1
|
Evans C, Clancy G, Evans K, Booth A, Nazmeen B, Sunney C, Clowes M, Jones N, Timmons S, Spiby H. Optimising digital clinical consultations in maternity care: a realist review and implementation principles. BMJ Open 2024; 14:e079153. [PMID: 39486829 PMCID: PMC11529580 DOI: 10.1136/bmjopen-2023-079153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/24/2024] [Indexed: 11/04/2024] Open
Abstract
OBJECTIVES The COVID-19 pandemic has led to increased use of digital clinical consultations (phone or video calls) within UK maternity services. This project aimed to review the evidence on digital clinical consultations in maternity systems to illuminate how, for whom and in what contexts, they can be used to support safe, personalised and equitable care. DESIGN A realist synthesis, drawing on diverse sources of evidence (2010-present) from OECD countries, alongside insights from knowledge user groups (representing healthcare providers and service users). METHODS The review used three analytical processes (induction, abduction and retroduction) within three iterative stages (development of initial programme theories; evidence retrieval and synthesis; validation and refinement of the programme theories). RESULTS Ninety-three evidence sources were included in the final synthesis. Fifteen programme theories were developed showing that digital clinical consultations involve different mechanisms operating across five key contexts: the organisation, healthcare providers, the clinical relationship, the reason for consultation and women. The review suggests that digital clinical consultations can be effective and acceptable to stakeholders if there is access to appropriate infrastructure/digital resources and if implementation is able to ensure personalisation, informed choice, professional autonomy and relationship-focused connections. The review found relatively less evidence in relation to safety and equity. CONCLUSIONS Due to the complexity of maternity systems, there can be 'no one-size fits all' approach to digital clinical consultations. Nonetheless, the review distills four 'CORE' implementation principles: C-creating the right environment, infrastructure and support for staff; O-optimising consultations to be responsive, flexible and personalised to different needs and preferences; R-recognising the importance of access and inclusion; and E-enabling quality and safety through relationship-focused connections. Service innovation and research are needed to operationalise, explore and evaluate these principles, particularly in relation to safety and equity. PROSPERO REGISTRATION NUMBER CRD42021288702.
Collapse
Affiliation(s)
- Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Georgia Clancy
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Kerry Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Benash Nazmeen
- School of Allied Health Professionals and Midwifery, University of Bradford, Bradford, UK
| | - Candice Sunney
- Notitngham Maternity Research Network, University of Nottingham, Nottingham, UK
| | - Mark Clowes
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Nia Jones
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Helen Spiby
- School of Health Sciences, University of Nottingham, Nottingham, UK
| |
Collapse
|
2
|
Vousden N, Bunch K, Kenyon S, Kurinczuk JJ, Knight M. Impact of maternal risk factors on ethnic disparities in maternal mortality: a national population-based cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 40:100893. [PMID: 38585675 PMCID: PMC10998184 DOI: 10.1016/j.lanepe.2024.100893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 04/09/2024]
Abstract
Background Ethnic disparities in maternal mortality are consistently reported. This study aimed to investigate the contribution of known risk factors including age, socioeconomic status, and medical comorbidities to observed ethnic disparities in the United Kingdom (UK). Methods A cohort of all women who died during or up to six weeks after pregnancy in the UK 2009-2019 were identified through national surveillance. No single denominator population included data on all risk factors, therefore we used logistic regression modelling to compare to 1) routine population birth and demographic data (2015-19) (routine data comparator) and 2) combined control groups of four UK Obstetric Surveillance System studies (UKOSS) control comparator)). Findings There were 801 maternal deaths in the UK between 2009 and 2019 (White: 70%, Asian: 13%, Black: 12%, Chinese/Other: 3%, Mixed: 2%). Using the routine data comparator (n = 3,519,931 maternities) to adjust for demographics, including social deprivation, women of Black ethnicity remained at significantly increased risk of maternal death compared with women of white ethnicity (adjusted OR 2.43 (95% Confidence Interval 1.92-3.08)). The risk was greatest in women of Caribbean ethnicity (aOR 3.55 (2.30-5.48)). Among women of White ethnicity, risk of mortality increased as deprivation increased, but women of Black ethnicity had greater risk irrespective of deprivation. Using the UKOSS control comparator (n = 2210), after multiple adjustments including smoking, body mass index, and comorbidities, women of Black and Asian ethnicity remained at increased risk (aOR 3.13 (2.21-4.43) and 1.57 (1.16-2.12) respectively). Interpretation Known risk factors do not fully explain ethnic disparities in maternal mortality. The impact of socioeconomic deprivation appears to differ between ethnic groups. Funding This research is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-127-21202.
