivery and/or caesarean section.

CONCLUSIONS AND IMPLICATIONS FOR PRACTISE

The core of the hospital birth experience is constituted by the need to establish a supportive relationship based on mutual trust, exchange information that offers internal and external control and the security necessary to overcome feelings of fear, and obtain support and guidance from an involved partner.

Patient-led decision making: Measuring autonomy and respect in Canadian maternity care

OBJECTIVE

The Changing Childbirth in British Columbia study explored women's preferences and experiences of maternity care, including women's role in decision-making.

METHODS

Following content validation by community members, we administered a cross-sectional online survey exploring novel topics, including drivers for interventions, and experiences of autonomy, respect, or mistreatment during maternity care. Using the Mothers Autonomy in Decision-Making (MADM) scale as an outcome measure in a mixed-effects analysis, we examined differential experiences by socio-demographic and prenatal risk profile, type of care provider, interventions received, and nature of communication with care providers.

RESULTS

A geographically representative sample of Canadian women (n = 2051) reported on 3400 pregnancies. Most women (95.2%) preferred to be the lead decision-maker during care. Patients of physicians had significantly lower autonomy (MADM) scores than midwifery clients as did women who felt pressured to accept interventions. Women who had a difference in opinion with their provider, and those who felt their provider seemed rushed reported the lowest MADM scores.

CONCLUSION

Women's autonomy is significantly altered by model of maternity care, the nature of interactions with care providers, and women's ability for self-determination.

PRACTICE IMPLICATIONS

If health professionals acquire skills in person-centred decision-making experience of autonomy among pregnant women may improve.

Links between patient safety and fear of childbirth-A meta-study of qualitative research

AIM

To conduct a meta-study of qualitative empirical research to explore the links between patient safety and fear of childbirth in the maternity care context. The review questions were: How are patient safety and fear of childbirth described? and What are the links between patient safety and fear of childbirth in the maternity care context?

DESIGN

Meta-study.

DATA SOURCES

The CINAHL, Cochrane, PubMed, Webb of Science, Proquest and Medline (Ovid) electronic databases were searched for articles published between June 2000-June 2016.

REVIEW METHODS

A meta-study of qualitative research with a thematic analysis followed by a synthesis.

RESULTS

Four descriptive themes emerged: "Physical risks associated with giving birth vaginally"; "Control and safety issues"; "Preventing psychological maternal trauma and optimizing foetal well-being"; and "Fear of the transition to motherhood due to lack of confidence". The two overarching analytical themes: "Opting for safety" and "An insecure environment breeds fear of childbirth", represent a deeper understanding and constitute the synthesis of the links between patient safety and fear of childbirth. This meta-study indicates the need for increased commitment to safe care and professional support to reduce risks and prevent unnecessary harm in maternity care.

Are we too far from being client centered?

Background

Quality of service provision in health facilities is fundamental to ensure effective care. However, women’s actual experience of care is often neglected.

Objective

To assess perceived quality of institutional delivery services and associated factors among women who delivered in public health facilities of Southwest Ethiopia.

Method

Community based cross-sectional study was conducted in three districts of Jimma zone, Southwestern Ethiopia, from February 29 to March 20, 2016. A total of 423 mothers who delivered in public health facilities during the last 12 months were selected to participate in the study. Study participants were identified using simple random sampling procedure. Principal component analysis was used to generate scores for three sub-dimensions of perceived quality. Multiple linear regression analysis was performed to identify predictors of these sub-dimensions.

Results

Perceived quality of institutional delivery services was measured with three dimensions: perceived interpersonal interaction, health care delivery and health facility/structure. We found that perceived quality of interpersonal interaction was negatively affected by educational level (read and write) (β: -0.331, 95% CI: -0.523, -0.140), urban residence (β: -0.485, 95% CI: -0.696, -0.275), antenatal care (less than three visits) (β: -0.238, 95% CI: -0.419,-0.056) and delivery service attended by male provider (β: -1.286, 95% CI: -1.463,-1.109). Perceived quality of health care delivery was negatively associated with still birth (β: -0.642, 95% CI: -1.092,-0.193) and delivery services attended by male provider (β: -0.689, 95% CI: -0.907,-0.472). Urban residence (β: -0.260, 95% CI: -0.515,-0.005), and antenatal care (less than three visits) (β: -0.394, 95% CI: -0.628,-0.161) were negatively associated with perceived quality of health facility/structure.

