On speaking terms: a Delphi study on shared decision-making in maternity care

Co-creation of a health literate-sensitive training and conversation aid to support shared decision-making in maternity care

Background

Maternity care increasingly aims to achieve Shared Decision-making (SDM), yet seemingly not to the benefit of clients with low health literacy (HL). We developed an SDM training for healthcare professionals (HCPs) and a conversation aid to support HL-sensitive SDM in maternity care.

Methods

The training and conversation aid were based on previous needs assessments and expert consultation, and were developed in co-creation with clients (n = 15) and HCPs (n = 7). Usability, acceptability and comprehension of the conversation aid were tested among new clients (n = 14) and HCPs (n = 6). Acceptability of the training was tested among midwifery students (n = 5).

Results

In the co-creation sessions, clients reported to expect that their midwife becomes acquainted with their general values, priorities and daily context. Clients also emphasized wanting to be supported in their preferred decisional role. User test interviews showed that clients and HCPs were positive towards using the conversation aid, but also apprehensive about the time it required. The user test of the training showed that more attention was needed for recognizing and adapting information provision to clients' HL level.

Conclusion and innovation

The newly developed conversation aid and training have potential to support HCPs and clients in HL-sensitive SDM.

Clinical decision-making during childbirth in health facilities from the perspectives of labouring women, relatives, and health care providers: A scoping review

PROBLEM

For health care providers to ensure appropriate decision-making in clinical settings during childbirth, facilitators and barriers must be identified.

BACKGROUND

Women who experience a sense of control by participating in the decision-making process, are more likely to have a positive birth experience. However, decision-making may involve hierarchies of close observation and control.

AIM

The aim of the scoping review was to map and summarise existing literature on the process of clinical decision-making during childbirth from the perspective of labouring women, relatives and health care providers.

METHODS

We carried out a scoping review in line with Joanna Briggs Institute scoping review methodology. The search identified studies in Scandinavian or English languages from 2010 - Jan 2023 comprising evidence at different levels of the pyramid, resulting in 18.227 hits. Following the PRISMA checklist, the final inclusion comprised 62 papers.

FINDINGS

Four main categories summarized the importance of the following factors: 1) Woman-caregiver relationship, with sub-categories The importance of communication and Midwifery care, 2) Consent and legal issues, 3) Organization, with sub-categories Medicalization, Working atmosphere, and Complexity, and 4) Decision-making tools and models, with sub-categories Shared decision-making, and Other tools and models for decision-making.

CONCLUSION

Balancing intuition and expertise of caregivers with evidence-based practices, is crucial to ensure women's participation in decision-making. Furthermore, a trusting relationship between the mother, partner, and health care provider is of utmost importance. Shared decision-making, which appeared to be the primary model for clinical decision-making regardless context, requires reflective practice and is a communication strategy.

"Ask for my ideas first": Experiences of antenatal care and shared decision-making for women with high body mass index

BACKGROUND

Shared decision-making supports women's choices in pregnancy. Women with high body mass index (≥35 kg/m2) experience a high rate of interventions in pregnancy, labour, and birth, providing an opportunity for clinicians to implement shared decision-making in practice. However, weight stigma may limit women's opportunities for shared decision-making.

AIM

To understand how pregnant women with high body mass index perceive their involvement in antenatal decision-making, including whether weight stigma influences their experience.

METHODS

Women with high body mass index were recruited via purposive sampling from two sites in Melbourne, Australia. Semi-structured interviews were audio-recorded, transcribed, and analysed using reflexive thematic analysis.

FINDINGS

Ten pregnant women consented to participate. Three themes and six sub-themes were identified. These were: 1) Trusting the system, 2) Who takes the lead?, and 3) Defying disease.

DISCUSSION

Shared decision-making is limited for women with high body mass index in antenatal care, and weight stigma is experienced by women. Clinical practice recommendations relating to excess weight have the potential to further limit women's involvement in decision-making if adequate support is not provided to ensure women's understanding and involvement in care.

CONCLUSION

Women's involvement in care is a central component of shared decision-making and it is currently limited for women with high body mass index. Transparency regarding the rationale for recommendations is required, and further work must be done to address the influence and impact of weight stigma on the care of women with high body mass index.

"We will be the ones bearing the consequences": A qualitative study of barriers and facilitators to shared decision-making in hospital-based maternity care

BACKGROUND

Pregnant women involved in decisions about their care report better health outcomes for themselves and their children. Shared decision-making (SDM) is a priority for health services; however, there is limited research on factors that help and hinder SDM in hospital-based maternity settings. The purpose of this study was to explore barriers and facilitators to SDM in a large tertiary maternity care service from the perspectives of multiple stakeholders.

METHODS

Qualitative semi-structured interviews were undertaken with 39 participants including women, clinicians, health service administrators and decision-makers, and government policymakers. The interview guide and thematic analysis were based on the Theoretical Domains Framework to identify barriers and facilitators to SDM.

RESULTS

Women expect to be included in decisions about their care. Health service administrators and decision-makers, government policymakers, and most clinicians want to include them in decisions. Key barriers to SDM included lack of care continuity, knowledge, and clinician skills, as well as professional role and decision-making factors. Key facilitators pertained to policy and guideline changes, increased knowledge, professional role factors, and social influences.

CONCLUSION

This study revealed common barriers and facilitators to SDM and highlighted the need to consider perspectives outside the patient-clinician dyad. It adds to the limited literature on barriers and facilitators to SDM in hospital care settings. Organizational- and system-wide changes to service delivery are necessary to facilitate SDM. These changes may be enabled by education and training, changes to policies and guidelines to include and support SDM, and adequately timed information provision to enable SDM conversations.

Attitudes Towards Non-directiveness Among Medical Geneticists in Germany and Switzerland

The principle of non-directiveness remains an important tenet in genetics. However, the concept has encountered growing criticism over the last two decades. There is an ongoing discussion about its appropriateness for specific situations in genetics, especially in light of recent significant advancements in genetic medicine. Despite the debate surrounding non-directiveness, there is a notable lack of up-to-date international research empirically investigating the issue from the perspective of those who actually do genetic counselling. Addressing this gap, our article delves into the viewpoints and experiences of medical geneticists in Germany and Switzerland. Twenty qualitative interviews were analysed employing reflexive thematic analysis. Participants' responses revealed substantial uncertainties and divergences in their understanding and application of the concept. It seems to cause distress since many geneticists stated that the principle was difficult to put into clinical practice and was no longer ethically justified given the increasing likelihood of therapeutic implications resulting from genomic testing outcomes. The insights provided by our qualitative empirical study accord with the ongoing theoretical debate regarding the definition, legitimacy, and feasibility of the principle. An adequately nuanced understanding and application of non-directiveness seems crucial to circumvent the risks inherent in the principle, while promoting patient autonomy and beneficence.

