Women's satisfaction with traditional and reduced antenatal visit schedules

It was tough, but necessary. Organizational changes in a community based maternity care system during the first wave of the COVID-19 pandemic: A qualitative analysis in the Netherlands

Introduction

The Coronavirus SARS-CoV-2pandemic necessitated several changes in maternity care. We investigated maternity care providers’ opinions on the positive and negative effects of these changes and on potential areas of improvement for future maternity care both in times of crisis and in regular maternity care.

Methods

We conducted nineteen semi-structured in-depth interviews with obstetricians, obstetric residents, community-based and hospital-based midwives and obstetric nurses. The interviews were thematically analysed using inductive Thematic analysis.

Results

Five themes were generated: ‘(Dis)proportionate measures’, ‘A significant impact of COVID-19’, ‘Differing views on inter-provider cooperation’, ‘Reluctance to seek help’ and ‘Lessons learnt’. The Central Organizing Concept was: ‘It was tough but necessary’. The majority of participants were positive about most of the measures that were taken and about their proportionality. These measures had a significant impact on maternity care providers, both mentally and on an organizational level. Most hospital-based care providers were positive about professional cooperation and communication, but some community-based midwives indicated that the cooperation between different midwifery care practices was suboptimal. Negative effects mentioned were a higher threshold for women to seek care, less partner involvement and perceived more fear among women and their partners, especially around birth. The most significant positive effect mentioned was increased use of eHealth tools. Recommendations for future care were to consider the necessity of prenatal and postnatal care more critically, to replace some face-to-face visits with eHealth and to provide more individualised care.

Conclusion

Maternity care providers experienced measures and organizational changes during the first wave of the COVID19-pandemic as tough, but necessary. They believed that a more critical consideration of medically necessary care, increased use of e-health and more individualised care might contribute to making maternity care more sustainable during and after the pandemic.

A Review of Prenatal Care Delivery to Inform the Michigan Plan for Appropriate Tailored Health Care in Pregnancy Panel

OBJECTIVE

To perform a literature review of key aspects of prenatal care delivery to inform new guidelines.

DATA SOURCES

A comprehensive review of Ovid MEDLINE, Elsevier's Scopus, Google Scholar, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

We included studies addressing components of prenatal care delivery (visit frequency, routine pregnancy assessments, and telemedicine) that assessed maternal and neonatal health outcomes, patient experience, or care utilization in pregnant individuals with and without medical conditions. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach. Articles were independently reviewed by at least two members of the study team for inclusion and data abstraction.

TABULATION, INTEGRATION, AND RESULTS

Of the 4,105 published abstracts identified, 53 studies met inclusion criteria, totaling 140,150 participants. There were no differences in maternal and neonatal outcomes among patients without medical conditions with reduced visit frequency schedules. For patients at risk of preterm birth, increased visit frequency with enhanced prenatal services was inconsistently associated with improved outcomes. Home monitoring of blood pressure and weight was feasible, but home monitoring of fetal heart tones and fundal height were not assessed. More frequent weight measurement did not lower rates of excessive weight gain. Home monitoring of blood pressure for individuals with medical conditions was feasible, accurate, and associated with lower clinic utilization. There were no differences in health outcomes for patients without medical conditions who received telemedicine visits for routine prenatal care, and patients had decreased care utilization. Telemedicine was a successful strategy for consultations among individuals with medical conditions; resulted in improved outcomes for patients with depression, diabetes, and hypertension; and had inconsistent results for patients with obesity and those at risk of preterm birth.

CONCLUSION

Existing evidence for many components of prenatal care delivery, including visit frequency, routine pregnancy assessments, and telemedicine, is limited.

Maternal Satisfaction with Antenatal Care and Associated Factors among Pregnant Women in Hossana Town

BACKGROUND

A woman's satisfaction with antenatal care service has immediate and long-term impacts on maternal and her baby's health. It also ensures further use of service. However, it is not well studied in Ethiopia in general and at the southern region in particular.