Conclusion

Overall, the perceived quality of institutional delivery services was low. We recommend that health managers and health care providers jointly work to transform birth care at the health facilities to deliver person-centered care. Addressing the preferences of clients is as important as taking care of structural concerns pinpointed in this study.

Women's views and experiences of publicly-funded homebirth programs in Victoria, Australia: A cross-sectional survey

BACKGROUND

It is critical women's voices are heard if there is to be more widespread implementation of midwifery-led continuity models. Publicly-funded homebirth is one such model, yet there has been limited systematic evaluation from the women's perspective.

AIM

Examine women's experiences of and views about the two publicly-funded homebirth programs in Victoria, Australia.

METHODS

A cross-sectional design was used. All eligible women enrolled in the two pilot homebirth programs in metropolitan Melbourne whose infants were eight weeks of age or more during the evaluation period were invited to participate in a postal survey. A structured questionnaire was used, with some open-ended questions to enable extra comments. We explored women's reasons for choosing homebirth; views of care; experience of labour and birth; views on transfer; and overall experience of the homebirth program. Data were analysed using descriptive statistics. Simple thematic analysis was used for open-ended questions.

FINDINGS

The survey response rate was 71% (96/136). A high percentage of women rated their care as 'Very good': pregnancy 81%; labour and birth 90%; and the early postpartum period 83%. Women reported low levels of anxiety during labour and birth, were able to express their feelings, felt in control, and coped physically and emotionally better than they had expected. They felt well supported by midwives and overall reported very positive experiences of the homebirth programs.

CONCLUSIONS

These two publicly-funded homebirth pilot programs demonstrated very positive care ratings by women. These findings, along with the clinical outcomes (reported separately), support the continuation and expansion of the program.

Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis

Background

What constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable.

Objectives

To develop a conceptualisation of RMC.

Search strategy

Key databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies.

Selection criteria

Primary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date.

Data collection and analysis

A combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings.

Main results

Sixty‐seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent.

Conclusions

This review presents an evidence‐based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes.

Tweetable abstract

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

A Qualitative Study on Women's Experiences of Intrapartum Nursing Care at Tamale Teaching Hospital (TTH), Ghana

Introduction: Labor and delivery process is an exciting, anxiety-provoking, but rewarding time for a woman and her family after successful delivery of a newborn. The intrapartum period is the time where mothers expect more care. Taking care of a mother through delivery with no side effects is the task of a professional midwife who is trained with the skill to take the responsibility of caring for mothers and babies. Therefore, the aim of this study was to explore mother's experiences regarding quality of intrapartum nursing/midwifery care. Methods: Focused ethnographic study was employed. Data were collected from May to June 2016 TTH, Ghana using semi structured interview guide. Purposive sampling was employed to recruit 20 participants. Eight individual interviews were conducted in the post natal ward after 48 hours of delivery, followed by three focus group discussions two weeks after delivery when mothers visited post natal clinic. Interviews lasted for about 30-45 minutes during each session. Data were analyzed using thematic analysis. Results: The average age of women were 29 years with ranging from 19-43 years. Participants' experiences of nursing/midwifery care during birth were influenced by reception and respect, provision of information, technical skill, providers' behavior, pain management and availability of nurses/midwives. Conclusion: The study findings have revealed that women's experience of care is affected by a wide range of determinants. Therefore, maternal health programs and policies in Ghana must take into account women's perspective on the care they need and their feedback on services they receive. Nursing education should re-enforce communication/relational skills.

Healthcare professionals' assertions and women's responses during labour: A conversation analytic study of data from One born every minute

OBJECTIVE

Communication during labour is consequential for women's experience yet analyses of situated labour-ward interaction are rare. This study demonstrates the value of explicating the interactional practices used to initiate 'decisions' during labour.

