Assessment of the implementation of the model of integrated and humanised midwifery health services in Chile

The effect of interventions in vaginal birth on fear of childbirth: A multicentre study

AIM

This cross-sectional multicentre study aimed to determine the effect of interventions during vaginal birth for fear of childbirth.

METHODS

In this cross-sectional and analytical study, 852 women who had a vaginal birth between 2019 and 2020 were enrolled. Data were collected using the Descriptive Questionnaire and Wijma Birth Expectation/Experience Scale Version B.

RESULTS

The mean total Wijma Birth Expectation/Experience Scale Version B score of the women was 97.00 ± 24.24, indicating severe and clinical levels of fear of childbirth. Moreover, 69.4% of the women had clinical, 18.6% had severe and 12% had moderate levels of fear of childbirth. During birth, women who had close supporters, who were allowed to move and who did not undergo amniotomy, enema, perineal shaving and electronic foetal monitoring had a low level of fear of childbirth. As the number of pregnant women in the labour room, frequency of vaginal examinations, duration of delivery/hour, severity of labour pain and negative perception of the approach of health professionals increased, the women's fear of childbirth increased. Fear of childbirth decreased as the frequency of antenatal follow-ups, number of births and satisfaction levels of the women increased (p < 0.05). Low income perception, irregular prenatal follow-up, severe labour pain and a long duration of labour were strong predictors of increased fear of childbirth. Increasing number of births, high birth satisfaction level and positive perception of the approach of health professionals were strong predictors of reduced fear of childbirth.

CONCLUSIONS

The reduction of interventions in vaginal delivery and support from health care providers during delivery can be effective in reducing fear of childbirth.

Autonomy in labour and delivery in a Latin American urban centre: a qualitative phenomenological analysis

The medicalisation of childbirth has diminished the role of labouring people. We conducted an exploratory phenomenological qualitative study, using purposive sampling, and then conducted 17 semi-structured interviews between December 2016 and October 2017 with people who had recently given birth in a public hospital in the Northern Metropolitan area of Santiago, Chile. The sufficiency of the study group was determined according to saturation criteria. Triangulated content analysis was applied to explore the clinical relationship and processes of autonomy and decision-making. The predominant clinical relationship observed was paternalism. The participation of labouring people in decision-making is scarce, with no evidence of ethically valid processes of informed consent.

A systematic review of population and patient perspectives and experiences as measured in Latin American and Caribbean surveys

High-quality health systems must provide accessible, people-centred care to both improve health and maintain population trust in health services. Furthermore, accurate measurement of population perspectives is vital to hold health systems accountable and to inform improvement efforts. To describe the current state of such measures in Latin America and the Caribbean (LAC), we conducted a systematic review of facility and population-based assessments that included patient-reported experience and satisfaction measures. Five databases were searched for publications on quantitative surveys assessing healthcare quality in Spanish- or Portuguese-speaking LAC countries, focusing on the domains of processes of care and quality impacts. We included articles published since 2011 with a national sampling frame or inclusion of multiple subnational regions. We tabulated and described these articles, identifying, classifying and summarizing the items used to assess healthcare quality into the domains mentioned earlier. Of the 5584 publications reviewed, 58 articles met our inclusion criteria. Most studies were cross-sectional (95%), assessed all levels of healthcare (57%) and were secondary analyses of existing surveys (86%). The articles yielded 33 unique surveys spanning 12 LAC countries; only eight of them are regularly administered surveys. The most common quality domains assessed were satisfaction (in 33 out of 58 articles, 57%), evidence-based/effective care (34%), waiting times (33%), clear communication (33%) and ease of use (31%). Items and reported ratings varied widely among instruments used, time points and geographical settings. Assessment of patient-reported quality measures through population- and facility-based surveys is present but heterogeneous in LAC countries. Satisfaction was measured frequently, although its use in accountability or informing quality improvement is limited. Measurement of healthcare quality in LAC needs to be more systematic, regular, comprehensive and to be led collaboratively by researchers, governments and policymakers to enable comparison of results across countries and to effectively inform policy implementation.

Approaches and geographical locations of respectful maternity care research: A scoping review

BACKGROUND

Peripartum mistreatment of women contributes to maternal mortality across the globe and disproportionately affects vulnerable populations. While traditionally recognized in low/low-middle-income countries, the extent of research on respectful maternity care and the types of mistreatment occurring in high-income countries is not well understood. We conducted a scoping review to 1) map existing respectful maternity care research by location, country income level, and approach, 2) determine if high-income countries have been studied equally when compared to low/low-middle-income countries, and 3) analyze the types of disrespectful care found in high-income countries.

METHODS

A systematic search for published literature up to April 2021 using PubMed/MEDLINE, EMBASE, CINAHL Complete, and the Maternity & Infant Care Database was performed. Studies were included if they were full-length journal articles, published in any language, reporting original data on disrespectful maternal care received from healthcare providers during childbirth. Study location, country income level, types of mistreatment reported, and treatment interventions were extracted. This study was registered on PROSPERO, number CRD42021255337.