OBJECTIVE

The main objective of this study is to assess the level of a maternal satisfaction with antenatal care services and associated factors.

METHODS

An institution-based cross-sectional study that involves both quantitative and qualitative methods of data collection was employed. A systematic sampling technique was used to obtain study participants, and quantitative data were collected using an interviewer-administered questionnaire. For qualitative data, Focus Group Discussions were done among clients that have a repeated visit by taking educational status as homogeneity criteria. EpiData version 3.1 and SPSS version 21 were used for analysis. Descriptive statistics, bivariate and multivariable logistic regression analyses were employed to describe and identify factors associated with maternal satisfaction on antenatal care. The qualitative data were analyzed thematically and manually.

RESULTS

Overall, 74% of mothers were satisfied with antenatal care services rendered in public health institutions of Hossana town. Most of the respondents were satisfied with privacy, cleanness, physical facility, and approaches of care. Age, educational status, privacy, cleanness, distance, and respect were significantly associated with a client's satisfaction.

CONCLUSION

Three-fourths of the respondents were satisfied with the service. Age, education, living distance, maintenance of privacy, cleanness of the facility, and respect from providers were the significant predictors of the satisfaction level.

Are Kazakhstani Women Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services

Women’s satisfaction is a part of the quality assurance process with potential to improve antenatal health services. The objective of this study was to assess the prevalence of women’s satisfaction with antenatal care in an urban Kazakhstani setting and investigate associated factors. A total of 1496 women who delivered in all maternity clinics from 6 February through 11 July 2013 in Semey, East Kazakhstan, filled out a standardized pretested questionnaire on satisfaction with antenatal care. Independent associations between dissatisfaction and its correlates were studied by logistic regression. Ninety percent of the women were satisfied with the antenatal care. Women who were dissatisfied had lower education. These women would have preferred more checkups, shorter intervals between checkups, more time with care providers, and shorter waiting times. The overall dissatisfaction was associated with long waiting times and insufficient information on general health in pregnancy, results of laboratory tests, treatment during pregnancy, and breastfeeding. Although most of the women in the study setting were satisfied with the new antenatal care model, we identified the main sources of dissatisfaction that should be addressed. Given that Semey is a typical Kazakhstani city, the results can be generalized to other Kazakhstani urban settings.

Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models

BACKGROUND

Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models.

METHODS

A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions.

RESULTS

Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.

CONCLUSIONS

Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.

Assessing the effect on outcomes of public or private provision of prenatal care in Portugal

To evaluate whether public and private prenatal care users experience similar outcomes, taking into consideration maternal pre-pregnancy social and clinical risk. We studied 7,325 women who delivered single newborns at five public maternity units in Porto, Portugal. Health behaviors and prenatal care were self-reported; pregnancy complications and delivery data were retrieved from medical files. The odds of inadequate weight gain, continuing to smoke, gestational hypertension, gestational diabetes, caesarean section, preterm birth, low birthweight, and small- and large-for-gestational-age were estimated for public and private providers using logistic regression, stratified by pre-pregnancy risk profile, adjusted for maternal characteristics. 38 % of women used private prenatal care. Among low-risk women, public care users were more likely to gain excessive weight (OR 1.26; 95 % CI 1.06-1.57) and be diagnosed with gestational diabetes (OR 1.37; 95 % CI 1.01-1.86). They were less likely to have a caesarean (OR 0.63; 95 % CI 0.51-0.78) and more likely to deliver small-for-gestational-age babies (OR 1.48; 95 % CI 1.19-1.83). Outcomes were similar in high-risk women although preterm and pre-labor caesarean were less frequent in public care users (OR 0.64 95 % CI 0.45-0.91; OR 0.69 95 % CI 0.49-0.97). The amount of care was not significantly related to risk profile in either case. Public care users experienced similar outcomes to those using private care, despite higher pre-pregnancy disadvantage. Low-risk women need further attention if narrowing inequalities in birth outcomes remains a priority.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2015), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, versus standard care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. We assessed studies for risk of bias and graded the quality of the evidence.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). Most of the data included in the review came from the three large, well-designed cluster-randomised trials that took place in Argentina, Cuba, Saudi Arabia, Thailand and Zimbabwe. All results have been adjusted for the cluster design effect. All of the trials were at some risk of bias as blinding of women and staff was not feasible with this type of intervention. For primary outcomes, evidence was graded as being of moderate or low quality, with downgrading decisions due to risks of bias and imprecision of effects.The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal-oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31; five trials, 56,431 babies; moderate-quality evidence). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (RR 0.90; 95% CI 0.45 to 1.80, two trials); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15; 95% CI 1.01 to 1.32, three trials).There was no clear difference between groups for our other primary outcomes: maternal death (RR 1.13, 95%CI 0.50 to 2.57, three cluster-randomised trials, 51,504 women, low-quality evidence); hypertensive disorders of pregnancy (various definitions including pre-eclampsia) (RR 0.95, 95% CI 0.80 to 1.12, six studies, 54,108 women, low-quality evidence); preterm birth (RR 1.02, 95% CI 0.94 to 1.11; seven studies, 53,661 women, moderate-quality evidence); and small-for-gestational age (RR 0.99, 95% CI 0.91 to 1.09, four studies 43,045 babies, moderate-quality evidence).Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02, five studies, 43,048 babies, moderate quality evidence). There were no clear differences between the groups for the other secondary clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

