Eliciting preferences for key attributes of intrapartum care in the Netherlands

Does the birth plan match what is relevant to women? Preferences of Spanish women when giving birth

BACKGROUND

To support women in making shared decisions, it is important to know what is relevant to them. The aim is to explore which of the options included in birth plans (BP) are of most interest to women, and which are more controversial. In addition, the possible association of this variability with personal characteristics.

METHODS

The data are part of a cross-sectional descriptive study, carried out in xxx, on the clinimetric characteristics of two instruments to measure women's needs in labour and postpartum. Women were recruited consecutively by their midwives during pregnancy check-ups, receive a link to a digital questionnaire and were allowed to provide links to the questionnaires to other pregnant women. Women were asked to determine their level of agreement with statements about the birth environment, accompaniment, pain relief, medical intervention and neonatal care. The relationship between agreement with each statement, socio-demographic variables and fear of childbirth (W-DEQ-A) was analysed using a combination of descriptive statistics to analyse frequencies, and regression models to test the effect of socio-demographic variables and fear of childbirth on those items with the greatest variability.

RESULTS

Two hundred forty-seven women responded. More than 90% preferred a hospital delivery, with information about and control over medical intervention, accompanied by their partner and continuous skin-to-skin contact with the newborn. There are other questions to which women attach less importance or which show greater variability, related to more clinical aspects, like foetal monitoring, placenta delivery, or cord clamping… Various factors are related to this variability; parity, nationality, educational level, risk factor or fear of childbirth are the most important.

CONCLUSIONS

Some items referring to the need for information and participation are practically unanimous among women, while other items on technical interventions generate greater variability. That should make us think about which ones require a decision after information and which ones should be included directly. The choice of more interventional deliveries is strongly associated with fear of childbirth.

Trading patients' choice in providers for quality of maternity care? A discrete choice experiment amongst pregnant women

BACKGROUND

The introduction of bundled payment for maternity care, aimed at improving the quality of maternity care, may affect pregnant women's choice in providers of maternity care. This paper describes a Dutch study which examined pregnant women's preferences when choosing a maternity care provider. The study focused on factors that enhance the quality of maternity care versus (restricted) provider choice.

METHODS

A discrete choice experiment was conducted amongst 611 pregnant women living in the Netherlands using an online questionnaire. The data were analysed with Latent Class Analyses. The outcome measure consisted of stated preferences in the discrete choice experiment. Included factors were: information exchange by care providers through electronic medical records, information provided by midwife, information provided by friends, freedom to choose maternity care provider and travel distance.

RESULTS

Four different preference structures were found. In two of those structures, respondents found aspects of the maternity care related to quality of care more important than being able to choose a provider (provider choice). In the two other preference structures, respondents found provider choice more important than aspects related to quality of maternity care.

CONCLUSIONS

In a country with presumed high-quality maternity care like the Netherlands, about half of pregnant women prefer being able to choose their maternity care provider over organisational factors that might imply better quality of care. A comparable amount of women find quality-related aspects most important when choosing a maternity care provider and are willing to accept limitations in their choice of provider. These insights are relevant for policy makers in order to be able to design a bundled payment model which justify the preferences of all pregnant women.

Is fear of childbirth related to the woman's preferred location for giving birth? A Dutch low-risk cohort study

BACKGROUND

In The Netherlands, women with low-risk pregnancy are routinely given the option of home birth, providing a unique opportunity to study the relationship between fear of childbirth (FOC) and preference for childbirth location, and whether women experience higher FOC when the actual location differs from their preference.

METHODS

In this prospective cohort study, 331 nulliparous and parous women completed a questionnaire at gestational week 30 (T1) and two months postpartum (T2). FOC was assessed using versions A (T1) and B (T2) of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ).

RESULTS

At T1, women who preferred home birth had significantly lower FOC compared with women who preferred a hospital birth (mean ± SD W-DEQ scores: 55 ± 19.8 and 64 ± 18.3, respectively, P < .01). About 28% of women who responded at T2 gave birth at home. Congruence between the preferred and actual childbirth location was not predictive of FOC assessed at T2 when adjusted for obstetric and psychological variables. In an extended analysis, we found that except for prepartum FOC, the following variables also correlated with postpartum FOC: being referred because of complications and poor neonatal condition.

CONCLUSIONS

Compared to women who prefer hospital birth, women who prefer home birth have lower prepartum and postpartum FOC. Giving birth at a location other than the preferred location does not appear to affect postpartum FOC. Whether giving birth at home or in the hospital, caregivers should pay extra attention to women with high FOC because they are vulnerable to postpartum FOC, especially after a complicated birth and referral.