Collapse
Affiliation(s)
- Nicola Vousden
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Kathryn Bunch
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Sara Kenyon
- Institute of Applied Health Research, University of Birmingham, UK
| | - Jennifer J. Kurinczuk
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Marian Knight
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| |
Collapse
|
3
|
Kilpatrick ML, Venn AJ, Barnden KR, Newett K, Harrison CL, Skouteris H, Hills AP, Hill B, Lim SS, Jose KA. Health System and Individual Barriers to Supporting Healthy Gestational Weight Gain and Nutrition: A Qualitative Study of the Experiences of Midwives and Obstetricians in Publicly Funded Antenatal Care in Tasmania, Australia. Nutrients 2024; 16:1251. [PMID: 38732498 PMCID: PMC11085055 DOI: 10.3390/nu16091251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/11/2024] [Accepted: 04/18/2024] [Indexed: 05/13/2024] Open
Abstract
Individual and health system barriers can impede clinicians from supporting weight-related behaviour change for pregnant women, particularly in publicly funded antenatal care accessed by women from diverse socioeconomic backgrounds. The aim was to understand clinicians' experiences of supporting healthy gestational weight gain for pregnant women in a publicly funded antenatal setting. The work was undertaken to guide the implementation of systems changes, resource development, and workforce capacity building related to nutrition, physical activity, and gestational weight gain in the service. The qualitative descriptive study used purposive sampling and semi-structured interviews conducted between October 2019 and February 2020. Nine midwives and five obstetricians from a publicly funded hospital antenatal service in Tasmania, Australia participated. Interview transcripts were analysed using inductive thematic analysis. The three dominant themes were prioritising immediate needs, continuity of care support weight-related conversations, and limited service capacity for weight- and nutrition-related support. The subthemes were different practices for women according to weight and the need for appropriately tailored resources. Improving access to continuity of care and clinician training, and providing resources that appropriately consider women's socioeconomic circumstances and health literacy would enhance the ability and opportunities for clinicians to better support all women.
Collapse
Affiliation(s)
- Michelle L. Kilpatrick
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia; (A.J.V.); (K.A.J.)
- Centre for Mental Health Service Innovation, Advocate House, Hobart, TAS 7000, Australia
| | - Alison J. Venn
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia; (A.J.V.); (K.A.J.)
| | | | - Kristy Newett
- Royal Hobart Hospital, Hobart, TAS 7000, Australia; (K.R.B.)
| | - Cheryce L. Harrison
- Monash Centre for Health Research and Implementation (MCHRI), Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3168, Australia;
| | - Helen Skouteris
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (H.S.); (B.H.)
- Warwick Business School, University of Warwick, Coventry CV4 7AL, UK
| | - Andrew P. Hills
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Launceston, TAS 7248, Australia;
| | - Briony Hill
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (H.S.); (B.H.)
| | - Siew S. Lim
- Eastern Health Clinical School, Monash University, Melbourne, VIC 3128, Australia;
| | - Kim A. Jose
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia; (A.J.V.); (K.A.J.)
| |
Collapse
|
4
|
Sandall J, Fernandez Turienzo C, Devane D, Soltani H, Gillespie P, Gates S, Jones LV, Shennan AH, Rayment-Jones H. Midwife continuity of care models versus other models of care for childbearing women. Cochrane Database Syst Rev 2024; 4:CD004667. [PMID: 38597126 PMCID: PMC11005019 DOI: 10.1002/14651858.cd004667.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016. OBJECTIVES To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies. SELECTION CRITERIA All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence. MAIN RESULTS We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models. AUTHORS' CONCLUSIONS Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.