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.

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.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, with standard care.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (five trials; risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (2 trials; RR 0.90; 95% CI 0.45 to 1.80); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (3 trials RR 1.15; 95% CI 1.01 to 1.32). Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02). There were no clear differences between the groups for the other reported clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

Clients' perceptions of the quality of antenatal care

OBJECTIVES

To assess perceptions of pregnant women about quality of antenatal care.

METHODS

Descriptive cross-sectional study in a developing country setting. Three-hundred-ninety-five previously booked pregnant women randomly selected from private and public health facilities at the 3 levels of care were interviewed using a 52-stem interviewer-administered, semistructured questionnaire. The questionnaire sought information about bio data, health information and services, interpersonal communications, amenities and constellation of services.

RESULTS

Mean gestational age at booking was 18.5 +/- 6.3 weeks. Only 25.8% of respondents booked in the first trimester. Mean number of antenatal visits was 4.0 +/- 2.4. Mean time spent during clinic visits was 3.9 +/- 1.4 hours. Waiting time was rated as appropriate by most women (67.1%). Women with high education and in upper socioeconomic class tended to rate the waiting time as too long. Counseling for HIV was the predominant health education subject. More than half (53.9%) of respondents did not receive information about cervical cancer. About 10% of patients did not receive information about danger signs during pregnancy, breast self-examination, family planning and prevention of sexually transmitted infections. Clinic amenities and constellation of services were rated highly. Most women (96.5%) were satisfied with the care received, would use the same facility in future pregnancies and would recommend it to friends.

CONCLUSIONS

The majority of pregnant women were satisfied with the care they received. However, frequent antenatal visits and long waiting times are the norm of our antenatal service. Measures for improving elements of quality of antenatal care are imperative.

What makes a good midwife? An integrative review of methodologically-diverse research

AIM

This paper reports an integrative review aimed at answering the question: 'What makes a good midwife?'

BACKGROUND

A research-based definition of a good midwife which can be used as an operational definition in research and as a basis for curriculum development could not be found. Research in nursing has identified that patients and nurses may give different responses when asked about the most important aspects of nurses' contribution to care. It is also possible that views of how to define a good midwife might differ.

METHODS

A four-stage systematic review process was used, consisting of protocol development, carrying out the search, appraisal/analysis of the papers retrieved, and synthesis of the information. The initial search covered the period from 1993 and used the keywords 'midwi*', 'nurse-midwi*' and 'good'. This was later extended to include the terms 'exemplary', 'excellent' and 'superb' as synonyms of 'good', and 'bad' as its antonym. The integrative review was descriptive and focussed on extracting from the papers the findings that contributed to answering the research question.