Tracking pregnant women displacements in Sao Paulo, Brazil: a complex systems approach to regionalization through the emergence of patterns

BACKGROUND

The healthcare system can be understood as the dynamic result of the interaction of hospitals, patients, providers, and government configuring a complex network of reciprocal influences. In order to better understand such a complex system, the analysis must include characteristics that are feasible to be studied in order to redesign its functioning. The analysis of the emergent patterns of pregnant women flows crossing municipal borders for birth-related hospitalizations in a region of São Paulo, Brazil, allowed to examine the functionality of the regional division in the state using a complex systems approach and to propose answers to the dilemma of concentration vs. distribution of maternal care regional services in the context of the Brazilian Unified Health System (SUS).

METHODS

Cross-sectional research of the areas of influence of hospitals using spatial interaction methods, recording the points of origin and destination of the patients and exploring the emergent patterns of displacement.

RESULTS

The resulting functional region is broader than the limits established in the legal provisions, verifying that 85% of patients move to hospitals with high technology to perform normal deliveries and cesarean sections. The region has high independence rates and behaves as a "service exporter." Patients going to centrally located hospitals travel twice as long as patients who receive care in other municipalities even when the patients' conditions do not demand technologically sophisticated services. The effects of regulation and the agents' preferences reinforce the tendency to refer patients to centrally located hospitals.

CONCLUSIONS

Displacement of patients during delivery may affect indicators of maternal and perinatal health. The emergent pattern of movements allowed examining the contradiction between wider deployments of services versus concentration of highly specialized resources in a few places. The study shows the potential of this type of analysis applied to other type of patients' flows, such as cancer or specialized surgery, as tools to guide the regionalization of the Brazilian Health System.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

Sharing special birth stories. An explorative study of online childbirth narratives

BACKGROUND

Increasingly, pregnant women, as active online media users, incorporate media driven values on childbirth that may not agree with professional midwifery values. In Dutch midwifery practice, online searching for other women's stories is often discouraged. However, online birth stories attract women as a means to learn from one another's experiences of childbirth.

AIM

This study aims to explore Dutch women's use of an online social media platform (Instagram) to represent childbirth by analyzing their narrative strategies.

METHOD

A collection of 110 Instagram-linked childbirth narratives (2015-2017) were analyzed applying an approach of interpretative repertoires.

FINDINGS

The Dutch women in this study linked birth stories on their Instagram accounts that represented impactful experiences of childbirth. In their narratives, three interconnected repertoires are played out: sharing your story, going into details, and doing it yourself. This study highlights that narrative details of the online birth stories illustrate the physical and procedural obstacles that women overcame in giving birth.

DISCUSSION

Reporting their emotional experiences in detail, women's online sharing of birth stories puts a focus on their personal preferences and decision making, and may ease the way for medical interventions. Without giving explicit advice, personal online birth stories could be instrumental in reformulating the standards of what childbirth is, or should be, like.

CONCLUSION

Social media networks allow women to exchange stories that structure narrating women's childbirth experiences and offer a structure for the lived or future experiences of others. This may have an impact on women's decision-making during pregnancy and childbirth.

Needs of parents and professionals to improve shared decision-making in interprofessional maternity care practice: A qualitative study

BACKGROUND

Shared decision-making (SDM) is a critical but challenging component of high quality maternity care. In co-creation with parents and professionals, we are developing an intervention to improve SDM. As a first step we aimed to explore the experiences and needs of parents and professionals regarding shared decision-making in interprofessional antenatal, natal, and postnatal care.

METHODS

We organized 11 focus groups in the Netherlands in November and December 2016. Parents, primary care midwives, hospital-based midwives, obstetricians, obstetric nurses, and maternity care assistants participated.

RESULTS

Parents and professionals recognized the SDM steps of introducing a decision (choice talk) and discussing options (option talk), but most parents did not seem to discuss preferences and weigh options with professionals before making their final decision (decision talk). Barriers to SDM were often related to interprofessional collaboration, while good communication skills of parents and professionals facilitated SDM. An intervention to improve SDM would need to: (a) increase awareness and offer insight into the SDM process and roles and responsibilities of parents and professionals, (b) develop good communication skills, and (c) encourage interprofessional collaboration. The preferred design of the intervention was online, interactive, and practical.