Association between decision-making during pregnancy and woman-centred care among Tanzanian pregnant women: A cross-sectional survey

BACKGROUND

Many women in Tanzania lack autonomy in decision-making for their pregnancy and childbirth. Woman-centred care (WCC) seeks to provide each woman with the appropriate information that promotes participation and highlights their informed decision-making. Thus, decision-making has been proposed as an essential determinant of WCC. This study aimed to assess the association between decision-making and WCC among Tanzanian pregnant women.

METHODS

We conducted a cross-sectional study among 710 pregnant women in Tanzania. The 23-item Woman-Centred Care English version questionnaire was used to assess how women perceived the care provided by midwives. Participants were categorized into two decision-making groups: decision-making for the birthing place by pregnant women themselves and by others. The pre-defined cut-off point of the top 20 percentile was used to indicate a high level of WCC. Binary logistic regression models were used to determine the association between decision-making and WCC.

RESULTS

The median score (interquartile range) of WCC was 97 (92-103) points when decisions were made by pregnant women, compared to 92 (88-96) points when decisions were made by others (p<0.001). There was a significant association between decision-maker and WCC in both unadjusted (p<0.001) and multivariable-adjusted (p=0.006) analyses. The unadjusted odds were approximately 5 times higher in the pregnant women decision-making group (OR: 4.80, 95% CI: 2.74-8.43) and 3 times higher (OR:2.90, 95% CI: 1.36-6.07) after the adjustment for covariates. We observed no significant interaction between decision-making and parity on the level of WCC (p for interaction=0.52).

CONCLUSION

Pregnant women who made decisions for the birthing place had a higher likelihood of having a high level of WCC compared with their counterparts. Our findings suggest that women should be empowered to be involved in decision-making to increase their satisfaction with the care provided by healthcare providers and foster a positive childbirth experience.

Informed consent to midwifery practices and interventions during the second stage of labor-An observational study within the Oneplus trial

OBJECTIVES

To study informed consent to midwifery practices and interventions during the second stage of labor and to investigate the association between informed consent and experiences of these practices and interventions and women's experiences of the second stage of labor.

METHODS

This study uses an observational design with data from a follow-up questionnaire sent to women one month after giving birth spontaneously in the Oneplus trial, a study aimed at evaluating collegial midwifery assistance to reduce severe perineal trauma. The trial was conducted between 2018-2020 at five Swedish maternity wards and trial registered at clinicaltrials.gov, no NCT03770962. The follow-up questionnaire contained questions about experiences of the second stage of labor, practices and interventions used and whether the women had provided informed consent. Evaluated practices and interventions were the use of warm compresses held at the perineum, manual perineal protection, vaginal examinations, perineal massage, levator pressure, intermittent catheterization of the bladder, fundal pressure, and episiotomy. Associations between informed consent and women's experiences were assessed by univariate and multivariable logistic regression.

FINDINGS

Of the 3049 women participating in the trial, 2849 consented to receive the questionnaire. Informed consent was reported by less than one in five women and was associated with feelings of being safe, strong, and in control. Informed consent was further associated with more positive experiences of clinical practices and interventions, and with less discomfort and pain from interventions involving physical penetration of the genital area.

CONCLUSION

The findings indicate that informed consent during the second stage is associated with feelings of safety and of being in control. With less than one in five women reporting informed consent to all practices and interventions performed by midwives, the results emphasize the need for further action to enhance midwives' knowledge and motivation in obtaining informed consent prior to performance of interventions.

The midwife's support during transition to motherhood: A modified Delphi study among care providers and childbearing women

OBJECTIVE

To reach consensus between care providers and childbearing women about the midwife's relevant and appropriate domains and elements to support transition to motherhood.

METHODS

A modified web-based Delphi study was conducted in Flanders (Belgium). After performing a systematic literature review, searching the grey literature and an online poll, a set of 79 items was generated. In two rounds, the items were presented to an expert panel of (1) care providers from various disciplines providing services to childbearing women and (2) to pregnant women and postpartum women up to 1-year postpartum. Consensus was defined when 70% or more of the experts scored ≥6, 5% or less scored ≤3, and a standard deviation of ≤1.1.

FINDINGS

In the first Delphi round, 91 experts reached consensus on 24 items. Seventeen round one items that met one or two consensus objectives were included in round two and were scored by 64 panel experts, reaching consensus on three additional items. The final 27 items covered seven domains: attributes, liaison, management of care from a woman-centred perspective, management of care from the midwife's focus, informational support, relational support, and the midwife's competencies.

CONCLUSION

The shared understanding between childbearing women and care providers shows that the midwife's transitional support is multifaceted. Our findings offer midwives a standard of care, criteria, guidance, and advice on how they can support childbearing women during transition to motherhood, beyond the existing recommendations and current provision of transitional care.

Maternity healthcare professionals' experiences of supporting women in decision-making for labour and birth: a qualitative study

OBJECTIVES

To explore and characterise maternity healthcare professionals' (MHCPs) experience and practice of shared decision-making (SDM), to inform policy, research and practice development.

DESIGN

Qualitative focus group study.

SETTING

Large Maternity Unit in the Southwest of England.

PARTICIPANTS

MHCPs who give information relating to clinical procedures and pregnancy care relating to labour and birth and are directly involved in decision-making conversations were purposively sampled to ensure representation across MHCP groups.

DATA COLLECTION

A semistructured topic guide was used.

DATA ANALYSIS

Reflexive thematic analysis was undertaken.

RESULTS

Seven focus groups were conducted, comprising a total of 24 participants (3-5 per group). Two themes were developed: contextualising decision-making and controversies in current decision-making. Contextual factors that influenced decision-making practices included lack of time and challenges faced in intrapartum care. MHCPs reported variation in how they approach decision-making conversations and asked for more training on how to consistently achieve SDM. There were communication challenges with women who did not speak English. Three controversies were explored: the role of prior clinical experience, the validity of informed consent when women were in pain and during life-threatening emergencies and instances where women declined medical advice.

CONCLUSIONS

We found that MHCPs are committed to SDM but need better support to deliver it. Structured processes including Core Information Sets, communication skills training and decision support aids may help to consistently deliver SDM in maternity care.

Integrative Review of Black Birthing People's Interactions With Clinicians During the Perinatal Period

Maternal morbidity and mortality disproportionately affect Black birthing people. Multiple factors contribute to these disparities, including variations in quality health care, structural racism, and implicit bias. Interactions between Black patients and perinatal clinicians could further affect perinatal care use and subsequent perinatal outcomes. This integrative review aims to synthesize quantitative and qualitative literature published in peer-reviewed journals in English within the past 10 years that address patient-clinician interactions during the perinatal period for Black birthing people in the United States. A systematic search of CINAHL, PubMed, PsycINFO, MEDLINE, and Embase recovered 24 articles that met the eligibility criteria for inclusion in this review. The following themes emerged from synthesizing Black patients' interactions with perinatal clinicians: Care Quality, Communication, Power Dynamic, and Established Relationships. Mutual respect, effective communication, and shared decision-making may be key modifiable factors to address through clinician education to improve perinatal care for many Black persons.