METHODS

Interactions between 26 labouring women, their birth partners and HCPs were transcribed from the British television programme, One Born Every Minute. Conversation analysis was used to examine how decisions were initiated and accomplished in interaction.

FINDINGS

HCPs initiate decision-making using interactional practices that vary the 'optionality' afforded labouring women in the responsive turn. Our focus here is on the minimisation of optionality through 'assertions'. An 'assertive' turn-design (e.g. 'we need to…') conveys strong expectation of agreement. HCPs assert decisions in contexts of risk but also in contexts of routine activities. Labouring women tend to acquiesce to assertions.

CONCLUSION

The expectation of agreement set up by an assertive initiating turn can reduce women's opportunities to participate in shared decision-making (SDM).

PRACTICE IMPLICATIONS

When decisions are asserted by HCPs there is a possible dissonance between the tenets of SDM in British health policy and what occurs in situ. This highlights an educational need for HCPs in how best to afford labouring women more optionality, particularly in low-risk contexts.

Characteristics of pregnant Jordanian women dissatisfied with life: A comparison between satisfied and dissatisfied women's demographics

Dissatisfied pregnant women who are at higher risk of negative outcomes perinatally have not been identified in Jordan. The purposes of the researchers were to identify and compare sociodemographic characteristics of satisfied pregnant women with dissatisfied pregnant women. A non-experimental, descriptive, comparative design was employed. Jordanian pregnant women (n =203) were consecutively selected. We found that younger, better educated pregnant women with a high economic status and a small number of children were more satisfied with their lives. Practitioners can identify dissatisfied women and develop an educational and interventional package that focuses on improving satisfaction with life for pregnant mothers.

Expectations of a group of Portuguese pregnant women in the districts of Viseu and Aveiro regarding motherhood

Motherhood is a complex phenomenon, supplementedwith expectations about the new reality, the hopes of all going well, taking into account the expected care. In order to meet the needs of the Portuguese expectant mother, it is necessary to know what she deems essential for herself and her family, so that strategies may be developed to facilitate the transition process. This study was intended to gain insight into fulfilled and unfulfilled expectations of health care in motherhood with a group pregnant females in Portugal. This is a qualitative, exploratory and descriptive study, with 22 Portuguese women belonging to the Clusters of Health Care Centers of the districts of Viseu and Aveiro. The data was collected through semi-structured interviews and analysed using content analysis proposed by Bardin, supported by QSR NVivo 10. It was observed that fulfilled expectations surpassed those unmet, especially in terms of high quality health care and competent health care professionals. Regarding unfulfilled expectations, they mainly refer to maternity incentives, with an emphasis on the wish of greater financial familly supportfrom the government.

Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women

Background

Satisfaction with birth care is part of quality assessment of care. The aim of this study was to investigate possible differences in satisfaction with intrapartum care among low-risk women, randomized to a midwifery unit or to an obstetric unit within the same hospital.

Methods

Randomized controlled trial conducted at the Department of Obstetrics and Gynecology, Østfold Hospital Trust, Norway. A total of 485 women with no expressed preference for level of birth care, assessed to be at low-risk at onset of spontaneous labor were included. To assess the overall satisfaction with intrapartum care, the Labour and Delivery Satisfaction Index (LADSI) questionnaire, was sent to the participants 6 months after birth. To assess women’s experience with intrapartum transfer, four additional items were added. In addition, we tested the effects of the following aspects on satisfaction; obstetrician involved, intrapartum transfer from the midwifery unit to the obstetric unit during labor, mode of delivery and epidural analgesia.

Results

Women randomized to the midwifery unit were significantly more satisfied with intrapartum care than those randomized to the obstetric unit (183 versus 176 of maximum 204 scoring points, mean difference 7.2, p = 0.002). No difference was found between the units for women who had an obstetrician involved during labor or delivery and who answered four additional questions on this aspect (mean item score 4.0 at the midwifery unit vs 4.3 at the obstetric unit, p = 0.3). Intrapartum transfer from the midwifery unit to an obstetric unit, operative delivery and epidurals influenced the level of overall satisfaction in a negative direction regardless of allocated unit (p < 0.001).