Collapse
Affiliation(s)
- Jane Sandall
- Department of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Cristina Fernandez Turienzo
- Department of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Declan Devane
- School of Nursing and Midwifery, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland and Cochrane Ireland, University of Galway, Galway, Ireland
| | - Hora Soltani
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Paddy Gillespie
- Health Economics and Policy Analysis Centre, School of Business and Economics, Institute for Lifecourse and Society, University of Galway, Galway, Ireland
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, School of Cancer Sciences, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Leanne V Jones
- Cochrane Pregnancy and Childbirth, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Hannah Rayment-Jones
- Department of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| |
Collapse
|
5
|
Dube M, Ireland S, Bromley A, Steel M, Gao Y, Kildea S. "It's all about cultural understanding": A reflexive thematic analysis of women's experiences at a dedicated refugee midwifery group practice service. Women Birth 2024; 37:410-418. [PMID: 38158322 DOI: 10.1016/j.wombi.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/27/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Inequitable maternity care provision in high-income countries contributes to ongoing poor outcomes for women of refugee backgrounds. To address barriers to quality maternity care and improve health equity, a co-designed maternity service incorporating community-based group antenatal care, onsite social worker and interpreters, continuity of midwifery carer through a caseload design with 24/7 phone access was implemented for women of refugee background. OBJECTIVE To explore and describe women's experiences and perceptions of care from a dedicated Refugee Midwifery Group Practice service. DESIGN Qualitative exploratory descriptive study using focus group discussions and interpreters. SETTING The study was conducted at a community-based Refugee Midwifery Group Practice service in a tertiary maternity hospital in Brisbane, Australia. METHODS We conducted three focus group discussions (June - December 2020) with 16 women, born in six different countries, in three language groups: Sudanese Arabic, Somali, and English. We used reflexive thematic analysis to interpret women's perspectives and generate informed meanings of experiences of care. RESULTS We generated four themes 1) accessibility of care, 2) women feeling accepted, 3) value of relationality, and 4), service expansion and promotion. Results demonstrate positive experiences and acceptability due to easy access, strong woman-midwife relationships, and culturally safe care. CONCLUSION The service addressed concerns raised in an early evaluation and provides evidence that redesigning maternity services to meet the needs of women with a refugee background speaking multiple languages from many countries is possible and promotes access, use, and satisfaction with care, contributing to improved health equity and perinatal outcomes.
Collapse
Affiliation(s)
- Mpho Dube
- Molly Wardaguga Research Centre, College of Nursing and Midwifery, Faculty of Health, Charles Darwin University, Brisbane City, Queensland 4000, Australia
| | - Sarah Ireland
- Molly Wardaguga Research Centre, College of Nursing and Midwifery, Faculty of Health, Charles Darwin University, Brisbane City, Queensland 4000, Australia
| | - Angela Bromley
- Molly Wardaguga Research Centre, College of Nursing and Midwifery, Faculty of Health, Charles Darwin University, Brisbane City, Queensland 4000, Australia
| | - Michelle Steel
- Mater Mothers Hospital, Aubigny Place, Raymond Terrace, South Brisbane, Queensland 4101, Australia
| | - Yu Gao
- Molly Wardaguga Research Centre, College of Nursing and Midwifery, Faculty of Health, Charles Darwin University, Brisbane City, Queensland 4000, Australia
| | - Sue Kildea
- Molly Wardaguga Research Centre, College of Nursing and Midwifery, Faculty of Health, Charles Darwin University, Brisbane City, Queensland 4000, Australia.