Achieving international consensus on the concept of woman-centred care: A Delphi study

PROBLEM

There is no internationally-informed understanding of how midwives perceive woman-centred care and use it in practice.

BACKGROUND

Woman-centred care is integral to the role of the midwife and to determining standards of practice. Few empirical studies have explored the meaning of woman-centred care, and those that have are limited to country specific research.

AIM

To gain an in-depth understanding and consensus on the concept of woman-centred care from an international perspective.

METHODS

A three round Delphi study was conducted, with surveys distributed online to a group of international expert midwives to draw consensus on the topic of woman-centred care.

FINDINGS

A panel of 59 expert midwives representing 22 countries participated. Fifty-nine statements about woman-centred care, of which 63% of statements reached the 75% a priori agreement level, were developed and categorised under four emergent themes: defining characteristics of woman-centred care (n = 17), the role of the midwife in woman-centred care (n = 19), woman-centred care and systems of care (n = 18), woman-centred care in education and research (n = 5).

DISCUSSION

Participants agreed that woman-centred care should be provided by any health care professional in any health care setting. Systems of maternity care should provide holistic care tailored for the individual woman rather than subject her to routine practices and policies. Although continuity of care is important to midwifery practice, it was not reported as a core characteristic of woman-centred care.

CONCLUSION

This is the first study to investigate the concept of woman-centred care as it is experienced globally by midwives. The findings of this study will be used to contribute to the development of an internationally informed evidence-based definition of woman-centred care.

Consent during labour and birth as observed by midwifery students: A mixed methods study

BACKGROUND

While consent is an integral part of respectful maternity care, how this is obtained during labour and birth presents conflicting understandings between midwives' and women's experiences. Midwifery students are well placed to observe interactions between women and midwives during the consent process.

AIM

The purpose of this study was to explore the observations and experiences of final year midwifery students of how midwives obtain consent during labour and birth.

METHODS

An online survey was distributed via universities and social media to final year midwifery students across Australia. Likert scale questions based on the principles of informed consent (indications, outcomes, risks, alternatives, and voluntariness) were posed for intrapartum care in general and for specific clinical procedures. Students could also record verbal descriptions of their observations via the survey app. Recorded responses were analysed thematically.

FINDINGS

225 students responded with 195 completed surveys; 20 students provided audio recorded data. Student's observations suggested that the consent process varied considerably depending on the clinical procedure. Discussions of risks and alternatives during labour were frequently omitted.

DISCUSSION

The student's accounts suggest that in many instances during labour and birth the principles of informed consent are not being applied consistently. Presenting interventions as routine care subverted choice for women in favour of the midwives' preferences.

CONCLUSIONS

Consent during labour and birth is invalidated by a lack of disclosure of risks and alternatives. Health and education institutions should include information in guidelines, theoretical and practice training on minimum consent standards for specific procedures inclusive of risks and alternatives.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Access to support during childbirth?: women's preferences and experiences of support person integration in a cross-sectional facility-based survey

BACKGROUND

Integrating support persons into maternity care, such as making them feel welcome or providing them with information, is positioned to increase support for women and improve birth outcomes. Little quantitative research has examined what support women need and how the healthcare system currently facilitates support for women. We introduce the Person-Centered Integration of Support Persons (PC-ISP) concept, based on a review of the literature and propose four PC-ISP domains-Welcoming environment, Decision-making support, Provision of information and education and Ability to ask questions and express concerns. We report on women's preferences and experiences of PC-ISP.

METHODS

We developed PC-ISP measures based on the literature and applied these in a facility-based survey with 1,138 women after childbirth in six health facilities in Nairobi and Kiambu counties in Kenya from September 2019 to January 2020.

RESULTS

We found an unmet need for integrating support persons during childbirth. Between 73.6 and 93.6% of women preferred integration of support persons during maternity care, but only 45.3-77.9% reported to have experienced integration. Women who reported having a male partner support person reported more PC-ISP experiences (B0.13; 95% CI 0.02, 0.23) than those without. Employed women were more likely to report having the opportunity to consult support persons on decisions (aOR1.26; 95% CI 1.07, 1.50) and report that providers asked if support persons should be informed about their condition and care (aOR1.29; 95% CI 1.07, 1.55). Women with more providers attending birth were more likely to report opportunities to consult support persons on decisions (aOR1.53; 95% CI 1.09, 2.15) and that support persons were welcome to ask questions (aOR1.84, 95% CI 1.07, 2.54).

CONCLUSIONS

Greater efforts to integrate support persons for specific roles, including decision-making support, bridging communication and advocacy, are needed to meet women's needs for support in maternity care.

The Dutch Solid Start program: describing the implementation and experiences of the program's first thousand days

BACKGROUND

In 2018, the Dutch government initiated the Solid Start program to provide each child the best start in life. The program focuses on the crucial first thousand days of life, which span from preconception to a child's second birthday, and has a specific focus towards (future) parents and young children in vulnerable situations. A key program element is improving collaboration between the medical and social sector by creating Solid Start coalitions. This study aimed to describe the implementation of the Dutch Solid Start program, in order to learn for future practice and policy. Specifically, this paper describes to what extent Solid Start is implemented within municipalities and outlines stakeholders' experiences with the implementation of Solid Start and the associated cross-sectoral collaboration.

METHODS

Quantitative and qualitative data were collected from 2019 until 2021. Questionnaires were sent to all 352 Dutch municipalities and analyzed using descriptive statistics. Qualitative data were obtained through focus group discussions(n = 6) and semi-structured interviews(n = 19) with representatives of care and support organizations, knowledge institutes and professional associations, Solid Start project leaders, advisors, municipal officials, researchers, clients and experts-by-experience. Qualitative data were analyzed using the Rainbow Model of Integrated Care.

RESULTS

Findings indicated progress in the development of Solid Start coalitions(n = 40 in 2019, n = 140 in 2021), and an increase in cross-sectoral collaboration. According to the stakeholders, initiating Solid Start increased the sense of urgency concerning the importance of the first thousand days and stimulated professionals from various backgrounds to get to know each other, resulting in more collaborative agreements on cross-sectoral care provision. Important elements mentioned for effective collaboration within coalitions were an active coordinator as driving force, and a shared societal goal. However, stakeholders experienced that Solid Start is not yet fully incorporated into all professionals' everyday practice. Most common barriers for collaboration related to systemic integration at macro-level, including limited resources and collaboration-inhibiting regulations. Stakeholders emphasized the importance of ensuring Solid Start and mentioned various needs, including sustainable funding, supportive regulations, responsiveness to stakeholders' needs, ongoing knowledge development, and client involvement.

CONCLUSION

Solid Start, as a national program with strong local focus, has led to various incremental changes that supported cross-sectoral collaboration to improve care during the first thousand days, without major transformations of systemic structures. However, to ensure the program's sustainability, needs such as sustainable funding should be addressed.

