Hospital Policies and Practices Concerning Normal Childbirth in Jordan

Assessing the Gap Between Women's Expectations and Perceptions of the Quality of Intrapartum Care in Jordan: A Two-Stage Study Using the SERVQUAL Model

INTRODUCTION

Although Jordan has made significant progress toward expanding the utilization of facility-based intrapartum care, prior research highlights that poor service quality is still persistent. This study aimed to identify quality gaps between women's expectations and perceptions of the actual intrapartum care received, while exploring the contributing factors.

METHODS

Utilizing a pre-post design, quality gaps in intrapartum care were assessed among 959 women pre- and postchildbirth at a prominent tertiary hospital in northern Jordan. Data were gathered using the SERVQUAL scale, measuring service quality across reliability, responsiveness, tangibles, assurance, and empathy dimensions.

RESULTS

The overall mean gap score between women's expectations and perceptions of the quality of intrapartum care was -0.60 (±0.56). The lowest and highest mean gap scores were found to be related to tangibles and assurance dimensions, -0.24 (±0.39) and -0.88 (±0.35), respectively. Significant negative quality gaps were identified in the dimensions of assurance, empathy, and responsiveness, as well as overall service quality (p < 0.001). The MLR analyses highlighted education (β = 0.61), mode of birth (β = -0.60), admission timing (β = -0.41), continuity of midwifery care (β = -0.43), physician's gender (β = -0.62), active labour duration (β = 0.37), and pain management (β = -0.33) to be the key determinants of the overall quality gap in intrapartum care.

CONCLUSION

Our findings underscore the importance of fostering a labour environment that prioritizes enhancing caregivers' empathetic, reassuring, and responsive skills to minimize service quality gaps and enhance the overall childbirth experience for women in Jordan.

PATIENT OR PUBLIC CONTRIBUTION

This paper is a collaborative effort involving women with lived experiences of childbirth, midwives, and obstetrics and gynaecologist physicians. The original idea, conceptualization, data generation, and coproduction, including manuscript editing, were shaped by the valuable contributions of stakeholders with unique perspectives on intrapartum care in Jordan.

Attitudes of midwives and obstetricians towards midwives practiced roles in hospitals: A national study in Jordan

AIMS

The aims of this study were to identify midwives' and obstetricians' attitudes towards midwives practised roles in hospitals and to identify the differences in their attitudes towards midwives practiced roles.

MATERIALS AND METHODS

A descriptive, cross-sectional, study design was used. A convenience sample of 303 midwives and 143 obstetricians were recruited. Participants were from 12 Ministry of Health (MOH) and Royal Medical Services (RMS) hospitals distributed across seven governorates. Two reliable and valid self-administered questionnaires were used to collect data including socio-demographic data-related characteristics of participants and obstetricians' and midwives' attitudes towards midwives' practiced role in hospitals.

RESULTS

There were significant differences between obstetricians in the three subscales of attitudes: midwives women relationship attitude subscale, midwives trust and mutual respect subscale and work environment attitudes subscale. A significant difference by the institution was reported: obstetricians and midwives who worked in MOH reported more positive attitudes than those who worked in RMS.

CONCLUSION

The results show that obstetricians recognise that midwives are qualified and competent professionals but still lack the competencies/skills to make them independent practitioners. The findings also confirm the need to improve midwives' practices by moving from being able to perform a specific task to possess all three attributes of "competencies," where they can intervene, manage and make decisions with confidence in each situation.

IMPLICATION FOR PRACTICE

Based on the current study findings, parallel cooperation between educational/academic policymakers from both midwives and obstetricians may re-evaluate and upgrade the midwifery curriculum to meet the ICM competencies and health sector needs as a step to graduate competent midwives where their responsibility is recognised and organised.

Conceptual Framework for Implementing the Saudi Childbirth Initiative

There are many efforts internationally to achieve safe and respectful Mother-Baby–Family maternity care. This article is the first to provide a conceptual framework for implementing the Saudi Childbirth Initiative (SCI) in all health institutions in Saudi Arabia. It introduces the 10 Steps of the SCI to strategically achieve a safe and respectful Mother-Baby–Family maternity care in order to improve maternal and infant outcome and implement evidence-based maternity care in Saudi Arabia. The SCI is developed upon previous initiatives and integrates and supports much of the current work being carried out by many organizations. The aim of the SCI's 10 Steps is to improve care throughout the childbearing continuum, to save lives, prevent illness and harm from the overuse of obstetric technologies, and promote health for mothers and babies and to provide clear guidelines for providing optimal maternity care. Safe and respectful Mother-Baby–Family Maternity Care is measurable and for each of the 10 Steps, there is an associated assessment tool to ensure these guidelines are being established by health institutions. SCI envisions that successful implementation of the 10 Steps can be measured and monitored using the a combination of statistical information and key performance indicators (KPIs) to measure maternal mortality and morbidity outcomes (currently in development) using local assessors.