Conclusion

Low-risk women with no expressed preference for level of birth care were more satisfied if allocated to the midwifery unit compared to the obstetric unit.

Trial registration

The trial is registered at www.clinicaltrials.govNCT00857129. Initially released 03/05/2009.

Evaluation of Mackey Childbirth Satisfaction Rating Scale in Iran: What Are the Psychometric Properties?

Background

With the integration of the evaluation of patient satisfaction in the overall assessment of healthcare services, authorities can be assured about the alignment of these services with patient needs and the suitability of care provided at the local level.

Objectives

This study was conducted in 2013 in Zahedan, Iran, in order to assess the psychometric properties of the Iranian version of the mackey childbirth satisfaction rating scale (MCSRS).

Patients and Methods

For this study, a methodological design was used. After translating the MCSRS and confirming its initial validity, the questionnaires were distributed among women with uncomplicated pregnancies and no prior history of cesarean section. The participants had given birth to healthy, full-term, singletons (with cephalic presentation) via normal vaginal delivery at hospitals within the past six months. Cronbach’s alpha and test-retest (via the intraclass correlation coefficient) were applied to analyze the internal consistency and reliability of the scale. Moreover, the validity of the scale was tested via exploratory factor analysis, confirmatory factor analysis, and convergent validity.

Results

The MCSRS consists of six subscales. Through the process of validation, two partner-related items (“partner” subscale) of the scale were excluded due to cultural barriers and hospital policies. Cronbach’s alpha for the total scale was 0.78. It ranged between 0.70 and 0.86 for five subscales, and was 0.31 for the “baby” subscale. Factor analysis confirmed the subscales of “nurse,” “physician,” and “baby,” which were identified in the original scale. However, in the translated version, the “self” subscale was divided into two separate dimensions. The six subscales explained 70.37% of the variance. Confirmatory factor analysis indicated a good fitness for the new model. Convergent validity showed a significant correlation between the MCSRS and the SERVQUAL scale (r = 0.72, P < 0.001). Moreover, the Farsi version of the MCSRS showed excellent repeatability (r = 0.81 - 0.96 for individual subscales and r = 0.96 for the entire scale).

Conclusions

The study findings indicated the Farsi version of the MCSRS is a reliable and valid instrument. However, according to the reliability assessment and factor analysis, the “baby” and “self” subscales need further revisions.

Continuity of care by a primary midwife (caseload midwifery) increases women's satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial

Background

Continuity of care by a primary midwife during the antenatal, intrapartum and postpartum periods has been recommended in Australia and many hospitals have introduced a caseload midwifery model of care. The aim of this paper is to evaluate the effect of caseload midwifery on women’s satisfaction with care across the maternity continuum.

Methods

Pregnant women at low risk of complications, booking for care at a tertiary hospital in Melbourne, Australia, were recruited to a randomised controlled trial between September 2007 and June 2010. Women were randomised to caseload midwifery or standard care. The caseload model included antenatal, intrapartum and postpartum care from a primary midwife with back-up provided by another known midwife when necessary. Women allocated to standard care received midwife-led care with varying levels of continuity, junior obstetric care, or community-based general practitioner care. Data for this paper were collected by background questionnaire prior to randomisation and a follow-up questionnaire sent at two months postpartum. The primary analysis was by intention to treat. A secondary analysis explored the effect of intrapartum continuity of carer on overall satisfaction rating.

Results

Two thousand, three hundred fourteen women were randomised: 1,156 to caseload care and 1,158 to standard care. The response rate to the two month survey was 88 % in the caseload group and 74 % in the standard care group. Compared with standard care, caseload care was associated with higher overall ratings of satisfaction with antenatal care (OR 3.35; 95 % CI 2.79, 4.03), intrapartum care (OR 2.14; 95 % CI 1.78, 2.57), hospital postpartum care (OR 1.56, 95 % CI 1.32, 1.85) and home-based postpartum care (OR 3.19; 95 % CI 2.64, 3.85).