A bit of medical paternalism? A qualitative study on power relations between women and healthcare providers when deciding on mode of birth in five public maternity wards of Argentina

BACKGROUND

Whether women should be able to decide on mode of birth in healthcare settings has been a topic of debate in the last few decades. In the context of a marked increase in global caesarean section rates, a central dilemma is whether pregnant women should be able to request this procedure without medical indication. Since 2015, Law 25,929 of Humanised Birth is in place in Argentina. This study aims at understanding the power relations between healthcare providers, pregnant women, and labour companions regarding decision-making on mode of birth in this new legal context. To do so, central concepts of power theory are used.

METHODS

This study uses a qualitative design. Twenty-six semi-structured interviews with healthcare providers were conducted in five maternity wards in different regions of Argentina. Participants were purposively selected using heterogeneity sampling and included obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. Reflexive thematic analysis was used to inductively develop themes and categories.

RESULTS

Three themes were developed: (1) Healthcare providers reconceptualize decision-making processes of mode of birth to make women's voices matter; (2) Healthcare providers feel powerless against women's request to choose mode of birth; (3) Healthcare providers struggle to redirect women's decision regarding mode of birth. An overarching theme was built to explain the power relations between healthcare providers, women and labour companions: Healthcare providers' loss of beneficial power in decision-making on mode of birth.

CONCLUSIONS

Our analysis highlights the complexity of the healthcare provider-woman interaction in a context in which women are, in practice, allowed to choose mode of birth. Even though healthcare providers claim to welcome women being an active part of the decision-making processes, they feel powerless when women make autonomous decisions regarding mode of birth. They perceive themselves to be losing beneficial power in the eyes of patients and consider fruitful communication on risks and benefits of each mode of birth to not always be possible. At the same time, providers perform an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place.

Validation of Insurance Billing Codes for Monitoring Antenatal Screening

BACKGROUND

Prevalence statistics for pregnancy complications identified through screening such as gestational diabetes usually assume universal screening. However, rates of screening completion in pregnancy are not available in many birth registries or hospital databases. We validated screening-test completion by comparing public insurance laboratory and radiology billing records with medical records at three hospitals in British Columbia, Canada.

METHODS

We abstracted a random sample of 140 delivery medical records (2014-2019), and successfully linked 127 to valid provincial insurance billings and maternal-newborn registry data. We compared billing records for gestational diabetes screening, any ultrasound before 14 weeks gestational age, and Group B streptococcus screening during each pregnancy to the gold standard of medical records by calculating sensitivity and specificity, positive predictive value, negative predictive value, and prevalence with 95% confidence intervals (CIs).

RESULTS

Gestational diabetes screening (screened vs. unscreened) in billing records had a high sensitivity (98% [95% CI = 93, 100]) and specificity (>99% [95% CI = 86, 100]). The use of specific glucose screening approaches (two-step vs. one-step) were also well characterized by billing data. Other tests showed high sensitivity (ultrasound 97% [95% CI = 92, 99]; Group B streptococcus 96% [95% CI = 89, 99]) but lower negative predictive values (ultrasound 64% [95% CI = 33, 99]; Group B streptococcus 70% [95% CI = 40, 89]). Lower negative predictive values were due to the high prevalence of these screening tests in our sample.

CONCLUSIONS

Laboratory and radiology insurance billing codes accurately identified those who completed routine antenatal screening tests with relatively low false-positive rates.

Digital adaptability competency for healthcare professionals: a modified explorative e-Delphi study

AIM

To establish items of the digital adaptability competency for healthcare professionals.

BACKGROUND

While the application and deployment of eHealth has continued at a rapid pace, healthcare professionals are expected to keep up and join the digital evolution. The implementation of eHealth requires a change in the healthcare professionals' competencies of which the ability to adapt to technological change is fundamental. There's more needed than just ICT skills, overall competencies to be digitally adaptable between patientcare and the use of eHealth are needed. Today, a distinct and relevant list of items for healthcare professionals related to the competency of digital adaptability is missing.

DESIGN

An exploratory modified e-Delphi study.

METHODS

This study was conducted in Flanders, Belgium. An expert group (n = 12) consisting of 2 policymakers of the Belgian federal government, 3 eHealth managers of large organizations in the Belgian healthcare sector, 1 nurse, 1 midwife, 2 health service users and 3 researchers specialized in eHealth research. Through a literature review an initial list of items was developed, consisting of 67 statements. A two-round Delphi survey was performed where experts could rate the relevance of each item. The third round comprised an online meeting, where the expert group discussed the remaining items until agreement was reached to retain, modify, or eliminate the item.

RESULTS

In round 1, eleven items were included to the final document. In round 2, ten items were included. In round 3, the panel unanimously agreed to add six items, one item was modified into two separate items. In total, 29 items were included in the final document.

CONCLUSIONS

The rather abstract concept of digital adaptability is now transformed into a more pragmatic concept of 29 items, reflecting the practical competencies of healthcare professionals necessary to be digital adaptable.

Development and Validity of an Intrapartum Self-Assessment Scale Aimed at Instilling Midwife-Led Care Competencies Used at Freestanding Midwifery Units

Building experience in midwife-led care at freestanding midwifery units is needed to enhance assessment, technical, and care competencies specific to midwives. This study aimed to develop a self-assessment scale for midwifery practice competency based on the characteristics of midwife-led care practices in freestanding midwifery units. This study was conducted at 65 childbirth facilities in Japan between September 2017 and March 2018. The items on the scale were developed based on a literature review, discussion at a professional meeting, and a preliminary survey conducted at two timepoints. The validity and reproducibility of the scale were evaluated based on item analysis, compositional concept validity, internal consistency, stability, and criterion-related validity using data from 401 midwives. The final version of the scale consisted of 40 items. Cronbach's α for the overall scale was 0.982. The results for compositional concept validity, internal validity, and criterion-related validity demonstrated that this scale is capable of evaluating a midwife's practice competencies in intrapartum care. Repeated self-assessment using this scale could improve the competencies of midwives from an early stage, maximize the roles of physicians and midwives, and create an environment that provides high-quality assistance to women.

Time-out in prolonged labour: development of a care model to prevent secondary fear of childbirth

Background

During qualitative improvement work, the statistics at the hospital reveal prolonged labour as one of the major causes of secondary fear of childbirth (FOC). The aim of this improvement work was to develop and implement a care process for prolonged labour to prevent secondary FOC.

Materials and methods

To explore the factors behind secondary FOC among multiparous women, a follow-up of referral reasons for 600 women with severe FOC was made between 2015 and 2017 at a Swedish University Hospital. In the group with the most common factor, namely prolonged labour, 41 women were interviewed. From their answers, further research and existing professional knowledge, a care process to prevent secondary FOC was designed, ‘Time-out in prolonged labour’ (the Time-out). To improve the quality of the care process, the functional resonance analysis method was used. The findings from the interviews were categorised into three themes: lack of involvement; lack of communication and information; and lack of care plan. The women explained that if these areas had been fulfilled, it may have reduced their FOC.