RESULTS

A total of 346 included studies were categorized by research approach, including direct labor observation, surveys, interviews, and focus groups. Interviews and surveys were the most common research approaches utilized (47% and 29% of all articles, respectively). Only 61 (17.6%) of these studies were conducted in high-income countries. The most common forms of mistreatment reported in high-income countries were lack of informed consent, emotional mistreatment, and stigma/discrimination.

CONCLUSIONS

Mapping existing research on respectful maternity care by location and country income level reveals limited research in high-income countries and identifies a need for a more global approach. Furthermore, studies of respectful maternity care in high-income countries identify the occurrence of all forms of mistreatment, clashing with biases that suggest respectful maternity care is only an issue in low-income countries and calling for additional research to identify interventions that embrace an equitable, patient-centric empowerment model of maternity care.

Examining the Role of Quality of Institutionalized Healthcare on Maternal Mortality in the Dominican Republic

The main study objective was to determine the extent to which the quality of institutionalized healthcare, sociodemographic factors of obstetric patients, and institutional factors affect maternal mortality in the Dominican Republic. COM-Poisson distribution and the Pearson correlation coefficient were used to determine the relationship of predictor factors (i.e., hospital bed rate, vaginal birth rate, teenage mother birth rate, single mother birth rate, unemployment rate, infant mortality rate, and sex of child rate) in influencing maternal mortality rate. The factors hospital bed rate, teenage mother birth rate, and unemployment rate were not correlated with maternal mortality. Maternal mortality increased as vaginal birth rates and infant death rates increased whereas it decreased as single mother birth rates increased. Further research to explore alternate response variables, such as maternal near-misses or severe maternal morbidity is warranted. Additionally, the link found between infant death and maternal mortality presents an opportunity for collaboration among medical specialists to develop multi-faceted solutions to combat adverse maternal and infant health outcomes in the DR.

Midwives' perceptions towards the ministry of health guidelines for the provision of immediate postpartum care in rural health facilities in Uganda

BACKGROUND

Guidelines for clinical practice have been part of the Ministry of health's efforts to improve the quality of care for over two decades. Their benefits have been documented in Uganda. However, having practice guidelines may not always result in their use in care provision. We explored the midwives' perceptions towards the ministry of health guidelines for providing immediate postpartum care.

METHODS

An exploratory descriptive qualitative study was conducted in three districts in Uganda from September 2020 to January 2021. In-depth interviews with 50 midwives from 35 health centers and 2 hospitals in Mpigi, Butambala, and Gomba districts were done. Thematic analysis of data was done.

RESULTS

Three themes emerged; awareness and use of the guidelines, perceived drivers, and perceived barriers to the provision of immediate postpartum care. The subthemes for theme I included; awareness of the guidelines, variations in the postpartum care practices, variations in preparedness to manage women with complications, and varied access to continuing midwifery education. Fear of complications and litigation were the perceived drivers of guideline use. On the other hand, lack of knowledge, busy maternity units, organization of the care, and the midwives' perceptions about their clients were the barriers to guideline use. Midwives felt that new guidelines and policies regarding immediate postpartum care should be disseminated widely.

CONCLUSION

The midwives felt that the guidelines were good for the prevention of postpartum complications but their knowledge of the guidelines for the provision of immediate postpartum care was suboptimal. They desired on-job training and mentorship to help them bridge the knowledge gaps. Variations in patient assessment, monitoring, and pre-discharge care were acknowledged and said to be due to a poor reading culture and health facility factors like patient-midwife ratios, unit setup, and prioritization of labor.

From global recommendations to (in)action: A scoping review of the coverage of companion of choice for women during labour and birth

Women greatly value and benefit from the presence of someone they trust to support them throughout labour and childbirth ('labour companion of choice'). Labour companionship improves maternal and perinatal outcomes, including enhancing physiological labour and birth experiences. Despite clear benefits, implementation is slow. We conducted a scoping review to assess coverage and models of labour companionship, including quantitative studies reporting coverage of labour companionship in any level health facility globally. We searched MEDLINE, CINAHL, and Global Health from 1 January 2010-14 December 2021. We extracted data on study design, labour companionship coverage, timing and type of companions allowed, and recoded data into categories for comparison across studies. We included data from a maternal health sentinel network of hospitals in Latin America, using descriptive statistics to assess coverage among 120,581 women giving birth in these sites from April 2018-April 2022. In the scoping review, we included 77 studies from 27 countries. There was wide variation in the coverage of labour companionship: almost one-third of studies reported coverage less than 40%, and one-third of studies reported coverage between 40-80%. Husbands or partners were the most frequent companion (37.7%, 29/77), followed by family member or friend (gender not specified) (32.5%, 25/77), family member or friend (female-only) (13.0%, 10/77). Across nine sentinel hospitals in five Latin American countries, there was variation in coverage, with no companion at any time ranging from 14.9%-93.8%. Despite the well-known benefits and factors affecting implementation of labour companionship, more work is needed to improve equitable coverage. Concerted efforts are needed to engage with communities, health workers, health managers, and policy-makers to establish policies, address implementation barriers, and integrate data on coverage into perinatal records and quality processes to ensure that all women have access. Harmonized reporting of labour companionship would greatly enhance understanding at global level.