| |
Collapse
|
6
|
Vasilevski V, Graham K, McKay F, Dunn M, Wright M, Radelaar E, Vuillermin PJ, Sweet L. Barriers and enablers to antenatal care attendance for women referred to social work services in a Victorian regional hospital: A qualitative descriptive study. Women Birth 2024; 37:443-450. [PMID: 38246853 DOI: 10.1016/j.wombi.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 12/20/2023] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND Women referred to social work services during pregnancy are more likely to experience social disadvantage than those who are not, resulting in reduced antenatal care attendance. Lack of antenatal care engagement leads to poor identification and management of concerns that can have immediate and long-term health consequences for women and their babies. Identifying the barriers and enablers to antenatal care attendance for women referred to social work services is important for designing models of care that promote effective engagement. AIMS This study aimed to explore the barriers and enablers to antenatal care attendance by women referred to social work services from the perspectives of women, and clinicians who provide antenatal healthcare. METHODS A qualitative descriptive study using constructivist grounded theory methods was undertaken. Ten women referred to social work services and 11 antenatal healthcare providers were purposively recruited for interviews from a regional maternity service in Victoria, Australia. FINDINGS Continuity of care and healthcare providers partnering with women were central to effective engagement with antenatal care services. Three interrelated concepts were identified: 1) experiences of the hospital environment and access to care; 2) perceptions of care influence engagement, and 3) motivations for regularly attending services. CONCLUSIONS Continuity of care is essential for supporting women referred to social work services to attend antenatal appointments. Women are better equipped to overcome other barriers to antenatal service attendance when they have a strong partnership with clinicians involved in their care.
Collapse
Affiliation(s)
- Vidanka Vasilevski
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, Victoria, Australia.
| | - Kristen Graham
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, Victoria, Australia; College of Nursing and Health Sciences, Flinders University, Australia; National Centre for Epidemiology and Population Health, The Australian National University
| | - Fiona McKay
- School of Health and Social Development, Institute for Health Transformation, Deakin University, Victoria, Australia
| | - Matthew Dunn
- School of Health and Social Development, Institute for Health Transformation, Deakin University, Victoria, Australia
| | | | | | - Peter J Vuillermin
- Barwon Health, Victoria, Australia; School of Medicine, Deakin University, Victoria, Australia
| | - Linda Sweet
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, Victoria, Australia
| |
Collapse
|
7
|
Rayment-Jones H, Dalrymple K, Harris JM, Harden A, Parslow E, Georgi T, Sandall J. Project20: maternity care mechanisms that improve access and engagement for women with social risk factors in the UK - a mixed-methods, realist evaluation. BMJ Open 2023; 13:e064291. [PMID: 36750277 PMCID: PMC9906302 DOI: 10.1136/bmjopen-2022-064291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
OBJECTIVES To evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how? DESIGN Realist evaluation. SETTING Two UK maternity service providers. PARTICIPANTS Women accessing maternity services in 2019 (n=1020). METHODS Prospective observational cohort with multinomial regression analysis to compare measures of access and engagement between models and place of antenatal care. Realist informed, longitudinal interviews with women accessing specialist models of care were analysed to identify mechanisms. MAIN OUTCOME MEASURES Measures of access and engagement, healthcare-seeking experiences. RESULTS The number of social risk factors women were experiencing increased with deprivation score, with the most deprived more likely to receive a specialist model that provided continuity of care. Women attending hospital-based antenatal care were more likely to access maternity care late (risk ratio (RR) 2.51, 95% CI 1.33 to 4.70), less likely to have the recommended number of antenatal appointments (RR 0.61, 95% CI 0.38 to 0.99) and more likely to have over 15 appointments (RR 4.90, 95% CI 2.50 to 9.61) compared with community-based care. Women accessing standard care (RR 0.02, 95% CI 0.00 to 0.11) and black women (RR 0.02, 95% CI 0.00 to 0.11) were less likely to have appointments with a known healthcare professional compared with the specialist model. Qualitative data revealed mechanisms for improved access and engagement including self-referral, relational continuity with a small team of midwives, flexibility and situating services within deprived community settings. CONCLUSION Inequalities in access and engagement with maternity care appears to have been mitigated by the community-based specialist model that provided continuity of care. The findings enabled the refinement of a realist programme theory to inform those developing maternity services in line with current policy.
Collapse
Affiliation(s)
| | | | - James M Harris
- Women's Health, Chelsea And Westminster NHS Foundation Trust, London, UK
| | - Angela Harden
- Department of Health Services Research and Management, City University of London, London, UK
| | - Elidh Parslow
- Maternity and Women's Health, North Middlesex University Hospital NHS Trust, London, UK
| | - Thomas Georgi
- Department of Women and Children's Health, King's College London, London, UK
| | - Jane Sandall
- Women and Children's Health, King's College London, London, UK
| |
Collapse
|