Result

To prevent the above-mentioned themes, ‘Time-out in prolonged labour’ was developed with supporting factors such as gathering the interprofessional team, collecting information, dialogue within the team and the involvement of the women when deciding the care plan. Result after implementation shows a reduction of referral reason due to prolonged labour for women with severe FOC from 28% in 2016 to 8.5% in 2020.

Conclusions

The Time-out is a good model to prevent secondary FOC. Central aspects of the model are to ensure women’s involvement, good communication and a documented care plan for women in prolonged labour. The supporting factor of interprofessional teamwork is of importance when using the Time-out in practice.

A case study on the use of Public Narrative as a leadership development approach for Patient Leaders in the English National Health Service

Background

In 2016 the National Health Service (NHS) England embraced the commitment to work for maternity services to become safer, more personalized, kinder, professional and more family-friendly. Achieving this involves including a service users' organizations to co-lead and deliver the services. This article explores how Public Narrative, a framework for leadership development used across geographical and cultural settings worldwide, can enhance the confidence, capability and skills of service-user representatives (or Patient Leaders) in the National Health Service (NHS) in England. Specifically, we analyse a pilot initiative conducted with one cohort of Patient Leaders, the Chairs of local Maternity Voices Partnerships (MVPs), and how they have used Public Narrative to enhance their effectiveness in leading transformation in maternity services as part of the NHS Maternity Transformation Programme.

Methods

Qualitative two-phase case study of a pilot training and coaching initiative using Public Narrative with a cohort of MVP Chairs. Phase 1 consisted of a 6-month period, during which the standard framework was adapted in co-design with the MVP Chairs. A core MVP Chair Co-Design Group underwent initial training and follow-up coaching in Public Narrative. Phase 2 consisted of qualitative data collection and data analysis.

Results

The study of this pilot initiative suggests two main ways in which Public Narrative can enhance the effectiveness of Patient Leaders in service improvement in general and maternity services in specific. First, training and coaching in the Public Narrative framework enables Patient Leaders to gain insight into, articulate and then craft their lived experience of healthcare services in a way that connects with and activates the underlying values of others ("shared purpose"), such that those experiences become an emotional resource on which Patient Leaders can draw to influence future service design and decision-making processes. Second, Public Narrative provides a simple and compelling structure through which Patient Leaders can enhance their skills, confidence and capability as "healthcare leaders," both individually and collectively.

Conclusions

The Public Narrative framework can significantly enhance the confidence, capability and skills of Patient Leaders, both to identify and coalesce around shared purpose and to advance genuine co-production in the design and improvement of healthcare services in general and maternity services in specific.

Women's decision-making autonomy in Dutch maternity care

BACKGROUND

A positive childbirth experience is an important outcome of maternity care. A significant component of a positive birth experience is the ability to exercise autonomy in decision-making. In this study, we explore women's reports of their autonomy during conversations about their care with maternity care practitioners during pregnancy and childbirth.

METHOD

Data were obtained from a cross-sectional survey of women living in The Netherlands that asked about their experiences during pregnancy and childbirth, including their role in conversations concerning decisions about their care.

RESULTS

A total of 3494 women were included in this study. Most women scored high on autonomy in decision-making conversations. During the latter stage of pregnancy (32+ weeks) and in childbirth, women reported significantly lower levels of autonomy in their care conversations with obstetricians as compared with midwives. Linear regression analyses showed that women's perception of personal treatment increased women's reported autonomy in their conversations with both midwives and obstetricians. Almost half (49.1%) of the women who had at least one intervention during birth reported pressure to accept or submit to that intervention. This was indicated by 48.3% of women with induced labor, 47.3% who had an instrumental vaginal birth, 45.2% whose labor was augmented, and 41.9% of women who had a cesarean birth.

CONCLUSIONS

In general, women's sense of autonomy in decision-making conversations during prenatal care and birth is high, but there is room for improvement, and this appeared most notably in conversations with obstetricians. Women's sense of autonomy can be enhanced with personal treatment, including shared decision-making and the avoidance of pressuring women to accept interventions.

Women's view on shared decision making and autonomy in childbirth: cohort study of Belgian women

Background

Health care providers have an important role to share evidence based information and empower patients to make informed choices. Previous studies indicate that shared decision making in pregnancy and childbirth may have an important impact on a woman’s birth experience. In Flemish social media, a large number of women expressed their concern about their birth experience, where they felt loss of control and limited possibilities to make their own choices. The aim of this study is to explore autonomy and shared decision making in the Flemish population.

Methods

This is a cross-sectional, non-interventional study to explore the birth experience of Flemish women. A self-assembled questionnaire was used to collect data, including the Pregnancy and Childbirth Questionnaire (PCQ), the Labor Agentry Scale (LAS), the Mothers Autonomy Decision Making Scale (MADM), the 9-item Shared Decision Making Questionnaire (SDM–Q9) and four questions on preparation for childbirth. Women who gave birth two to 12 months ago were recruited by means of social media in the Flemish area (Northern part of Belgium).

Linear mixed-effect modelling with backwards variable selection was applied to examine relations with autonomy in decision making.

Results

In total, 1029 mothers participated in this study of which 617 filled out the survey completely. In general, mothers experienced moderate autonomy in decision-making, both with an obstetrician and with a midwife with an average on the MADM score of respectively 18.5 (± 7.2) and 29.4 (±10.4) out of 42. The linear mixed-effects model showed a relationship between autonomy in decision-making (MADM) for the type of healthcare provider (p < 0.001), the level of self-control during labour and birth (LAS) (p = 0.003), the level of perceived quality of care (PCQ) (p < 0.001), having epidural analgesia during childbirth (p = 0.026) and feeling to have received sufficient information about the normal course of childbirth (p < 0.001).

Conclusions

Childbearing women in Flanders experience moderate levels of autonomy in decision- making with their health care providers, where lower autonomy was observed for obstetricians compared to midwives. Future research should focus more on why differences occur between obstetrics and midwives in terms of autonomy and shared decision-making as perceived by the mother.

Ethical Considerations in Neonatal Research

Children are considered a vulnerable population and have traditionally been excluded from research studies. This exclusion of children in general, and neonates in particular, from clinical research hampers the development of safe and effective therapies in this population. However, research involving children (including infants) is essential to guide therapy and optimize care. Neonatal research is complex, time intensive, difficult and expensive to conduct, and raises some unique ethical considerations. The complexity of research in this population is highlighted by the fear of causing harm to fragile sick infants which has led to the creation of special regulations on the degree of risk exposure permissible in research involving infants. This is further compounded by the inability of infants to provide informed consent or assent and the reliance on obtaining surrogate consent from parents who may themselves be vulnerable and overwhelmed by their infant's illness and the amount of information provided to them. In this review, we discuss the evolution of ethical regulations related to research, the justification for research in infants, and some of the ethical nuances of research in this population.

