"You Probably Won't Notice Any Symptoms": Blood Pressure in Pregnancy-Discourses of Contested Expertise in an Era of Self-Care and Responsibilization

Participatory Surveillance and Candidacy: A Discourse Analysis of Views on Self-Testing for Proteinuria in Pregnancy

Actively involving people in self-monitoring and management during their pregnancy is an emerging clinical and social practice. Self-monitoring of blood pressure and self-testing for proteinuria, key diagnostic tests for pre-eclampsia, are becoming commonplace in hypertensive pregnancies. While evidence exists on the acceptability and feasibility of self-monitoring blood pressure, evidence for self-testing for proteinuria in pregnancy is thin, with little knowledge of how it might affect the traditional structures of maternity care. As part of a diagnostic accuracy study on self-testing for proteinuria, pregnant people and healthcare professionals were recruited to a qualitative study to understand their experiences of, and attitudes to, self-testing. Multiple qualitative methods were used, including interviews, focus groups, and free text postcards. A discourse analysis was conducted to understand how self-testing might inform and reshape routine antenatal care. Analysis revealed a tension between the empowering concept of participatory surveillance, which pregnant people and healthcare professionals were broadly positive about, and the adjudications made by healthcare professionals about the candidacy, or suitability, of certain pregnant people to self-test. Candidacy is a framework for understanding what influences access to healthcare for socially disadvantaged groups, including professional judgments that impact access to interventions. While participatory surveillance was felt to have the potential to empower pregnant people in antenatal care, the loss of the traditional clinical gaze was disquieting for some, and pregnant people and healthcare professionals were reluctant to cede professional responsibility.

Lost in the System: Responsibilisation and Burden for Women With Multiple Long-Term Health Conditions During Pregnancy

INTRODUCTION

Over a fifth of pregnant women are living with multiple long-term health conditions, which is associated with increased risks of adverse outcomes for mothers and infants. While there are many examples of research exploring individuals' experiences and care pathways for pregnancy with a single health condition, evidence relating to multiple health conditions is limited. This study aimed to explore experiences and care of women with multiple long-term health conditions around the time of pregnancy.

METHODS

Semistructured interviews were conducted between March 2022 and May 2023 with women with multiple long-term health conditions who were at least 28 weeks pregnant or had had a baby in the last 2 years, and healthcare professionals with experience of caring for these women. Participants were recruited from across the United Kingdom. Data were analysed using thematic analysis.

RESULTS

Fifty-seven women and 51 healthcare professionals participated. Five themes were identified. Women with long-term health conditions and professionals recognised that it takes a team to avoid inconsistent care and communication, for example, medication management. Often, women were required to take a care navigation role to link up their healthcare providers. Women described mixed experiences regarding care for their multiple identities and the whole person. Postnatally, women and professionals recognised a downgrade in care, particularly for women's long-term health conditions. Some professionals detailed the importance of engaging with women's knowledge, and recognising their own professional boundaries of expertise. Many participants described difficulties in providing informational continuity and subsequent impacts on care. Specifically, the setup of care systems made it difficult for everyone to access necessary information, especially when care involved multiple sites.

CONCLUSION

Pregnant women with long-term health conditions can experience a substantial burden of responsibility to maintain communication with their care team, often feeling vulnerable, patronised, and let down by a lack of acknowledgement of their expertise. These results will be used to inform the content of coproduction workshops aimed at developing a list of care recommendations for affected women. It will also inform future interventional studies aimed at improving outcomes for these women and their babies.

PATIENT OR PUBLIC CONTRIBUTION

Our Patient and Public Involvement group were involved in the design of the study and the analysis and interpretation of the data, and a public study investigator was part of the author group.

Self-monitoring blood pressure in Pregnancy: Evaluation of health professional experiences of the BUMP trials

BACKGROUND

The BUMP trials evaluated a self-monitoring of blood pressure intervention in addition to usual care, testing whether they improved detection or control of hypertension for women at risk of hypertension or with hypertension during pregnancy. This process evaluation aimed to understand healthcare professionals' perspectives and experiences of the BUMP trials of self-monitoring of blood pressure during pregnancy.

METHODS

Twenty-two in-depth qualitative interviews and an online survey with 328 healthcare professionals providing care for pregnant people in the BUMP trials were carried out across five maternity units in England.

RESULTS

Analysis used Normalisation Process Theory to identify factors required for successful implementation and integration into routine practice. Healthcare professionals felt self-monitoring of blood pressure did not over-medicalise pregnancy for women with, or at risk of, hypertension. Most said self-monitored readings positively affected their clinical encounters and professional roles, provided additive information on which to base decisions and enriched their relationships with pregnant people. Self-monitoring of blood pressure shifts responsibilities. Some healthcare professionals felt women having responsibility to decide on timing of monitoring and whether to act on self-monitored readings was unduly burdensome, and resulted in healthcare professionals taking additional responsibility for supporting them.