Violencia obstétrica en Chile: percepción de las mujeres y diferencias entre centros de salud

Objetivo.

El objetivo del presente artículo es reportar los resultados de la primera encuesta sobre violencia obstétrica en Chile, de modo de hacer visible una realidad más frecuente de lo que creemos y comparar su ocurrencia según tipo de servicio (público o privado) en que se ha atendido el parto.

Métodos.

Se trata de un estudio descriptivo y de tipo transversal conducido entre los meses de diciembre de 2019 y mayo de 2020. La muestra quedó compuesta por 2105 mujeres de todas las regiones de Chile.

Resultados.

Los análisis de los datos indican que un 79,3% de las mujeres cree haber experimentado alguna forma de violencia obstétrica. A pesar de la gran cantidad de informes de violencia en centros de salud públicos y privados, se detectan diferencias estadísticas significativas entre ambos, y son más frecuentes en los centros públicos. Del mismo modo, se detectan más informes de violencia obstétrica en mujeres jóvenes (18-29 años), en quienes se identifican con pueblos originarios y entre quienes tienen una orientación sexual no heterosexual.

Conclusiones.

La violencia obstétrica es parte del continuo de violencia hacia las mujeres e informada de modo sistemático por quienes atienden sus partos tanto en servicios públicos como privados de salud. Es una forma de violencia tiene graves consecuencias en las mujeres debido tanto a la posición del equipo médico y a la relevancia del evento de parto en la vida de cualquier mujer.

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.

Childbirth experiences of immigrant women in Chile: Trading human rights and autonomy for dignity and good care

BACKGROUND

Childbirth is a transcendent life experience but may also be a moment of great vulnerability, especially when it occurs outside the mother's country of origin.

OBJECTIVE

To explore the perceptions and experiences of Spanish-speaking immigrant women regarding the healthcare they received during labour and childbirth in Santiago, Chile.

METHODS

This qualitative, transcendental phenomenological research was performed at two maternity hospitals using purposive criterion sampling. Eighteen individual and two group interviews were conducted. The resulting information was transcribed and then coded and categorised using phenomenological analysis.

RESULTS

Six categories were extracted from the narratives which reflect a pragmatic relationship with the healthcare team that included a perception of 'justified' lack of care. The mothers' exercise of autonomy was subjugated by power-knowledge relations between the women and caregiver that compelled them to refrain from expressing their needs and preferences out of fear of abuse. The women valued emotional support, pain relief and satisfaction of needs in association with medical procedures and companionship. The women rated their experiences as positive if they avoided mistreatment and, as 'the essence of the experience', perceived the care as a favour rather than a right.

CONCLUSION

Most immigrant women felt that they had received treatment similar to that of native-born mothers. However, low expectations of autonomy shaped their evaluations of the experiences. Also, a high value on companionship and pain relief, characterised the women's experiences of childbirth. These findings of the interviews reflect a need for a stronger focus on empowerment with an emphasis on gender and rights.

Protecting Women's and Newborns' Rights in a Public Maternity Unit During the COVID-19 Outbreak: The Case of Dra. Eloísa Díaz - La Florida Hospital in Santiago, Chile

The Maternity in Dra. Eloísa Díaz' hospital, located in the municipality of La Florida and city of Santiago, Chile, opened its doors in 2014, and has integrated a humanistic model of care called the "Safe Model of Personalized Childbirth" since 2016. With around 3,000 births per year, it has been recognized as an example of excellence in maternity care in the country. The COVID-19 outbreak presented a big challenge to this Maternity: to maintain its quality of care standards despite the health crisis. This article presents the Maternity's responses to the pandemic from March to July 2020, describing the strategies that were deployed and the obstetric outcomes achieved. Semi-structured interviews with midwives and OB-GYNs, and a retrospective review of the childbirth standards of care and outcomes of the 55 women who tested positive for SARS-CoV-2, were carried out. The results show how the Maternity's staff responded in order to avoid a significant negative impact on the rights of women and newborns. Protocols to reestablish the companion during labor and childbirth and skin-to-skin contact, which were suspended for almost three weeks at the beginning of the outbreak, and the creation of an Instagram account to communicate with the external community were some of the measures taken. After some initial weeks of adjustment, the standards of care for all women, included for those diagnosed with COVID-19, were reestablished almost to pre-pandemic levels. This case shows that quality of care can be maintained and the rights of women and newborns can be respected during health crisis such as the COVID-19 pandemic.

Implementation science in maternity care: a scoping review

BACKGROUND

Despite wide recognition that clinical care should be informed by the best available evidence, this does not always occur. Despite a myriad of theories, models and frameworks to promote evidence-based population health, there is still a long way to go, particularly in maternity care. The aim of this study is to appraise the scientific study of methods to promote the systematic uptake of evidence-based interventions in maternity care. This is achieved by clarifying if and how implementation science theories, models, and frameworks are used.