Midwifery scale to support shared decision-making for unplanned pregnancies: A cross-sectional study

Midwives significantly support women with unplanned pregnancies-promoting a shared perspective on the decision-making process. This study aimed to develop a scale to support midwives self-assess their practice of this vital role. Following the derivation of scale items and pilot testing, the final version of the scale was administered to 531 midwives to establish internal consistency and construct criterion-related validity. Through exploratory factor analysis, 35 items with a five-factor structure were retained to form the midwifery practice self-assessment scale to promote shared decision-making in women with unplanned pregnancies. These factors illustrate midwives' general aptitude and competencies in understanding environmental factors, collaborating with significant others and the interprofessional group, forming rapport and problem sharing, focusing on consultation content, and promoting autonomous decision-making. There were high and low scores on the scales after attending the workshops to support the decision-making of women with unplanned pregnancies. The reliability analysis showed acceptable Cronbach's alpha values for the five factors, from .85-.87. The scale was demonstrated to be a reliable and valid measure that would help improve the quality of midwives' practice. This article is protected by copyright. All rights reserved.

Exploring women's experiences of participation in shared decision-making during childbirth: a qualitative study at a reference hospital in Spain

BACKGROUND

Women's engagement in healthcare decision-making during childbirth has been increasingly emphasised as a priority in maternity care, since it increases satisfaction with the childbirth experience and provides health benefits for women and newborns. The birth plan was developed as a tool to facilitate communication between health professionals and women in Spain, but their value in routine practice has been questioned. Besides, little is known about women's experiences of participation in decision-making in the Spanish context. Thus, this study aimed to explore women's experiences of participation in shared decision-making during hospital childbirth.

METHODS

An exploratory qualitative study using focus groups was carried out in one maternity unit of a large reference hospital in Barcelona, Spain. Participants were first-time mothers aged 18 years or older who had had a live birth at the same hospital in the previous 12 months. Data collected were transcribed verbatim and analysed using a six-phase inductive thematic analysis process.

RESULTS

Twenty-three women participated in three focus groups. Three major themes emerged from the data: "Women's low participation in shared decision-making", "Lack of information provision for shared decision-making", and "Suggestions to improve women's participation in shared decision-making". The women who were willing to take an active role in decision-making encountered barriers to achieving this and some women did not feel prepared to do so. The birth plan was experienced as a deficient method to promote women's participation, as health professionals did not use them. Participants described the information given as insufficient and not offered at a timely or useful point where it could aid their decision-making. Potential improvements identified that could promote women's participation were having a mutually respectful relationship with their providers, the support of partners and other members of the family and receiving continuity of a coordinated and personalised perinatal care.

CONCLUSION

Enhancing women's involvement in shared decision-making requires the acquisition of skills by health professionals and women. The development and implementation of interventions that encompass a training programme for health professionals and women, accompanied by an effective tool to promote women's participation in shared decision-making during childbirth, is highly recommended.

What Do Women Want? Consent for the Use of Electronic Fetal Monitoring

BACKGROUND

Guidelines published by professional associations of midwives, obstetricians, and nurses in the United States recommend against using continuous cardiotocography (CTG) in low-risk patients. In the United States, CTG or electronic fetal/uterine monitoring (EFM) rather than auscultation with a fetoscope or Pinard horn is the norm. Interpretation of the fetal heart rate (FHR) and uterine activity (UA) tracings provided by continuous EFM may be associated with the decision for a cesarean birth. Typically, consent is not sought in the decision about type of monitoring. No studies were identified where women's attitudes about the need to consent to the type of fetal monitoring used during labor have been explored. Therefore, the purpose of this research was to examine women's attitudes about the use of EFM in a healthcare setting.

METHODS

We asked a sample of women aged 18–50 years to respond to one of three monitoringscenarios. The scenarios were used to distinguish between attitudes about monitoring in general, monitoring the health of a mother in labor, and monitoring the health of the fetus during labor. Wemeasured their level of interest in being monitored and their opinions about whether healthcare providers should be required to obtain consent for the monitoring described in the scenario.

RESULTS

Interest in receiving monitoring (across all three scenarios) was moderate, with the highest level of interest in monitoring the fetus during labor and the least interest in monitoring a general health context. Across all scenarios, 82% of respondents believed that practitioners should obtain consent for monitoring, 14% were unsure, and 4% said there should not be a requirement for consent. While low (6%), the percentage responding that consent was not needed was highest in monitoring a fetus in labor.

CONCLUSIONS

Women in our study expressed a strong preference for the opportunity to consent to the use of monitoring regardless of the healthcare scenario. There is findings suggest the need for further research exploring what women do and do not know about CTG and what their informed performance are a pressing need to rethink the role of a pressing need to rethink the role of shared decision-making and informed consent about the type of monitoring use during labor.

Shared decision-making for women facing an unplanned pregnancy: A qualitative study

This study aimed to explore the competencies of health care practitioners who promote shared decision-making (SDM)-based care for women facing an unplanned pregnancy in Japan. We conducted semistructured interviews with 12 care providers who are pioneers in care for women facing an unplanned pregnancy and adopted a modified grounded theory approach for data analysis. A three-step model for shared decision making in practice (team talk, option talk, and decision talk) was used as a reference. The answers given by the care providers were analyzed to identify the competencies involved in shared decision making. We identified three stages: (i) building trust and promoting women's expression; (ii) discussing women's real needs; and (iii) exploring the intentions and goals expressed by women and finding the best choices while promoting women's autonomy in decision-making. The coordination between the support of partners, families, and professionals, and the care provided to strengthen women's identities facilitated shared decision making. Women facing an unplanned pregnancy can benefit from interventions designed to improve shared decision making. A key component of shared decision making-based care relates to practitioners' raised awareness toward their roles and responsibilities: developing good communication skills and fostering collaboration between all stakeholders.

I felt so much conflict instead of joy: an analysis of open-ended comments from people in British Columbia who declined care recommendations during pregnancy and childbirth

Background

No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended.

Methods

In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations.

Results

More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences.

Conclusions

Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.

Can a simple assessment of fear of childbirth in pregnant women predict requests and use of non-urgent obstetric interventions during labour?

OBJECTIVE

To examine whether the Wijma Delivery Expectation Questionnaire (W-DEQ-A) and the one-item Fear of Childbirth-Postpartum-Visual Analogue Scale (FOCP-VAS) - measuring high FOC - are useful tools in predicting requested and received non-urgent obstetric interventions in pregnant women.

DESIGN

A prospective cohort study.

POPULATION AND SETTING

Self-selected pregnant women from midwifery care settings (n=401).

METHODS

W-DEQ-A and FOCP-VAS were assessed at two timepoints in pregnancy. Measures of non-urgent obstetric interventions which were derived from medical files were: induction of labour, epidural analgesia, augmentation with oxytocin due to failure to progress and self-requested caesarean section. Hierarchical logistics regression models were used.