Ethnographic study of the use of interventions during the second stage of labor in Jeddah, Saudi Arabia

BACKGROUND

Routine use of medical interventions during labor has been identified as a clinical area for concern, since such routinized practice is not consistent with an evidence-based approach to care and continues to increase despite efforts to encourage normal childbirth. Therefore, the aim of our study was to explore maternity health professionals' use of interventions during the second stage of labor in two hospitals in Jeddah, Saudi Arabia, to understand what influences their decision-making and practices.

METHODS

This was an exploratory study using an ethnographic approach. Data collection methods included participant observations of 19 labors and births (n = 8 at City Hospital and n = 11 at King's Hospital) and semi-structured interviews with 29 health care professionals. In addition, the hospital labor and delivery ward policies and guidelines from those hospitals were collected. Data were analyzed thematically.

RESULTS

Medical interventions were used during the second stage of labor routinely, regardless of clinical indication. Three core influences that shaped the clinical decision-making were identified as follows: (a) organizational culture, (b) a medical concept of birth, and (c) a hierarchical system of control. We suggest that the clinical decision-making and routine practice in this setting arises out of the interface between these three core influences whereby hierarchical control and clinicians' exercise of power and feelings of powerlessness are fundamental drivers for an organizational culture of medicalized childbirth, despite the differing models of childbirth which professionals described.

CONCLUSIONS

Clinical decisions relating to the use of interventions during childbirth are both complex and socially negotiated. The findings reflect the complexity of the use of interventions during the second stage of labor and the multiple influences on professionals' practices. We have shown how three key influences interact to shape clinical decision-making during the second stage of labor in this cultural setting and how the use of medical interventions can be analyzed as an illustration of the power dynamic in the maternity health care system. We suggest that written policies are insufficient to bring about evidence-based practice and approaches to change need to take into account these different levels of influence.

Episiotomy practice in the Middle East: A Lebanese teaching tertiary care centre experience

PROBLEM

There is lack of data on the rate of episiotomy in Lebanon and the study's hospital.

BACKGROUND

Only a few studies have addressed episiotomy practice in Lebanon and the Middle East and they show varying rates.

AIM

To identify the rate, and change in rate, of episiotomy practice over the years at a teaching hospital in Lebanon and to assess whether maternal age, parity, fetal weight, woman's hospital admission class, and physician's gender were associated with episiotomy. We also tested the association between episiotomy and postpartum hemorrhage and/or high degree perineal tears.

METHODS

A retrospective observational study was conducted on 1756 records for women having a normal vaginal birth at a single centre from January 2009 to January 2014.

FINDINGS

The rate of episiotomy at the hospital was very high, with 97.4% of women receiving an episiotomy in 2009. A major decrease in the rate was identified with a decline from 97.4% in 2009 to 73.3% in January 2014. Episiotomy was found to be associated with parity, maternal age, and with high degree perineal tears.

DISCUSSION

The episiotomy rate at this centre remains higher than the 10% rate recommended by the World Health Organization, although there has been a significant reduction after a call for restrictive rather than liberal use.

CONCLUSION

Raising awareness among providers appeared to play a significant role in reducing this rate, although more efforts remain warranted. Other strategies - such as raising awareness of women about potential risks of episiotomy - are also worth exploring.

Health research in a turbulent region: the Reproductive Health Working Group

The Reproductive Health Working Group (RHWG) was established in 1988 in Cairo to advance research in the Arab countries and Turkey on the health of women, broadly defined. The paper considers the ways in which the group contributed to global health conversations through three examples of interdisciplinary research that, in privileging local contexts, modified or even challenged prevailing approaches to health and often raised entirely new issues for consideration. The three examples cited in the paper are: (i) the network's early research on reproductive morbidity; (ii) a broad set of ongoing studies on childbirth/maternal health; and (iii) emerging research on health and conflict. The paper discusses how the RHWG has strengthened research capability in the region, and explores the reasons for the longevity of this research network.