METHODS

To map relevant literature, a scoping review was conducted of articles published between January 2005 and December 2019, guided by Peters and colleagues' (2015) approach. Specifically, the following academic databases were systematically searched to identify publications that presented findings on implementation science or the implementation process (rather than just the intervention effect): Business Source Complete; CINAHL Plus with Full Text; Health Business Elite; Health Source: Nursing/Academic Edition; Medline; PsycARTICLES; PsycINFO; and PubMed. Information about each study was extracted using a purposely designed data extraction form.

RESULTS

Of the 1181 publications identified, 158 were included in this review. Most of these reported on factors that enabled implementation, including knowledge, training, service provider motivation, effective multilevel coordination, leadership and effective communication-yet there was limited expressed use of a theory, model or framework to guide implementation. Of the 158 publications, 144 solely reported on factors that helped and/or hindered implementation, while only 14 reported the use of a theory, model and/or framework. When a theory, model or framework was used, it typically guided data analysis or, to a lesser extent, the development of data collection tools-rather than for instance, the design of the study.

CONCLUSION

Given that models and frameworks can help to describe phenomenon, and theories can help to both describe and explain it, evidence-based maternity care might be promoted via the greater expressed use of these to ultimately inform implementation science. Specifically, advancing evidence-based maternity care, worldwide, will require the academic community to make greater explicit and judicious use of theories, models, and frameworks.

REGISTRATION

Registered with the Joanna Briggs Institute (registration number not provided).

Stakeholders' perceptions of humanized birth practices and obstetric violence in Chile: A scoping review

Introduction

Chile has an incipient policy regarding humanized birth practices. Obstetric violence is becoming an issue in the public discussion, as brought up by women. Despite this advancement, no initiatives were observed to overcome the conflict. Questions arise from the different points of view of the main stakeholders involved. These questions help identify strategies contributing to the development of health policies that consider influencing actors.

Objectives

To identify stakeholders' perceptions of humanized care in childbirth and obstetric violence.

Methods

We conducted a scoping review that included articles and analysis of texts reflecting the scientific communities' point of view. We included statements from governmental, social, professional, and political actors as expressed in institutional websites. Moreover, we performed a qualitative inductive, thematic content analysis.

Results

We included seventy documents. The scientific community is visualized as aligned with ministerial recommendations for personalized childbirth. Several researchers analyze the difficulties for its improvement due to the historical, socio-cultural, and economic construction of the predominantly biomedical model for birthing. Convergence is observed among the scientific community and other stakeholders in recognition of humanized birth benefits and the need to overcome institutional obstacles within the health sector. However, the progress of the proposed change is slow, and health professionals' resistance to address women's complaints towards obstetric violence and claim of quality care is observed. This discussion finds its reflection in a parliamentary discussion.

Conclusions

The stakeholders' analysis reflects areas of conflict and consensus, as well as the diverse interacting dimensions that hinder the advance of humanized care in childbirth. This broad analysis strategy contributes to identifying critical aspects to be addressed in the development of integral and effective health policies.

A Survey of University Students' Preferences for Midwifery Care and Community Birth Options in 8 High-Income Countries

INTRODUCTION

Midwifery care is associated with positive birth outcomes, access to community birth options, and judicious use of interventions. The aim of this study was to characterize and compare maternity care preferences of university students across a range of maternity care systems and to explore whether preferences align with evidence-based recommendations and options available.

METHODS

A cross-sectional, web-based survey was completed in 2014 and 2015 by a convenience sample of university students in 8 high-income countries across 4 continents (N = 4569). In addition to describing preferences for midwifery care and community birth options across countries, this study examined sociodemographic characteristics, psychological factors, knowledge about pregnancy and birth, and sources of information that shaped students' attitudes toward birth in relation to preferences for midwifery care and community birth options.

RESULTS

Approximately half of the student respondents (48.2%) preferred midwifery-led care for a healthy pregnancy; 9.5% would choose to give birth in a birthing center, and 4.5% preferred a home birth. Preference for midwifery care varied from 10.3% among women in the United States to 78.6% among women in the United Kingdom. Preferences for home birth varied from 0.3% among US women to 18.3% among Canadian women. Women, health science students, those with low childbirth fear, those who learned about pregnancy and birth from friends (compared with other sources, eg, the media), and those who responded from Europe were significantly more likely to prefer midwifery care and community birth. High confidence in knowledge of pregnancy and birth was linked to significantly higher odds of community birth preferences and midwifery care preferences.

DISCUSSION

It would be beneficial to integrate childbirth education into high school curricula to promote knowledge of midwifery care, pregnancy, and childbirth and to reduce fear among prospective parents. Community birth options need to be expanded to meet demand among the next generation of maternity service users.