Conclusion

For women at low risk of medical complications, caseload midwifery increases women’s satisfaction with antenatal, intrapartum and postpartum care.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN012607000073404 (registration complete 23rd January 2007).

Expectations and satisfaction with antenatal care among pregnant women with a focus on vulnerable groups: a descriptive study in Ghent

Background

Previous studies demonstrate that people’s satisfaction with healthcare influences their further use of that healthcare system. Satisfied patients are more likely to take part in the decision making process and to complete treatment. One of the important determinants of satisfaction is the fulfillment of expectations. This study aims to analyse both expectations and satisfaction with antenatal care among pregnant women, with a particular focus on vulnerable groups.

Methods

A quantitative descriptive study was conducted in 155 women seeking antenatal care at the University Hospital of Ghent (Belgium), of whom 139 completed the questionnaire. The statistical program SPSS-21 was used for data analysis.

Results

Women had high expectations relating to continuity of care and women-centered care, while expectations regarding availability of other services and complete care were low. We observed significantly lower expectations among women without higher education, with low income, younger than 26 years and women who reported intimate partner violence. General satisfaction with antenatal care was high. Women were satisfied with their relationship with the healthcare worker, however ; they evaluated the information received during the consultation and the organizational aspects of antenatal care as less satisfactory.

Conclusions

In order to improve satisfaction with antenatal care, organizational aspects of antenatal care (e.g. reducing waiting times and increasing accessibility) need to be improved. In addition, women would appreciate a better provision of information during consultation. More research is needed for an in-depth understanding of the determinants of satisfaction and the relationship with low socio economic status (SES).

Electronic supplementary material

The online version of this article (doi:10.1186/s12905-015-0266-2) contains supplementary material, which is available to authorized users.

Antenatal telephone support intervention and uterine artery Doppler screening: A qualitative exploration of women׳s views

OBJECTIVES

to gain insight into low risk nulliparous women׳s experiences of a telephone support intervention (TSI) and TSI with uterine artery Doppler screening (UADS) intervention and their views of the structure of current antenatal care provision.

DESIGN

postnatal semi-structured interviews were analysed using a thematic framework approach. The interviews formed a subset of data from a mixed methods study.

SETTING AND PARTICIPANTS

participants were 45 low risk nulliparous women who had consented to take part in a randomised controlled trial of two antenatal support interventions; the trial was conducted at a large maternity unit in the North East of England, UK from 2004 to 2007.

FINDINGS

most of the women in the study expressed positive views about the telephone support intervention (TSI) and the antenatal care they had received. Uterine artery Doppler screening was acceptable to women but did not feature highly when women recalled their antenatal experiences. Those who viewed their pregnancy as complicated by medical, social or emotional difficulties would have preferred more frequent antenatal visits. Views of antenatal care provision were influenced by women׳s perception of their pregnancy progression and the relationship developed with their midwife.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

although the TSI was viewed positively by women, it was valued most by those who required additional support. The intervention was not a substitute for face to face midwifery visits. Future research is needed to investigate the potential of utilising telephone contact to provide antenatal care for women who have pregnancies complicated by physical, psychological or emotional issues. The findings were consistent with previous evidence to show that the relationship between women and midwives is fundamental to women׳s experience of antenatal care.

Individualised, flexible postnatal care: a feasibility study for a randomised controlled trial

BACKGROUND

Postnatal care in hospital is often provided using defined care pathways, with limited opportunity for more refined and individualised care. We explored whether a tertiary maternity service could provide flexible, individualised early postnatal care for women in a dynamic and timely manner, and if this approach was acceptable to women.

METHODS

A feasibility study was designed to inform a future randomised controlled trial to evaluate an alternative approach to postnatal care. English-speaking women at low risk of medical complications were recruited around 26 weeks gestation to explore their willingness to participate in a study of a new, flexible model of care that involved antenatal planning for early postpartum discharge with additional home-based postnatal care. The earlier women were discharged from hospital, the more home-based visits they were eligible to receive. Program uptake was measured, women's views obtained by a postal survey sent at eight weeks postpartum and clinical data collected from medical records.