FINDINGS

Thirty-three research-based papers were included in the review, and these had used a range of approaches and methods. Eight key concepts were derived from the data: attributes of a midwife, education, research, what a midwife does, care organization, other professionals, partners and an international perspective.

CONCLUSION

Having good communication skills made the greatest contribution to being 'a good midwife', while being compassionate, kind, supportive (affective domain), knowledgeable (cognitive domain) and skilful (psychomotor domain) also made major contributions. Being involved in education and research were necessary requirements, and midwives' abilities to treat women as individuals, adopt a caring approach, and 'be there' for women were essential. A good midwife can compensate for poor management systems, but women should be able to choose who provides their care, and partners should be involved in this care.

Referral and attendance at a specialist antenatal clinic: qualitative study of women's views

OBJECTIVE

To explore women's views on being referred to and attending a specialist antenatal hypertension clinic.

DESIGN

Qualitative interview study.

SETTING

A pregnancy hypertension clinic in a large teaching hospital in the East Midlands.

POPULATION

Twenty-one women (aged 18 years and above) attending the pregnancy hypertension clinic for the first time during their current pregnancy.

METHODS

Women who had been referred to and attended a specialist antenatal clinic participated in semi-structured interviews. Data analysis was based on the constant comparative method.

MAIN OUTCOME MEASURES

Women's experiences and perceptions of being referred to and attending a specialist antenatal clinic.

RESULTS

Being referred to the clinic conferred an 'at risk' status on women. Some women welcomed the referral but others experienced it as unsettling. Many were unclear about why they had been identified as being at risk or had difficulties in accepting the legitimacy of the reason for referral. Women were often inadequately informed about why they were referred to the clinic, what they could expect and the benefits of attending the clinic over management in the community. Although attendance at the clinic was cited as a source of reassurance, the reassurance was often made necessary by concern raised by the initial referral.

CONCLUSIONS

Women's accounts suggest that the interface between community and secondary antenatal services needs improvement to minimise possible adverse effects from identifying women as being 'at risk' during pregnancy.

A review of mothers' prenatal and postnatal quality of life

Background

Contemporary broad descriptions of health and well-being are reflected in an increasing appreciation of quality of life issues; in turn this has led to a growing number of tools to measure this.

Methods

This paper reviews articles cited in MEDLINE, CINAHL and BIDS which have addressed the concept of quality of life in pregnancy and the period following childbirth.

Results

It describes five groups of articles: those explicitly assessing quality of life in this area; those using broader health assessments as an indicator of quality of life; those articles equating quality of life with certain pregnancy outcomes in identified groups of patients; those studies which identify the possibility of pregnancy as an outcome measure and infer from this that quality of life has been improved; and those articles which are themselves reviews or commentaries of pregnancy and childbirth and which identify quality of life as a feature.

Conclusions

The term 'quality of life' is used inconsistently in the literature. There are few quality of life tools specifically designed for the maternity care setting. Improved or adversely affected quality of life is frequently inferred from certain clinical conditions.

Are women and providers satisfied with antenatal care? Views on a standard and a simplified, evidence-based model of care in four developing countries

BACKGROUND: This study assessed women and providers' satisfaction with a new evidence-based antenatal care (ANC) model within the WHO randomized trial conducted in four developing countries. The WHO study was a randomized controlled trial that compared a new ANC model with the standard type offered in each country. The new model of ANC emphasized actions known to be effective in improving maternal or neonatal health, excluded other interventions that have not proved to be beneficial, and improved the information component, especially alerting pregnant women to potential health problems and instructing them on appropriate responses. These activities were distributed within four antenatal care visits for women that did not need any further assessment. METHODS: Satisfaction was measured through a standardized questionnaire administered to a random sample of 1,600 pregnant women and another to all antenatal care providers. RESULTS: Most women in both arms expressed satisfaction with ANC. More women in the intervention arm were satisfied with information on labor, delivery, family planning, pregnancy complications and emergency procedures. More providers in the experimental clinics were worried about visit spacing, but more satisfied with the time spent and information provided. CONCLUSIONS: Women and providers accepted the new ANC model generally. The safety of fewer visits for women without complications with longer spacing would have to be reinforced, if such a model is to be introduced into routine practice.