MAIN OUTCOME MEASURES

The change in the Nagelkerke R² was examined for three models predicting two outcome measures: (1) explicitly requested non-urgent obstetric interventions during pregnancy and (2) received non-urgent obstetric interventions during labour. The first model only included participants' characteristics, the second model also included FOCP-VAS ≥5, and in the third model the W-DEQ-A ≥66 was added.

RESULTS

High FOC measured with FOCP-VAS≥5 predicted requested (pseudo-R²=0.33, X²=59.82, P<0.001) and received non-urgent obstetric interventions (pseudo-R²=0.19, X²=32.81, P<0.001) better than high FOC measured with W-DEQ-A≥66.

CONCLUSION

This study is the first evaluating self-reported FOC and postpartum based on VAS (subjective outcome) in relation to actual pregnancy and childbirth outcomes derived from medical files (objective outcome). Non-urgent obstetric interventions could already be predicted in the first half of pregnancy by means of a simple FOC assessment with the one-item FOCP-VAS. Implementing this easy to use one-item screening tool in midwifery care is suggested.

The maternal health-related issues that matter most to women in Ireland as they transition to motherhood - A qualitative study

BACKGROUND

Many studies on women's maternity care experiences reveal recurring issues that are poor or less than optimal. Women's opinions on the maternal health-related issues that matter most to them are essential if care and services are to be improved.

AIMS

To identify the maternal health-related issues that matter most to women in Ireland, based on their own experiences of maternity care, services and motherhood.

METHODS

A qualitative exploratory study with 24 women. Following university ethical approval, audio-recorded one-to-one telephone interviews were conducted and thematically analysed.

FINDINGS

We identified two themes, each with four subthemes, connected to a central concept of the invisible woman. Pendulum of care, and subthemes Inconsistent services, All about the baby, Induced anxiety and Information seesaw, illustrated the extremes of care and services that women experienced. Magnitude of motherhood, and subthemes Weight of responsibility, Real-time reassurance, Change of identity and Growth into advocacy, depicted the intensity of their new role while transitioning to motherhood.

DISCUSSION

Findings articulate the issues that mattered most to women in Ireland as they transitioned to motherhood. Some women identified specific research topics/areas, but all of the issues identified can be translated into researchable topics that seek to improve local care and service provision.

CONCLUSION

Given the recurring nature of women's less than satisfactory experiences of aspects of maternity care in many countries, it is likely that conducting research on issues that matters most to women will have the greatest impact on their health, wellbeing and lives as they transition to motherhood.

Women's Participation in Decision-Making in Maternity Care: A Qualitative Exploration of Clients' Health Literacy Skills and Needs for Support

Shared decision-making requires adequate functional health literacy (HL) skills from clients to understand information, as well as interactive and critical HL skills to obtain, appraise and apply information about available options. This study aimed to explore women's HL skills and needs for support regarding shared decision-making in maternity care. In-depth interviews were held among women in Dutch maternity care who scored low (n = 10) and high (n = 13) on basic health literacy screening test(s). HL skills and perceived needs for support were identified through thematic analysis. Women appeared to be highly engaged in the decision-making process. They mentioned searching and selecting general information about pregnancy and labor, constructing their preferences based on their own pre-existing knowledge and experiences and by discussions with partners and significant others. However, women with low basic skills and primigravida perceived difficulties in finding reliable information, understanding probabilistic information, constructing preferences based on benefit/harm information and preparing for consultations. Women also emphasized dealing with uncertainties, changing circumstances of pregnancy and labor, and emotions. Maternity care professionals could further support clients by guiding them towards reliable information. To facilitate participation in decision-making, preparing women for consultations (e.g., agenda setting) and supporting them in a timely manner to understand benefit/harm information seem important.

Qualitative evaluation of an innovative midwifery continuity scheme: Lessons from using a quality care framework

INTRODUCTION

Innovative midwifery schemes must be robustly evaluated to establish whether they should be modified or can be replicated. Assessing quality of care can help to ascertain a scheme's acceptability and effectiveness. We used an established quality care framework as a benchmark in our qualitative evaluation of a combined continuity of caregiver and planned home birth scheme in Scotland.

METHODS

Qualitative evaluation of stakeholder perceptions using the Quality Maternal and Newborn Care Framework was the basis for six focus groups and two one-to-one interviews with stakeholders (new mothers, partners, midwives). A thematic analytical approach was used.

RESULTS

The qualitative evaluation found universal approval among participants. Flexible working patterns helped to nurture positive relationships, and information and support were highly valued. The principal themes-Organization of Care/Work Culture; Information and Support; Relationships-were strongly inter-related. They shared several subthemes, notably continuity of caregiver, flexible family-centered care, and the benefits of being at home. Flexibility and mutual respect helped women to express autonomy and develop agency. Women related their birth experiences to friends, family, and colleagues, thereby helping to normalize home birth.

CONCLUSIONS

This qualitative evaluation of an innovative scheme used an established quality framework as a benchmark against which to assess stakeholder experiences. This approach helped to identify the critical codependence of factors involved in care delivery, which in turn helps to identify lessons for others considering similar schemes. Although our evaluation relates to one specific scheme, identifying the scheme's critical quality care aspects may assist others when planning similar schemes.

Communication in high risk ante-natal consultations: a direct observational study of interactions between patients and obstetricians

Background

Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where the outcome affects more than one person. While higher levels of patient participation and shared decision making are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective communication practices in a high-risk ante-natal clinic.

Methods

We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13 obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in conjunction with thematic analysis of interview transcripts.

Results

Most patients reported high quality communication and high levels of satisfaction; the detailed consultation analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations, acknowledgement of the patient’s experience, consideration of patient wishes, and realistic and honest answers to patient questions. On the patient side, these included a high level of engagement with technical aspects of events and procedures, and appropriate questioning of obstetricians.

Conclusions

This study has demonstrated the utility of combining direct observation of consultations with data from patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care. The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.

Measuring women's experiences of decision-making and aspects of midwifery support: a confirmatory factor analysis of the revised Childbirth Experience Questionnaire

BACKGROUND

Women's experiences of labour and birth can have both short- and long-term effects on their physical and psychological health. The original Swedish version of the Childbirth Experience Questionnaire (CEQ) has shown to have good psychometric quality and ability to differentiate between groups known to differ in childbirth experience. Two subscales were revised in order to include new items with more relevant content about decision-making and aspects of midwifery support. The aim of the study was to develop new items in two subscales and to test construct validity and reliability of the revised version of CEQ, called CEQ2.

METHOD

A total of 11 new items (Professional Support and Participation) and 14 original items from the first CEQ (Own capacity and Perceived safety), were answered by 682 women with spontaneous onset of labour. Confirmatory factor analysis was used to analyse model fit.

RESULTS

The hypothesised four-factor model showed good fit (CMIN = 2.79; RMR = 0.33; GFI = 0.94; CFI = 0.94; TLI = 0.93; RMSEA = 0.054 and PCLOSE = 0.12) Cronbach's alpha was good for all subscales (0.82, 0.83, 0.76 and 0.73) and for the total scale (0.91).