CONCLUSIONS

Parents and professionals will benefit from an intervention designed to improve SDM. A practical e-learning for all maternity care providers and e-health information for parents seems most appropriate. Key elements for the e-learning are raising awareness of the roles and responsibilities of parents and professionals, developing good communication skills and encouraging interprofessional collaboration. This requires a variety of educational strategies.

Women's Preferences for Birthing Hospital in Denmark: A Discrete Choice Experiment

BACKGROUND

Free choice of hospital has been introduced in many healthcare systems to accommodate patient preferences and incentivize hospitals to compete; however, little is known about what patients actually prefer.

OBJECTIVES

This study assessed women's preferences for birthing hospital in Denmark by quantifying the utility and trade-offs of hospital attributes.

METHODS

We conducted a discrete-choice experiment survey with 12 hypothetical scenarios in which women had to choose between three hospitals characterized by five attributes: continuity of midwifery care, availability of a neonatal intensive care unit (NICU), hospital services offered, level of specialization to handle rare events, and travel time. A random parameter logit model was used to estimate the utility and marginal willingness to travel (WTT) for improvements in other hospital attributes.

RESULTS

A total of 517 women completed the survey. Significant preferences were expressed for all attributes (p < 0.01), with the availability of a NICU being the most important driver of women's preferences; women were willing to travel 30 more minutes (95% confidence interval 28-32) to reach a hospital with a highly specialized NICU. The subgroup analyses revealed differences in WTT, with substantial heterogeneity due to prior experience with giving birth and regarding risk attitude and health literacy.

CONCLUSION

A high specialization level was the most influential factor for women without previous birth experience and for risk-averse individuals but not for women with a high health literacy score. Hence, more information about the woman's risk profile and services required could play a role in affecting hospital choice.

Development and validation of the Midwife Profiling Questionnaire assessing women's preferred perinatal care professional and knowledge of midwives' legal competences

OBJECTIVES

Currently maternity care organisation is developing worldwide. Therefore insight in the position of the midwife is important. The 'Midwife Profiling Questionnaire' (MidProQ) measures women's preferred perinatal care professional and their knowledge of midwives' legal competences. MidProQ is based on the European legal framework and was tested in a pilot study. This study aims to determine its content and face validity.

STUDY DESIGN

A two-phase validation study with a Delphi method questioning content experts (n = 10) on items relevance and clarity as well as its scale and face validity. Further semi-structured interviews were performed with lay experts (n = 10) to evaluate the questionnaire's clarity, layout, phrasing and wording.

RESULTS

After round one, most questions (42/47) were considered content valid for relevance and clarity (Item Content Validity Index 0.80-1.00). Scale (Scale Content Validity Index 0.92) and face validity (Face Validity Index 0.89) of the entire instrument was obtained. Five questions were revised until item content (0.83-1.00), scale content (0.92) and face validity (1.00) were appropriate. Lay experts' suggestions for improving the readability and usability were taken into account.

CONCLUSIONS

We developed a valid instrument to elicit women's preferred health professional for uncomplicated pregnancy, labour and childbirth and to determine their knowledge about midwives' legal competences. Our instrument can be valuable in identifying knowledge gaps and improving the knowledge of the general population about the midwifery profession and maternity care. Finally, the MidProQ may improve research in the domain of maternity care culture, scale up midwifery and facilitate a more women-centred care.

Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study

Background

In several developed countries women with a low risk of complications during pregnancy and childbirth can make choices regarding place of birth. In the Netherlands, these women receive midwife-led care and can choose between a home or hospital birth. The declining rate of midwife-led home births alongside the recent debate on safety of home births in the Netherlands, however, suggest an association of choice of birth place with psychological factors related to safety and risk perception. In this study associations of pregnancy related anxiety and general anxious or depressed mood with (changes in) planned place of birth were explored in low risk women in midwife-led care until the start of labour.

Methods

Data (n = 2854 low risk women in midwife-led care at the onset of labour) were selected from the prospective multicenter DELIVER study. Women completed the Pregnancy Related Anxiety Questionnaire-Revised (PRAQ-R) to assess pregnancy related anxiety and the EuroQol-6D (EQ-6D) for an anxious and/or depressed mood.