RESULTS

Study uptake was 39% (109/277 approached). Most women (n=103) completed a postnatal care plan during pregnancy; 17% planned to leave hospital within 12 hours of giving birth and 36% planned to stay 48 hours. At eight weeks postpartum most women (90%) were positive about the concept and 88% would opt for the same program again. Of the 28% who stayed in hospital for the length they had planned, less than half (43%) received the appropriate number of home visits, and only 41% were given an option for the timing of the visit. Most (62%) stayed in hospital longer than planned (probably due to clinical complications); 11% stayed shorter than planned.

CONCLUSIONS

Women were very positive about individualised postnatal care planning that commenced during pregnancy. Given the hospital stay may be impacted by clinical factors, individualised care planning needs to continue into the postnatal period to take into account circumstances which cannot be planned for during pregnancy. However, individualised care planning during the postnatal period which incorporates a high level of flexibility may be challenging for organisations to manage and implement, and a randomised controlled trial of such an approach may not be feasible.

Quality of prenatal care questionnaire: instrument development and testing

Background

Utilization indices exist to measure quantity of prenatal care, but currently there is no published instrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ).

Methods

Data for this instrument development study were collected in five Canadian cities. Items for the QPCQ were generated through interviews with 40 pregnant women and 40 health care providers and a review of prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to establish its construct validity, and internal consistency and test-retest reliability.

Results

Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently were validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing approach; there was a significant positive association between women’s ratings of the quality of prenatal care and their satisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of the Prenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability (Cronbach’s alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient = 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stability testing confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum.

Conclusion

The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measure to compare quality of care across geographic regions, populations, and service delivery models, and to assess the relationship between quality of care and maternal and infant health outcomes.

A randomised controlled trial on the Four Pillars Approach in managing pregnant women with anaemia in Yogyakarta-Indonesia: a study protocol

Background

Anaemia is a common health problem among pregnant women and a contributing factor with a major influence on maternal mortality in Indonesia. The Four Pillars Approach is a new approach to anaemia in pregnancy, combining four strategies to improve antenatal and delivery care. The primary objective of this study is to measure the effectiveness of the Four Pillars Approach. The barriers, the facilitators, and the patients’ as well as the midwives’ satisfaction with the Four Pillars Approach will also be measured.

Methods/Design

This study will use a cluster randomised controlled trial. This intervention study will be conducted in the Public Health Centres with basic emergency obstetric care in Yogyakarta Special Province and in Central Java Province. We will involve all the Public Health Centres (24) with emergency obstetric care in Yogyakarta Special Province. Another 24 Public Health Centres with emergency obstetric care in Central Java Province which have similarities in their demographic, population characteristics, and facilities will also be involved. Each Public Health Centre will be asked to choose two or three nurse-midwives to participate in this study. For the intervention group, the Public Health Centres in Yogyakarta Special Province, training on the Four Pillars Approach will be held prior to the model’s implementation. Consecutively, we will recruit 360 pregnant women with anaemia to take part in part in the study to measure the effectiveness of the intervention. The outcome measurements are the differences in haemoglobin levels between the intervention and control groups in the third trimester of pregnancy, the frequency of antenatal care attendance, and the presence of a nurse-midwife during labour. Qualitative data will be used to investigate the barriers and facilitating factors, as to nurse-midwives’ satisfaction with the implementation of the Four Pillars Approach.

Discussion

If the Four Pillars Approach is effective in improving the outcome for pregnant women with anaemia, this approach could be implemented nationwide and be taken into consideration to improve the outcome for other conditions in pregnancy, after further research.

Trial registration

Current Controlled Trials ISRCTN35822126.

Development of the Pregnancy and Childbirth Questionnaire (PCQ): evaluating quality of care as perceived by women who recently gave birth

OBJECTIVE

To develop an instrument to the assess quality of care during pregnancy and delivery as perceived by women who recently gave birth.

STUDY DESIGN

Prospective design from focus group interviews to validation of the questionnaire. The focus groups consisted of seven care providers, ten pregnant women and six women who recently gave birth. With the results of the focus group interviews, a draft questionnaire of 52 items was composed and its psychometric properties were tested in a first cohort of 300 women who recently gave birth (sample I) by means of exploratory factor analysis (EFA) and reliability analysis. The final version was further explored by confirmatory factor analyses (CFA) in another sample of 289 women (sample II) with similar characteristics as sample I.