Reduced frequency prenatal visits in midwifery practice: attitudes and use

Recent research supports the use of reduced frequency prenatal visit schedules (RFVS) for women of low obstetric risk. However, for the RFVS to be widely adopted for use in practice, health care providers must implement and support its use. The purpose of this study was to explore midwives' attitudes toward and use of reduced frequency prenatal care visit schedules for the care of low-risk women. A descriptive, correlational study was conducted at the 1999 Annual Meeting of the American College of Nurse-Midwives with completed surveys received from 234 midwives. Seventy-two percent (n = 170) responded that they were familiar with the reduced frequency visit schedule. Of those, 71% agreed that they could give effective prenatal care by using reduced frequency scheduling, although few (17%) reported using it in practice. Significant differences were found between the midwives who were familiar versus those who were unfamiliar with the visit schedule in their perceptions for five central themes: 1) quality of care of the RFVS, 2) women's empowerment or self-care with the RFVS, 3) ability to manage practice, 4) patient satisfaction, and 5) barriers to the use of RFVS. Providers' responses to the use of RFVS have been mixed. Successful integration of this schedule into prenatal care services may require more than knowledge of its safety for low-risk women. Careful selection of women for whom the schedule is appropriate and a commitment from midwives to tailor prenatal care to the individual women's needs is indicated. Further research is also needed to evaluate the barriers that prevent midwives from using a reduced frequency visit schedule for the prenatal care of low-risk clients.

Finnish women's experiences of antenatal care

OBJECTIVE

to explore and describe women's experiences of antenatal care.

DESIGN

semi-structured interviews, dialogical interviews and non-participant observation in two phases both during and after pregnancy were analysed according to Colaizzi's phenomenological method.

SETTING

four maternity clinics in one rural and one urban primary health care centre and one outpatient maternity clinic at a central hospital in Finland.

PARTICIPANTS

in the first phase a purposive sample of nine women were interviewed at 36 weeks gestation, three weeks, three months and two and a half years after birth. In the second phase, data were collected for further breadth and depth and 31 women, who were going through different stages of pregnancy, delivery and the puerperium participated. Data were collected by means of interviews supplemented by non-participatory observation. In the total sample of 40 Finnish women, one half was primigravidae and the other half multigravidae.

FINDINGS

a main thread running through the women's experiences of antenatal care were their needs and wishes that concerned the health of the unborn baby, but also the health and dignity of themselves and their family. The pregnant women wanted to share their pregnancy and childbirth story in a confident relationship based on humaneness and interest in a peaceful atmosphere. They needed protection safeguarded through scientifically based and humane surveillance, and professional competence was expected. They wanted to continuously participate in the new situations through knowledge in dialogues and they wanted to involve their family in the care on their own terms. The childbirth preparation groups had an important multidimensional role in the care.

IMPLICATIONS FOR PRACTICE

the findings challenge the antenatal care that so far has been focused on the physical health, the needs of the primigravida and a blurred family perspective. The family perspective implies knowing both the pregnant woman and her partner in terms of the pregnancy, the birth and a new parenthood. Humane, scientifically based perinatal care can be developed by innovations from these findings, especially considering the multidimensional role of the parent groups.

Development and testing of the patient expectations and satisfaction with prenatal care instrument

Addressing consumer needs requires the development of a valid means of specifically measuring pregnant women's satisfaction with prenatal care. This study's purpose was to develop items for, to pilot-test, and to examine the structural validity of the Patient Expectations and Satisfaction with Prenatal Care (PESPC) instrument. Extant literature and information obtained from focus groups were used in the development. The PESPC was pilot-tested with a sample of 114 pregnant women receiving prenatal care. To structurally validate the PESPC, data collected from 587 women who participated in a cross-sectional, self-administered survey were used. Structural equation modeling and confirmatory factor analysis were used to develop and cross-validate the PESPC. The PESPC was found to be structurally valid, and the subscales of Expectations and Satisfaction demonstrated acceptable levels of internal consistency.