What constitutes patient-centred care for women: a theoretical rapid review

BACKGROUND

Women experience disparities in health care delivery and outcomes. Patient-centred care for women (PCCW) is needed. This study examined how PCC has been conceptualized and operationalized in women's health research.

METHODS

We conducted a theoretical rapid review of PCCW in MEDLINE, EMBASE, CINAHL and SCOPUS from 2008 to 2018 for studies involving women aged 18 years or greater with any condition, and analyzed data using an established 6-domain framework of patient-centred communication.

RESULTS

We included 39 studies, which covered the following clinical areas: maternal care, cancer, diabetes, HIV, endometriosis, dementia, distal radius fracture, overactive bladder, and lupus erythematosus. The 34 (87.2%) studies that defined or described PCC varied in the PCC elements they addressed, and none addressed all 6 PCC domains. Common domains were exchanging information (25, 73.5%) and fostering the patient-clinician relationship (22, 64.7%). Fewer studies addressed making decisions (16, 47.1%), enabling patient self-management (15, 44.1%), responding to emotions (12, 35.3%), or managing uncertainty (1, 2.9%). Compared with mixed-gender studies, those comprised largely of women more frequently prioritized exchanging information above other domains. Few studies tested strategies to support PCCW or evaluated the impact of PCCW; those that did demonstrated beneficial impact on patient knowledge, satisfaction, well-being, self-care and clinical outcomes.

CONCLUSIONS

Studies varied in how they conceptualized PCCW, and in many it was defined narrowly. Few studies examined how to implement or measure PCCW; thus, we lack insight on how to operationlize PCCW. Thus, further research is needed to confirm this, and whether PCCW differs across conditions, knowledge needed to inform policies, guidelines and measures aimed at improving health care and associated outcomes for women.

[Disrespect and abuse during childbirth and abortion in Latin America: systematic review and meta-analysisDesrespeito e maus-tratos durante o parto e o aborto na América Latina: revisão sistemática e meta-análise]

Objetivo.

Esta revisión sintetiza la evidencia cuantitativa, general y desglosada por categorías tipológicas de la falta de respeto y maltrato en la atención institucional del parto y el aborto en América Latina y el Caribe.

Métodos.

Mediante búsquedas sistemáticas se identificaron 18 estudios primarios. Se calcularon Q e I² y se realizaron metaanálisis, metarregresiones y análisis de subgrupos con la aplicación de un modelo de Der Simonian-Laird de efectos aleatorios agrupados con varianza inversa y la transformación arco-seno doble de Freeman-Tukey.

Resultados.

Se identificaron estudios realizados en cinco países de América Latina. No se identificaron estudios del Caribe. La prevalencia agregada de falta de respeto y maltrato durante el parto y el aborto fue de 39%. La medida agregada para este fenómeno durante el parto fue de 43% y la medida agregada en los casos de aborto fue de 29%. La heterogeneidad elevada no permitió generar medidas agregadas según categorías tipológicas. No obstante, se presentan las frecuencias de formas específicas del fenómeno agrupadas tipológicamente.

Conclusiones.

La evidencia sugiere que la falta de respeto y maltrato durante la atención del parto y el aborto son problemas de derechos humanos y salud pública prevalentes en algunos países de la Región. Es necesario lograr consenso internacional sobre la definición y operacionalización de este problema y desarrollar métodos estandarizados para su medición. Lo anterior es imprescindible para el alcance de las metas de la Agenda 2030 relacionadas con la reducción de la morbimortalidad maternoperinatal y la eliminación de todas las formas de violencia y discriminación contra la mujer.

Preference for caesarean attitudes toward birth in a Chilean sample of young adults

BACKGROUND

Little empirical research exists about what motivates birth mode preferences, and even less about this topic in Latin America, where obstetric interventions and caesareans are some of the highest worldwide.

AIM

To identify factors associated with caesarean preference among Chilean men and women who plan to have children and to inform childbirth education and informed consent procedures.

METHODS

An online cross-sectional survey measuring attitudes toward birth was administered to graduate students at a large public university in Chile. Eligible students were under the age of 40 and had no children but intended to have children. Logistic regression modelling was used to determine which sociodemographic factors, knowledge and beliefs were associated with caesarean preference.

FINDINGS

Among eligible students, 730 responded and 664 provided complete answers to the variables of interest. Respondents had a mean age of 28.8; 38% were male and 62% female. Positive attitude toward technological intervention (Odds Ratio 7.4, 95% Confidence Interval 3.9-14.0), high risk perception of vaginal birth (Odds Ratio 1.8, 95% Confidence Interval 1.1-2.8), family history of caesarean (Odds Ratio 1.9, 95% Confidence Interval 1.0-3.8) and high fear of birth (Odds Ratio 3.7, 95% Confidence Interval 2.0-6.8) were associated with caesarean preference.

DISCUSSION

Preference for caesarean birth was highly associated with positive attitudes toward technological intervention and may be related to a lack of knowledge about the realities of caesarean and vaginal birth.

CONCLUSIONS

Patient-centered education on the relative benefits and risks of birth modes has the potential to influence preferences toward vaginal birth.