RESULTS

EFA in sample I suggested an 18-item scale with two components concerning the quality of care during pregnancy: 'personal treatment' (11 items, Cronbach's alpha (α)=0.87) and 'educational information' (7 items, α=0.90); the 'delivery' scale showed a single domain (7 items, α=0.88). CFA in sample II confirmed both factor structures with an adequate model fit. Overall, satisfaction with care was highest among women who only received midwife-led care, while women who were referred to an obstetrician during pregnancy reported less satisfaction.

CONCLUSIONS

The 25-item PCQ, primarily based on the experiences and perceptions of pregnant women and women who recently gave birth, showed adequate psychometric properties evaluating the quality of care during pregnancy and delivery. This user-friendly instrument might be a valuable instrument for future research to further evaluate the quality of care to pregnant women.

Why some women fail to give birth at health facilities: a qualitative study of women's perceptions of perinatal care from rural Southern Malawi

BACKGROUND

Despite Malawi government's policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care.

OBJECTIVE

The study explores the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care.

METHODS

A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using a semi- structured interview guide that collected information on women's perception on perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. The women were asked how they perceived the care they received from health workers before, during, and after delivery. Data were manually analyzed using thematic analysis.

RESULTS

Onset of labor at night, rainy season, rapid labor, socio-cultural factors and health workers' attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbors. Two women delivered alone. Most women went to the health facility the same day after delivery.

CONCLUSIONS

This study reveals beliefs about labor and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. Even though, it is not easy to change cultural beliefs to convince women to use health facilities for deliveries. There is a need for further exploration of barriers that prevent women from accessing health care for better understanding and subsequently identification of optimal solutions with involvement of the communities themselves.

A systematic approach towards the development of a set of quality indicators for public reporting in community-based maternity care

OBJECTIVE

to demonstrate the process and outcome of a systematic approach towards the development of a set of quality indicators for public reporting on quality of community-based maternity care.

DESIGN AND SETTING

a four-stepped approach was adopted. Firstly, we defined key elements of community-based maternity care, by performing a systematic search on care guidelines/ standards. Secondly, the literature was searched for existing indicators for maternity care, which were subsequently categorised according to the key elements and systematically selected on suitability of public presentation. The emerging set of indicators suitable for public reporting was presented to five health-care professionals using a Delphi technique (step 3). Based on the comments of the professionals, the set was adjusted and subsequently presented to the health-care consumers (a sample of pregnant women) in step four to test its validity, after which the final set was composed.

PARTICIPANTS

health-care professionals in the field of maternity care and pregnant women.

FINDINGS

key elements of community-based maternity care were extracted from eight guidelines and care standards. We then extracted 10 documents with 223 indicators in total, from which 19 indicators covering the key elements were included in the first set and presented to experts. Based on their comments three indicators were deleted and four indicators were added to the set or slightly rephrased. These were subsequently judged by 13 pregnant women. Seventy-five per cent of the indicators were judged positively by them; no indicator was judged negatively. The set of indicators was thus left unchanged after this final step. KEY CONCLUSIONS AND IMPLICATIONS FOR CLINICAL PRACTICE: the systematic approach adopted in this study resulted in an indicator set that was considered valid by both maternity care professionals and pregnant women, and is likely to satisfy the essential requirements on clinimetric properties. The next step will be to pilot test the indicator set on feasibility in daily clinical practice and to refine the set when necessary. In the future, maternity care professionals may use the set to present the quality of care they provide and to define issues of improvement. Pregnant women may use the information to make a founded choice between maternity care professionals, which ultimately should result in improved safety and quality of maternity care as well as patient satisfaction. Although we focused on the Dutch, community-based maternity care system, the approach used may be extrapolated to other care processes and health-care systems. Extrapolation of the results itself (i.e. the indicator set) may need to be limited to systems with an emphasis on community-based maternity care.