Results

A high PRAQ-R score was associated with planned hospital birth in nulliparous (aOR 1.92; 95% CI 1.32–2.81) and parous women (aOR 2.08; 95% CI 1.55–2.80). An anxious or depressed mood was associated with planned hospital birth (aOR 1.58; 95% CI 1.20–2.08) and with being undecided (aOR 1.99; 95% CI 1.23–2.99) in parous women only. The majority of women did not change their planned place of birth. Changing from an initially planned home birth to a hospital birth later in pregnancy was, however, associated with becoming anxious or depressed after 35 weeks gestation in nulliparous women (aOR 4.17; 95% CI 1.35–12.89) and with pregnancy related anxiety at 20 weeks gestation in parous women (aOR 3.91; 95% CI 1.32–11.61).

Conclusion

Low risk women who planned hospital birth (or who were undecided) more often reported pregnancy related anxiety or an anxious or depressed mood. Women who changed from home to hospital birth during pregnancy more often reported pregnancy related anxiety or an anxious or depressed mood in late pregnancy. Anxiety should be adequately addressed in the process of informed decision-making regarding planned place of birth in low risk women.

What women want: Exploring pregnant women's preferences for alternative models of maternity care

Depending on obstetric risk, maternity care may be provided in one of two locations at hospital level: a consultant-led unit (CLU) or a midwifery-led unit (MLU). Care in a MLU is sparsely provided in Ireland, comprising as few as two units out of a total 21 maternity units. Given its potential for greater efficiencies of care and cost-savings for the state, there has been an increased interest to expand MLUs in Ireland. Yet, very little is known about women's preferences for midwifery-led care, and whether they would utilise this service when presented with the choice of delivering in a CLU or MLU. This study seeks to involve women in the future planning of maternity care by investigating their preferences for care and subsequent motivations when choosing place of birth. Qualitative research is undertaken to explore maternal preferences for these different models of care. Women only revealed a preference for the MLU when co-located with a CLU due to its close proximity to medical services. However, the results suggest women do not have a clear preference for either model of care, but rather a hybrid model of care which encompasses features of both consultant- and midwifery-led care.

Women's birth place preferences in the United Kingdom: a systematic review and narrative synthesis of the quantitative literature

BACKGROUND

Current clinical guidelines and national policy in England support offering 'low risk' women a choice of birth setting, but despite an increase in provison of midwifery units in England the vast majority of women still give birth in obstetric units and there is uncertainty around how best to configure services. There is therefore a need to better understand women's birth place preferences. The aim of this review was to summarise the recent quantitative evidence on UK women's birth place preferences with a focus on identifying the service attributes that 'low risk' women prefer and on identifying which attributes women prioritise when choosing their intended maternity unit or birth setting.

METHODS

We searched Medline, Embase, PsycINFO, Science Citation Index, Social Science Index, CINAHL and ASSIA to identify quantitative studies published in scientific journals since 1992 and designed to describe and explore women's preferences in relation to place of birth. We included experimental stated preference studies, surveys and mixed-methods studies containing relevant quantitative data, where participants were 'low risk' or 'unselected' groups of women with experience of UK maternity services.

RESULTS

We included five experimental stated preference studies and four observational surveys, including a total of 4201 respondents. Most studies were old with only three conducted since 2000. Methodological quality was generally poor. The attributes and preferences most commonly explored related to pain relief, continuity of midwife, involvement/availability of medical staff, 'homely' environment/atmosphere, decision-making style, distance/travel time and need for transfer. Service attributes that were almost universally valued by women included local services, being attended by a known midwife and a preference for a degree of control and involvement in decision-making. A substantial proportion of women had a strong preference for care in a hospital setting where medical staff are not necessarily involved in their care, but are readily available.

CONCLUSIONS

The majority of women appear to value some service attributes while preferences differ for others. Policy makers, commissioners and service providers might usefully consider how to extend the availability of services that most women value while offering a choice of options that enable women to access services that best fit their needs and preferences.

Association between home birth and breast feeding outcomes: a cross-sectional study in 28 125 mother-infant pairs from Ireland and the UK

OBJECTIVES

To examine the association between breast feeding outcomes and place of birth (home vs hospital birth).

DESIGN

Population-based cross-sectional study.

SETTING

Ireland and UK.

PARTICIPANTS

10 604 mother-infant pairs from the Growing Up in Ireland study (GUI, 2008-2009) and 17 521 pairs from the UK Millennium Cohort Study (UKMCS, 2001-2002) at low risk of delivery complications were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Breast feeding initiation, exclusivity and duration.