Dimensions of childbirth care associated with maternal satisfaction among low-risk Chilean women

The authors of this study aimed to describe the level of maternal satisfaction during labor reported by a national sample of low-risk childbearing women in Chile by identifying the dimensions of intrapartum care most determinant for overall satisfaction. Maternal satisfaction was measured in the postpartum period with an instrument previously validated in Chile. Almost half of the participants (49.4%) reported having optimal satisfaction, 29% adequate, and 22% worse. Treatment of women by professionals and the physical environment were the most important dimension predicting of maternal satisfaction, consistent with findings from developing countries emphasizing patient-provider interaction during labor as a key component of birth care quality.

Perceptions and experiences of labour companionship: a qualitative evidence synthesis

BACKGROUND

Labour companionship refers to support provided to a woman during labour and childbirth, and may be provided by a partner, family member, friend, doula or healthcare professional. A Cochrane systematic review of interventions by Bohren and colleagues, concluded that having a labour companion improves outcomes for women and babies. The presence of a labour companion is therefore regarded as an important aspect of improving quality of care during labour and childbirth; however implementation of the intervention is not universal. Implementation of labour companionship may be hampered by limited understanding of factors affecting successful implementation across contexts.

OBJECTIVES

The objectives of the review were to describe and explore the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders regarding labour companionship; to identify factors affecting successful implementation and sustainability of labour companionship; and to explore how the findings of this review can enhance understanding of the related Cochrane systematic review of interventions.

SEARCH METHODS

We searched MEDLINE, CINAHL, and POPLINE K4Health databases for eligible studies from inception to 9 September 2018. There were no language, date or geographic restrictions.

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; focused on women's, partners', family members', doulas', providers', or other relevant stakeholders' perceptions and experiences of labour companionship; and were from any type of health facility in any setting globally.

DATA COLLECTION AND ANALYSIS

We used a thematic analysis approach for data extraction and synthesis, and assessed the confidence in the findings using the GRADE-CERQual approach. We used two approaches to integrate qualitative findings with the intervention review findings. We used a logic model to theorise links between elements of the intervention and health and well-being outcomes. We also used a matrix model to compare features of labour companionship identified as important in the qualitative evidence synthesis with the interventions included in the intervention review.

MAIN RESULTS

We found 51 studies (52 papers), mostly from high-income countries and mostly describing women's perspectives. We assessed our level of confidence in each finding using the GRADE-CERQual approach. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this.Labour companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating non-pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (low confidence). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision-making.Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign-born women in high-income settings may appreciate support from community-based doulas to receive culturally-competent care (low confidence).Factors affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).We compared our findings from this synthesis to the companionship programmes/approaches assessed in Bohren's review of effectiveness. We found that most of these programmes did not appear to address these key features of labour companionship.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several of these review findings. Further research, especially in low- and middle-income settings and with different cadres of healthcare providers, could strengthen the evidence for low- or very low-confidence findings. Ahead of implementation of labour companionship, researchers and programmers should consider factors that may affect implementation, including training content and timing for providers, women and companions; physical structure of the labour ward; specifying clear roles for companions and providers; integration of companions; and measuring the impact of companionship on women's experiences of care. Implementation research or studies conducted on labour companionship should include a qualitative component to evaluate the process and context of implementation, in order to better interpret results and share findings across contexts.

Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis

OBJECTIVE

To establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans.

DESIGN

Qualitative evidence synthesis.

SETTING

Studies undertaken in high-income, middle-income and low-income settings.

DATA SOURCES

Seven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar.

STUDY SELECTION

Qualitative or mixed-method studies reporting health professionals' views.

DATA EXTRACTION AND SYNTHESIS

Two authors independently assessed study quality prior to extraction of primary data and authors' interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed.

RESULTS

17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth (four SoFs); (2) social and cultural context (five SoFs); and (3) negotiation within system (five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision.

CONCLUSION

For maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans.

PROSPERO REGISTRATION NUMBER

CRD42017059455.

Respectful and disrespectful care in the Czech Republic: an online survey

BACKGROUND

Respectful maternity care includes treating women with dignity, consulting them about preferences, gaining consent for treatment, respecting their wishes, and giving care based on evidence, not routines. In the absence of any documented evidence, this study aimed to ascertain maternity care-givers' perceptions of respectful care provided for childbearing women in Czech Republic.

METHODS

Following ethical approval, an online quantitative survey with qualitative comments was completed by 52 respondents recruited from workshops on promoting normal birth, followed by snowball sampling. The majority were midwives (50%) or doulas (46%) working in one of 51 hospitals, or with homebirths. Chi-square analysis was used for comparisons.