Evidence-based prenatal care visits: when less is more

Traditionally, low-risk pregnant women in the United States who participate in prenatal care have been scheduled for approximately 14-16 prenatal visits, which is the schedule recommended by the American College of Obstetricians and Gynecologists. In 1989, an expert panel convened by the United States Department of Health and Human Services proposed a reduced frequency prenatal visit schedule for low-risk, healthy women based on the timing of specific tests or events that occur in pregnancy. Available evidence shows no adverse effect on maternal or neonatal outcomes for low-risk pregnant women who follow a reduced visit schedule, making it a highly important consideration for pregnant women and their health care providers. Other important aspects of prenatal care, especially related to adequacy and content, will be explored in-depth in a future segment of this series on evidence-based prenatal care.

Patterns of routine antenatal care for low-risk pregnancy

BACKGROUND

It has been suggested that reduced antenatal care packages or prenatal care managed by providers other than obstetricians for low risk women can be as effective as standard models of antenatal care.

OBJECTIVES

The objective of this review was to assess the effects of antenatal care programmes for low-risk women.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register, reference lists of articles and we also contacted researchers in the field. Date of last search: April 1999.

SELECTION CRITERIA

Randomised trials comparing programmes of antenatal care with varied frequency and timing of the visits and different types of care providers.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by two reviewers independently. Study authors were contacted for additional information and they were provided with the final version of the review.

MAIN RESULTS

Nine trials involving over 25000 women were included. Six trials evaluated the number of visits and three trials evaluated the type of care provider. Most trials were of acceptable quality. Moderate reduction in the number of visits was not associated with an increase in any of the negative perinatal outcomes reviewed. However, trials from developed countries suggest that women can be less satisfied with the reduced number of visits and feel that their expectations with care are not fulfilled. Antenatal care provided by a midwife/general practitioner was associated with improved perception of care by women. Clinical effectiveness of midwife/general practitioner managed care was similar to that of obstetrician/gynaecologist led shared care.

REVIEWER'S CONCLUSIONS

It appears that a moderate reduction in the number of antenatal care visits with an increased emphasis on the content of the visits could be implemented without any increase in adverse biological perinatal outcomes. Women can be less satisfied with reduced visits. While clinical effectiveness seemed similar, women appeared to be slightly more satisfied with midwife/general practitioner managed care compared to obstetrician/gynaecologist led shared care.

To see or not to see? Midwives' perceptions of reduced antenatal attendances for 'low-risk' women

OBJECTIVE

To explore the views of midwives towards traditional and flexible schedules of antenatal attendance for women at low risk.

DESIGN

A qualitative approach using focus groups.

SETTING

Three NHS Trusts providing maternity care in and around Bristol.

SAMPLE

14 midwives who had provided antenatal care to women participating in the Bristol Antenatal Care Study.

FINDINGS

Midwives generally expressed support for a move away from the traditional schedule of antenatal attendances, suggesting that this represented a move towards the acceptance of pregnancy as a normal life event. They recognised that some women would prefer flexible care and the possibility of a reduction in the number of antenatal attendances. However, they suggested that some women would require additional information in order to feel confident in these circumstances. The midwives also recognised that both they and pregnant women have reservations about reducing contact during the antenatal period. Central to these reservations is a concern that women's psychosocial as well as physical needs may go unmet if antenatal contact is reduced.

IMPLICATIONS FOR PRACTICE

Although in principle supporting a move away from the traditional schedule of antenatal attendances, the reservations felt by midwives towards a reduction in antenatal attendances are reflected in their practice. These concerns currently impede any radical move away from the traditional schedule of antenatal check-ups and will need to be addressed by midwifery managers prior to the implementation of a more flexible schedule of antenatal attendances, if any such change is to be sustainable.