RESULTS

Home birth was found to be significantly associated with breast feeding at all examined time points, including at birth, 8 weeks, 6 months and breast feeding exclusively at 6 months. In GUI, adjusted OR was 1.90 (95% CI 1.19 to 3.02), 1.78 (1.18 to 2.69), 1.85 (1.23 to 2.77) and 2.77 (1.78 to 4.33), respectively, and in UKMCS it was 2.49 (1.84 to 3.44), 2.49 (1.92 to 3.26), 2.90 (2.25 to 3.73) and 2.24 (1.14 to 4.03).

CONCLUSIONS

Home birth was strongly associated with improved breast feeding outcomes in low-risk deliveries. While the association between home birth and breast feeding is unlikely to be directly causal, further research is needed to determine which factor(s) drive the observed differences, to facilitate development of perinatal care that supports breast feeding.

Maternal attitudes towards home birth and their effect on birth outcomes in Iceland: A prospective cohort study

OBJECTIVE

to examine the relationship between attitudes towards home birth and birth outcomes, and whether women's attitudes towards birth and intervention affected this relationship.

DESIGN

a prospective cohort study.

SETTING

the study was set in Iceland, a sparsely populated island with harsh terrain, 325,000 inhabitants, high fertility and home birth rates, and less than 5000 births a year.

PARTICIPANTS

a convenience sample of women who attended antenatal care in Icelandic health care centres, participated in the Childbirth and Health Study in 2009-2011, and expressed consistent attitudes towards home birth (n=809).

FINDINGS

of the participants, 164 (20.3%) expressed positive attitudes towards choosing home birth and 645 (79.7%) expressed negative attitudes. Women who had a positive attitude towards home birth had significantly more positive attitudes towards birth and more negative attitudes towards intervention than did women who had a negative attitude towards home birth. Of the 340 self-reported low-risk women that answered questionnaires on birth outcomes, 78 (22.9%) had a positive attitude towards home birth and 262 (77.1%) had a negative attitude. Oxytocin augmentation (19.2% (n=15) versus 39.1% (n=100)), epidural analgesia (19.2% (n=15) versus 33.6% (n=88)), and neonatal intensive care unit admission rates (0.0% (n=0) versus 5.0% (n=13)) were significantly lower among women who had a positive attitude towards home birth. Women's attitudes towards birth and intervention affected the relationship between attitudes towards home birth and oxytocin augmentation or epidural analgesia.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the beneficial effect of planned home birth on maternal outcome in Iceland may depend to some extent on women's attitudes towards birth and intervention. Efforts to de-stigmatise out-of-hospital birth and de-medicalize women's attitudes towards birth might increase women׳s use of health-appropriate birth services.

The influence of preferred place of birth on the course of pregnancy and labor among healthy nulliparous women: a prospective cohort study

Background

Most studies on birth settings investigate the association between planned place of birth at the start of labor and birth outcomes and intervention rates. To optimize maternity care it also is important to pay attention to the entire process of pregnancy and childbirth. This study explores the association between the initial preferred place of birth and model of care, and the course of pregnancy and labor in low-risk nulliparous women in the Netherlands.

Methods

As part of a Dutch prospective cohort study (2007–2011), we compared medical indications during pregnancy and birth outcomes of 576 women who initially preferred a home birth (n = 226), a midwife-led hospital birth (n = 168) or an obstetrician-led hospital birth (n = 182). Data were obtained by a questionnaire before 20 weeks of gestation and by medical records. Analyses were performed according to the initial preferred place of birth.

Results

Low-risk nulliparous women who preferred a home birth with midwife-led care were less likely to be diagnosed with a medical indication during pregnancy compared to women who preferred a birth with obstetrician-led care (OR 0.41 95% CI 0.25-0.66). Preferring a birth with midwife-led care – both at home and in hospital - was associated with lower odds of induced labor (OR 0.51 95% CI 0.28-0.95 respectively OR 0.42 95% CI 0.21-0.85) and epidural analgesia (OR 0.32 95% CI 0.18-0.56 respectively OR 0.34 95% CI 0.19-0.62) compared to preferring a birth with obstetrician-led care. In addition, women who preferred a home birth were less likely to experience augmentation of labor (OR 0.54 95% CI 0.32-0.93) and narcotic analgesia (OR 0.41 95% CI 0.21-0.79) compared to women who preferred a birth with obstetrician-led care. We observed no significant association between preferred place of birth and mode of birth.

Conclusions

Nulliparous women who initially preferred a home birth were less likely to be diagnosed with a medical indication during pregnancy. Women who initially preferred a birth with midwife-led care – both at home and in hospital – experienced lower rates of interventions during labor. Although some differences can be attributed to the model of care, we suggest that characteristics and attitudes of women themselves also play an important role.