RESULTS

Non-evidenced-based interventions, described as 'always' or 'frequently' used in hospitals, included application of electronic fetal monitoring in normal labour (n = 40, 91%), shaving the perineum (n = 10, 29%), and closed-glottal pushing (n = 32, 94%). Positions stated as most often used for spontaneous vaginal births were semi-recumbent (n = 31, 65%) or lying flat (n = 15, 31%) in hospital, and upright at home (n = 27, 100%). Average episiotomy and induction of labour rates were estimated at 40 and 26%, respectively, higher than accepted norms. Eighteen respondents (46%) said reasons for performing vaginal examinations were not explained to women in hospitals, and 21 (51%) said consent was 'never' sought. At home, 25 (89%) said reasons were explained, and permission 'always' sought (n = 22, 81%). Thirteen (32%) said hospital clinicians explained why artificial rupture of membranes was necessary, but only ten (25%) said they 'always' sought permission. The majority said that hospital clinicians 'never'/'almost never' explained reasons for performing an episiotomy (13 = 34%), gained permission (n = 20, 54%) or gave local anaesthetic (n = 19, 51%). Contrastingly, 17 (100%) said midwives at home explained the reasons for episiotomy and asked permission. When clinicians disagreed with women's decisions, 13 (35%) respondents said women might be told to 'face the consequences', six (16%) stated that the 'psychological pressure' experienced caused women to 'give up and give their permission', and four (11%) said the intervention would be performed 'against her will.'

CONCLUSIONS

Findings reveal considerable levels of disrespectful, non-evidenced-based, non-consensual and abusive practices that may leave women with life-long trauma.

First do no harm - interventions during labor and maternal satisfaction: a descriptive cross-sectional study

BACKGROUND

Interventions can be lifesaving when properly implemented but can also put the lives of both mother and child at risk by disrupting normal physiological childbirth when used indiscriminately without indications. Therefore, this study was performed to investigate the effect of frequent interventions during labor on maternal satisfaction and to provide evidence-based recommendations for labor management decisions.

METHODS

The study was performed in descriptive design in a state hospital in Kars, Turkey with 351 pregnant women who were recruited from the delivery ward. The data were collected using three questionnaires: a survey form containing sociodemographic and obstetric characteristics, the Scale for Measuring Maternal Satisfaction in Vaginal Birth, and an intervention observation form.

RESULTS

The average satisfaction scores of the mothers giving birth in our study were found to be low, at 139.59 ± 29.02 (≥150.5 = high satisfaction level, < 150.5 = low satisfaction level). The percentages of the interventions that were carried out were as follows: 80.6%, enema; 22.2%, perineal shaving; 70.7%, induction; 95.4%, continuous EFM; 92.3%, listening to fetal heart sounds; 72.9%, vaginal examination (two-hourly); 31.9%, amniotomy; 31.3%, medication for pain control; 74.9%, intravenous fluids; 80.3%, restricting food/liquid intake; 54.7%, palpation of contractions on the fundus; 35.0%, restriction of movement; 99.1%, vaginal irrigation with chlorhexidine; 85.5%, using a "hands on" method; 68.9%, episiotomy; 74.6%, closed glottis pushing; 43.3%, fundal pressure; 55.3%, delayed umbilical cord clamping; 86.0%, delayed skin-to-skin contact; 60.1%, controlled cord traction; 68.9%, postpartum hemorrhage control; and 27.6%, uterine massage. The satisfaction levels of those who experienced the interventions of induction, EFM, restriction of movement, two-hourly vaginal examinations, intravenous fluid, fundal pressure, episiotomy, palpation of contractions on the fundus, closed glottis pushing, delayed umbilical cord clamping, delayed skin-to-skin contact, fluid/food restriction, and of those who were not provided pharmacological pain control were found to be lower (p < 0.05).

CONCLUSION

Medical interventions carried out at high rates had a negative impact on women's childbirth experience. Therefore, a proper assessment in the light of medical evidence should be made before deciding that it is absolutely necessary to intervene in the birthing process and the interdisciplinary team should ensure that intrapartum caregivers will "first do no harm."

Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies

OBJECTIVE

When medically indicated, caesarean section can prevent deaths and other serious complications in mothers and babies. Lack of access to caesarean section may result in increased maternal and perinatal mortality and morbidity. However, rising caesarean section rates globally suggest overuse in healthy women and babies, with consequent iatrogenic damage for women and babies, and adverse impacts on the sustainability of maternity care provision. To date, interventions to ensure that caesarean section is appropriately used have not reversed the upward trend in rates. Qualitative evidence has the potential to explain why and how interventions may or may not work in specific contexts. We aimed to establish stakeholders' views on the barriers and facilitators to non-clinical interventions targeted at organizations, facilities and systems, to reduce unnecessary caesarean section.

METHODS

We undertook a systematic qualitative evidence synthesis using a five-stage modified, meta-ethnography approach. We searched MEDLINE, CINAHL, PsychINFO, EMBASE and grey literature databases (Global Index Medicus, POPLINE, AJOL) using pre-defined terms. Inclusion criteria were qualitative and mixed-method studies, investigating any non-clinical intervention to reduce caesarean section, in any setting and language, published after 1984. Study quality was assessed prior to data extraction. Interpretive thematic synthesis was undertaken using a barriers and facilitators lens. Confidence in the resulting Summaries of Findings was assessed using GRADE-CERQual.