Routine perineal shaving on admission in labour

BackgroundPubic or perineal shaving is a procedure performed before birth in order to lessen the risk of infection if there is a spontaneous perinealtear or if an episiotomy is performed.ObjectivesTo assess the effects of routine perineal shaving before birth onmaternal and neonatal outcomes, according to the best available evidence.Search methodsWe searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (12 June 2014).Selection criteriaAll controlled trials (including quasi-randomised) that compare perineal shaving versus no perineal shaving.Data collection and analysisTwo review authors independently assessed all potential studies for inclusion, assessed risk of bias and extracted the data using apredesigned form. Data were checked for accuracy.Main resultsThree randomised controlled trials (1039 women) published between 1922 and 2005 fulfilled the prespecified criteria. In the earliesttrial, 389 women were alternately allocated to receive either skin preparation and perineal shaving or clipping of vulval hair only. In thesecond trial, which included 150 participants, perineal shaving was compared with the cutting of long hairs for procedures only. In thethird and most recent trial, 500 women were randomly allocated to shaving of perineal area or cutting of perineal hair. The primaryoutcome for all three trials was maternal febrile morbidity; no differences were found (risk ratio (RR) 1.14, 95% confidence interval(CI) 0.73 to 1.76). No differences were found in terms of perineal wound infection (RR 1.47, 95% CI 0.80 to 2.70) and perinealwound dehiscence (RR 0.33, 95% CI 0.01 to 8.00) in the most recent trial involving 500 women, which was the only trial to assessthese outcomes. In the smallest trial, fewer women who had not been shaved had Gram-negative bacterial colonisation compared withwomen who had been shaved (RR 0.83, 95% CI 0.70 to 0.98). There were no instances of neonatal infection in either group in theone trial that reported this outcome. There were no differences in maternal satisfaction between groups in the larger trial reporting this outcome (mean difference (MD) 0.00, 95% CI -0.13 to 0.13). No trial reported on perineal trauma. One trial reported on side-effectsand these included irritation, redness, burning and itching.The overall quality of evidence ranged from very low (for the outcomes postpartum maternal febrile morbidity and neonatal infection)to low (for the outcome maternal satisfaction and wound infection).Authors’ conclusionsThere is insufficient evidence to recommend perineal shaving for women on admission in labour.

Jordanian women's dissatisfaction with childbirth care

BACKGROUND

Dissatisfaction with childbirth care can have a negative impact on a woman's health and well-being, as well as her relationships with her infant.

AIM

To investigate the prevalence and associated factors of dissatisfaction with intrapartum care by Jordanian women.

METHOD

A descriptive cross-sectional study was used. Participants (n = 320) who were 7 weeks post-partum were recruited from five maternal and child health centres in Irbid city in northern Jordan. Participants provided personal and obstetric information, and completed the Satisfaction with Childbirth Care Scale.

RESULTS

The majority of women (75.6%) were dissatisfied with their intrapartum care. Dissatisfaction was associated with the attendance of unknown and unwanted persons during childbirth, experiencing labour as more painful than expected, and perceptions of inadequate help from healthcare providers to manage pain during labour.

LIMITATIONS

Findings are limited to Jordanian women accessing public sector perinatal health services.

CONCLUSION

The high percentage of women reporting dissatisfaction with intrapartum care in this study is of concern. Women's perception of pain and expectations of staff during labour and birth need to be addressed through education and improved communication by staff.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Development of national evidence-based policies and quality assurance systems would help reduce the rate of obstetric interventions and give greater emphasis to respect for women's preferences during labour and birth.

Childbirth care practices in public sector facilities in Jeddah, Saudi Arabia: a descriptive study

OBJECTIVES

to explore reported hospital policies and practices during normal childbirth in maternity wards in Jeddah, Saudi Arabia, to assess and verify whether these practices are evidence-based.

DESIGN

quantitative design, in the form of a descriptive questionnaire, based on a tool extracted from the literature.

SETTING

nine government hospitals in Jeddah, Saudi Arabia. These hospitals have varied ownership, including Ministry of Health (MOH), military, teaching and other government hospitals.

PARTICIPANTS

key individuals responsible for the day-to-day running of the maternity ward.

MEASUREMENTS

nine interviews using descriptive structured questionnaire were conducted. Data were analysed using SPSS for Windows (version 16.0).

FINDINGS

the surveyed hospitals were found to be well equipped to deal with obstetric emergencies, and many follow evidence-based procedures. On average, the caesarean section rate was found to be 22.4%, but with considerable variances between hospitals. Some unnecessary procedures that are known to be ineffective or harmful and that are not recommended for routine use, including pubic shaving, enemas, episiotomy, electronic fetal monitoring (EFM) and intravenous (IV) infusion, were found to be frequently practiced. Only 22% of the hospitals sampled reported allowing a companion to attend labour and childbirth.

KEY CONCLUSIONS

many aspects of recommended EBP were used in the hospitals studied. However, the results of this study clearly indicate that there is wide variation between hospitals in Jeddah, Saudi Arabia in some obstetric practices. Furthermore, the findings suggest that some practices at these hospitals are not supported by evidence as being beneficial for mothers or infants and are positively discouraged under international guidelines.

IMPLICATIONS FOR PRACTICE

this study has specific implications for obstetricians, midwives and nurses working in maternity units. It gives an overview of current hospital policies and practices during normal childbirth. It is likely to contribute to improving the health and well-being of women, and have implications for service provision. It could also help in the development of technical information for policy-makers, and health care professionals for normal childbirth care.