CONCLUSIONS

Despite healthcare professionals' early concerns that self-monitoring of blood pressure might over-medicalise pregnancy, our analysis shows the opposite was the case when used in the care of pregnant people with, or at higher risk of, hypertension. While professionals retained ultimate clinical responsibility, they viewed self-monitoring of blood pressure as a means of sharing responsibility and empowering women to understand their bodies, to make judgements and decisions, and to contribute to their care.

A qualitative study of the dynamics of access to remote antenatal care through the lens of candidacy

OBJECTIVE

We aimed to explore the experiences and perspectives of pregnant women, antenatal healthcare professionals, and system leaders to understand the impact of the implementation of remote provision of antenatal care during the COVID-19 pandemic and beyond.

METHODS

We conducted a qualitative study involving semi-structured interviews with 93 participants, including 45 individuals who had been pregnant during the study period, 34 health care professionals, and 14 managers and system-level stakeholders. Analysis was based on the constant comparative method and used the theoretical framework of candidacy.

RESULTS

We found that remote antenatal care had far-reaching effects on access when understood through the lens of candidacy. It altered women's own identification of themselves and their babies as eligible for antenatal care. Navigating services became more challenging, often requiring considerable digital literacy and sociocultural capital. Services became less permeable, meaning that they were more difficult to use and demanding of the personal and social resources of users. Remote consultations were seen as more transactional in character and were limited by lack of face-to-face contact and safe spaces, making it more difficult for women to make their needs - both clinical and social - known, and for professionals to assess them. Operational and institutional challenges, including problems in sharing of antenatal records, were consequential. There were suggestions that a shift to remote provision of antenatal care might increase risks of inequities in access to care in relation to every feature of candidacy we characterised.

CONCLUSION

It is important to recognise the implications for access to antenatal care of a shift to remote delivery. It is not a simple swap: it restructures many aspects of candidacy for care in ways that pose risks of amplifying existing intersectional inequalities that lead to poorer outcomes. Addressing these challenges through policy and practice action is needed to tackle these risks.

A survey of Australian women's digital media usage in pregnancy and labour and birth

BACKGROUND

Given the rapid growth of digital media resources, it is worth exploring childbearing women's use of digital media to address their information needs. The aim of this study was to explore the use of digital media during pregnancy and birth in the local population of Western Victorian women in Melbourne, Australia.

METHODS

A descriptive exploratory approach was used. An online survey consisted of both quantitative and qualitative questions to identify and measure digital media use in pregnancy and the birthing period. Descriptive statistics and Pearson Chi-square test were used to analyse the quantitative data, while content analysis was used to analyse the qualitative data.

RESULTS

Digital media has become an integral part of the experience in pregnancy with increasing growth of digital media in labour. The most used medium for digital media use was pregnancy applications, followed by websites, social media, YouTube, podcasts, online discussion forums and lastly, labour applications. Information seeking was the main reason for using digital media, and two main themes emerged from the qualitative data; 'connection with others for social support and reassurance' and 'information seeking and providing to assist decision making and providing reassurance'.

CONCLUSION

This study highlights the need for future midwifery practice to include digital media sources in antenatal education and care. There is a need for healthcare institutions to improve digital media technology to meet the needs of women. This is crucial as digital media is constantly evolving, and as healthcare providers, we need to integrate digital media with healthcare services.

Is self-management a burden? What are the experiences of women self-managing chronic conditions during pregnancy? A systematic review

OBJECTIVE

This systematic review examines the qualitative literature on women's experiences of self-managing chronic conditions in pregnancy.

DESIGN

Systematic review of qualitative literature. Searches were performed in PubMed and CINAHL from inception to February 2021. Critical interpretive synthesis informed the coding framework and the analysis of the data. The Burden of Treatment theory emerged during the initial analysis as having the most synergy with the included literature, themes were refined to consider key concepts from this theory.

PARTICIPANTS

Pregnant women who are self-managing a chronic condition.

RESULTS

A total of 2695 articles were screened and 25 were reviewed in detail. All 16 included studies concerned diabetes self-management in pregnancy. Common themes coalesced around motivations for, and barriers to, self-management. Women self-managed primarily for the health of their baby. Barriers identified were anxiety, lack of understanding and a lack of support from families and healthcare professionals.

CONCLUSIONS

Pregnant women have different motivating factors for self-management than the general population and further research on a range of self-management of chronic conditions in pregnancy is needed.

PROSPERO REGISTRATION NUMBER

CRD42019136681.