RESULTS

8,219 studies were identified. 25 studies were included, from 17 countries, published between 1993-2016, encompassing the views of over 1,565 stakeholders. Nineteen Summary of Findings statements were derived. They mapped onto three distinct themes: Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs). The synthesis showed how inter- and intra-system power differentials, and stakeholder commitment, exert strong mechanisms of effect on caesarean section rates, independent of the theoretical efficacy of specific interventions to reduce them.

CONCLUSIONS

Non-clinical interventions to reduce caesarean section are strongly mediated by organisational power differentials and stakeholder commitment. Barriers may be greatest where implementation plans contradict system and cultural norms.

PROTOCOL REGISTRATION

PROSPERO: CRD42017059456.

Effectiveness of respectful care policies for women using routine intrapartum services: a systematic review

Background

Several studies have identified how mistreatment during labour and childbirth can act as a barrier to the use of health facilities. Despite general agreement that respectful maternity care (RMC) is a fundamental human right, and an important component of quality intrapartum care that every pregnant woman should receive, the effectiveness of proposed policies remains uncertain. We performed a systematic review to assess the effectiveness of introducing RMC policies into health facilities providing intrapartum services.

Methods

We included randomized and non-randomized controlled studies evaluating the effectiveness of introducing RMC policies into health facilities. We searched PubMed, CINAHL, LILACS, AJOL, WHO RHL, and Popline, along with ongoing trials registers (ISRCT register, ICTRP register), and the White Ribbon Respectful Maternity Care Repository. Included studies were assessed for risk of bias. Certainty of evidence was assessed using GRADE criteria.

Findings

Five studies were included. All were undertaken in Africa (Kenya, Tanzania, Sudan, South Africa), and involved a range of components. Two were cluster RCTs, and three were before/after studies. In total, over 8000 women were included at baseline and over 7500 at the endpoints. Moderate certainty evidence suggested that RMC interventions increases women’s experiences of respectful care (one cRCT, approx. 3000 participants; adjusted odds ratio (aOR) 3.44, 95% CI 2.45–4.84); two observational studies also reported positive changes. Reports of good quality care increased. Experiences of disrespectful or abusive care, and, specifically, physical abuse, were reduced. Low certainty evidence indicated fewer accounts of non-dignified care, lack of privacy, verbal abuse, neglect and abandonment with RMC interventions, but no difference in satisfaction rates. Other than low certainty evidence of reduced episiotomy rates, there were no data on the pre-specified clinical outcomes.

Conclusion

Multi-component RMC policies appear to reduce women’s overall experiences of disrespect and abuse, and some components of this experience. However, the sustainability of the demonstrated effect over time is unclear, and the elements of the programmes that have most effect have not been examined. While the tested RMC policies show promising results, there is a need for rigorous research to refine the optimum approach to deliver and achieve RMC in all settings.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

OBJECTIVES

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

SEARCH METHODS

Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

SELECTION CRITERIA

We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

MAIN RESULTS

We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

AUTHORS' CONCLUSIONS

Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

The Process of Intrapartum Care Among Skilled Birth Attendants in the Dominican Republic and Maternal Perceptions of Care During Labor and Birth: A Case Report

INTRODUCTION

The World Health Organization calls for situation analyses of maternity settings globally to improve maternal-newborn health. This study evaluated the care processes of skilled birth attendants and women's satisfaction with the care in a public hospital in the Dominican Republic. The purpose of the assessment was to establish a baseline to build quality improvements.

METHODS

A cross-sectional, mixed-methods, observational study was conducted by an international team. Eighty-four participants were included in the Intrapartum Data Set (American College of Nurse-Midwives), and 55 participants completed the Chilean Maternal Well-Being Scale. The data set was analyzed using descriptive statistics. Three focus groups were conducted with health providers, and 4 focus groups were conducted with postpartum women. Themes were derived using content analysis.

RESULTS

Nurses were the skilled birth attendants (SBAs) for 54% of women; 46% were attended by either obstetricians or family medicine residents. Ninety-one percent of newborns with nurse attendants had immediate skin-to-skin contact, compared to 79% of newborns with physician attendants. Newborns breastfed within the first hour of life for 67% of the dyads with nurse SBAs, whereas 24% of newborns attended by physicians did so. The well-being survey indicated most women perceived care was adequate or better, irrespective of attending provider. Nevertheless, 67% of rural women perceived care negatively. Qualitative findings indicated that some women felt neither respected nor heard.

DISCUSSION

When nurses managed the labor and birth, their care was comparable to that of physicians. Moreover, women were more likely to receive evidence-based newborn care, including skin-to-skin contact, immediate breastfeeding, and discharge instructions. Qualitative findings highlighted the discrepancy between health care providers' perception of the care they provided and patients' perceptions of that care. Reflexive practice and frequent communication with patients about their experience of care should be a part of every practitioner's toolkit, wherever that care is provided.