Enemas during labour

BACKGROUND

Although the use of enemas during labour usually reflects the preference of the attending healthcare provider, enemas may cause discomfort for women.

OBJECTIVES

To assess the effects of enemas applied during the first stage of labour on maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013), the Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effectiveness (The Cochrane Library 2013, Issue 5), PubMed (1966 to 31 May 2013), LILACS (31 May 2013), the Search Portal of the International Clinical Trials Registry Platform (ICTRP) (31 May 2013), Health Technology Assessment Program, UK (31 May 2013), Medical Research Council, UK (31 May 2013), The Wellcome Trust, UK (31 May 2013) and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion.

MAIN RESULTS

Four RCTs (1917 women) met the inclusion criteria. One study was judged as having a low risk of bias. In the meta-analysis we conducted of two trials, we found no significant difference in infection rates for puerperal women (two RCTs; 594 women; risk ratio (RR) 0.66, 95% confidence (CI) 0.42 to 1.04). No significant differences were found in neonatal umbilical infection rates (two RCTs; 592 women; RR 3.16, 95% CI 0.50 to 19.82; I(2) 0%. In addition, meta-analysis of two studies found that there were no significant differences in the degree of perineal tear between groups. Finally, meta-analysis of two trials found no significant differences in the mean duration of labour.

AUTHORS' CONCLUSIONS

The evidence provided by the four included RCTs shows that enemas do not have a significant beneficial effect on infection rates such as perineal wound infection or other neonatal infections and women's satisfaction. These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged.

Enemas during labour

BACKGROUND

Although the use of enemas during labour usually reflects the preference of the attending healthcare provider, enemas may cause discomfort for women.

OBJECTIVES

To assess the effects of enemas applied during the first stage of labour on maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 May 2012), the Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effectiveness (The Cochrane Library 2012, Issue 5), PubMed (1966 to 17 May 2012), LILACS (17 May 2012), the Search Portal of the International Clinical Trials Registry Platform (ICTRP) (17 May 2012), Health Technology Assessment Program, UK (17 May 2012), Medical Research Council, UK (17 May 2012), The Wellcome Trust, UK (17 May 2012) and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. 

MAIN RESULTS

Four RCTs (1917 women) met the inclusion criteria. One study was judged as having a low risk of bias. In the meta-analysis we conducted of two trials, we found no significant difference in infection rates for puerperal women (two RCTs; 594 women; risk ratio (RR) 0.66, 95% confidence (CI) 0.42 to 1.04). No significant differences were found in neonatal umbilical infection rates (two RCTs; 592 women; RR 3.16, 95% CI 0.50 to 19.82; I² 0%. In addition, meta-analysis of two studies found that there were no significant differences in the degree of perineal tear between groups. Finally, meta-analysis of two trials found no significant differences in the mean duration of labour.

AUTHORS' CONCLUSIONS

The evidence provided by the four included RCTs shows that enemas do not have a significant beneficial effect on infection rates such as perineal wound infection or other neonatal infections and women's satisfaction. These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged.

Birth memories of Jordanian women: findings from qualitative data

Background:

Birth memories about their childbirth experience are powerful factors influencing women’s future fertility and exploring birth memories is important. Birth memories of women in Jordan have never been reported previously.

Objective:

To explore the childbirth memories of women in Jordan.

Design:

An exploratory descriptive study was conducted to collect quantitative and qualitative data on 160 first-time mothers giving birth in Northern Jordan’s Bade' a Hospital. Data were collected using three open-ended questions up to six weeks after the birth. Major themes emerging from the analysis were subject to manifest and latent content analysis to quantify qualitative data where appropriate.

Results:

All women were married and their age ranged from 17 to 37 years. About two-thirds (64.5%) had school education and 35.5% had graduate education. The majority (72.5%) were housewives. The major themes to emerge from the data were negative childbirth memories, women being processed, dehumanised birth, vivid recall, halo effect, the joy of becoming a mother and praise for the support of Allah.

Conclusion:

Findings provide evidence of the poor care that women receive during labour and birth. Women seem to be processed as objects to give birth in a technological manner. They are treated more like machines devoid of feeling than independent women requiring information, childbirth education or supportive ‘one to one’ care. Childbirth care was based on a medical model where the birth process is institutionalised, managed and controlled by the use of birth technology. There was no evidence of holistic care provided for women, and little consideration of their psychological, environmental or family relationships.

The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon

OBJECTIVE

to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes.

DESIGN

a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health.

SETTING

childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon.

PARTICIPANTS

in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected.

MEASUREMENTS

the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008.

FINDINGS

the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.