CONCLUSIONS

CEQ2, like the first CEQ, yields four important aspects of experience during labour and birth showing good psychometric performance, including decision-making and aspects of midwifery support, in both primiparous and multiparous women.

Evaluating Shared Decision Making in Trial of Labor After Cesarean Counseling Using Objective Structured Clinical Examinations

INTRODUCTION

Although shared decision making (SDM) is optimal for trial of labor after cesarean (TOLAC) counseling, resources to assess residents' clinical competency and communication skills are lacking. We addressed this gap by developing and testing an objective structured clinical examination (OSCE) to evaluate whether learners were able to use SDM in TOLAC counseling.

METHODS

We created three simulation scenarios with increasing complexity to assess the skills of residents in their first, second, or third postgraduate year in using SDM in TOLAC counseling. All cases involved a standardized patient requesting a TOLAC consultation. Residents were provided with a medical history and instructed to counsel and develop a care plan. A 10-item scoring rubric was used, and each item was rated 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters; discrepancies were resolved by consensus.

RESULTS

Over 3 years, 39 residents participated in 60 OSCE encounters. The majority provided complete discussions of the clinical issue (93%), chances of success (72%), and maternal and fetal risks (100% and 85%, respectively) but obtained partial assessments of understanding (78%). Discussions of benefits were typically absent, with the exception of the maternal benefits (47%). More than 40% of residents did not discuss the patient's goals, 53% lacked discussion of uncertainties related to TOLAC, and half failed to explore the patient's preference, with most deferring a decision to a future encounter.

DISCUSSION

Residents consistently discussed diagnosis, prognosis, and maternal risks yet infrequently addressed goals and preferences-two critical elements of SDM.

Informed consent for neonatal trials: practical points to consider and a check list

Obtaining informed consent from parents of critically ill neonates can be challenging. The parental decision-making process is influenced by the severity of the child's condition, the benefit-risk balance, their emotional state and the quality of the relationship with the clinical team. Independent of local legislation, parents may prefer that consent is sought from both. Misconceptions about the absence of risks or unrealistic expectations about benefits should be openly addressed to avoid misunderstandings which may harm the relationship with the clinical team. Continuous consent can be sought where it is unclear whether the free choice of parental consent has been compromised. Obtaining informed consent is a dynamic process building on trusting relationships. It should include open and honest discussions about benefits and risks. Investigators may benefit from training in effective communication. Finally, involving parents in neonatal research including the development of the informed consent form and the process of obtaining consent should be considered standard practice.

Shared decision-making in maternity care: Acknowledging and overcoming epistemic defeaters

Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of "the doctor knows best" and "patient acquiescence" that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required.

Shared decision aids in pregnancy care: A scoping review

BACKGROUND

Shared decision making in pregnancy, labour, and birth is vital to woman-centred care and despite strong evidence for the effectiveness of shared decision making in pregnancy care, practical uptake has been slow.

DESIGN AND AIM

This scoping review aimed to identify and describe effective and appropriate shared decision aids designed to be provided to women in the antenatal period to assist them in making informed decisions for both pregnancy and birth. Two questions guided the enquiry: (i) what shared decision aids for pregnancy and perinatal care are of appropriate quality and feasibility for application in Australia? (ii) which of these decision aids have been shown to be effective and appropriate for Aboriginal and Torres Strait Islander peoples, culturally diverse women, or those with low literacy?

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) was used to conduct the review. Five key databases and selected grey literature sources were examined. English language evidence from Australia, Europe, Canada, United Kingdom, New Zealand, and United States of America produced from 2009 was eligible for inclusion, checked against apriori inclusion criteria, and assessed for quality and usability using the International Patient Decision Aid Standards.

RESULTS

From a total of 5,209 search results, 35 sources of evidence reporting on 27 decision aids were included following title/abstract and full-text review. Most of the decision aids concerned decisions around birth (52%, n = 14) or antenatal screening 37% (n = 10). The quality of the decision aids was moderate to high, with most communicating risks, benefits, and choice pathways via a mix of Likert-style scales, quizzes, and pictures or graphs. Use of decision aids resulted in significant reductions in decisional conflict and increased knowledge. The format of decision aids appeared to have no effect on these outcomes, indicating that paper-based are as effective as video- or audio-based decision aids. Eleven decision aids were suitable for low literacy or low health literacy women, and six were either developed for culturally diverse groups or have been translated into other languages. No decision aids found were specific to Aboriginal and Torres Strait Islander peoples.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The 27 decision aids are readily adoptable into westernised healthcare settings and can be used by midwives or multidisciplinary teams in conjunction with women. Decision aids are designed to support women, and families to arrive at informed choices and supplement the decision-making process rather than to replace consumer-healthcare professional interaction. If given before an appointment, high quality decision aids can increase a woman's familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflict and increasing knowledge.

Views and preferences of medical professionals and pregnant women about a novel primary prevention intervention for hypertensive disorders of pregnancy: a qualitative study

Background

Calcium and low-dose aspirin are two potential approaches for primary prevention of hypertensive disorders of pregnancy (HDP). This study aimed to explore the acceptability, views and preferences of pregnant women and primary healthcare providers for a fixed-dose combined preparation of aspirin and calcium (a polypill) as primary prevention of HDP in an unselected pregnant population.

Methods

In this qualitative study eight in-depth semi-structured interviews were conducted with Dutch primary care midwives and general practitioners. Seven focus group discussions were organised with women with low-risk pregnancies. Topics discussed were: perceptions of preeclampsia; information provision about preeclampsia and a polypill; views on the polypill concept; preferences and needs regarding implementation of a polypill. Thematic analysis of the data transcripts was carried out to identify emerging themes.

Results

Two major themes shaped medical professionals’ and women’s views on the polypill concept: ‘Informed Choice’ and ‘Medicalisation’. Both could be divided into subthemes related to information provision, personal choice and discussions with regard to the balance between ‘unnecessary medicalisation’ and ‘scientific progress’.

Conclusions

In general, women and healthcare practitioners expressed a positive attitude towards a polypill intervention as primary prevention strategy with aspirin and calcium, providing some conditions are met. The most important conditions for implementation of such a strategy were safety, effectiveness and the possibility to make a well-informed autonomous decision.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0707-8) contains supplementary material, which is available to authorized users.

Patient-led decision making: Measuring autonomy and respect in Canadian maternity care

OBJECTIVE

The Changing Childbirth in British Columbia study explored women's preferences and experiences of maternity care, including women's role in decision-making.

METHODS

Following content validation by community members, we administered a cross-sectional online survey exploring novel topics, including drivers for interventions, and experiences of autonomy, respect, or mistreatment during maternity care. Using the Mothers Autonomy in Decision-Making (MADM) scale as an outcome measure in a mixed-effects analysis, we examined differential experiences by socio-demographic and prenatal risk profile, type of care provider, interventions received, and nature of communication with care providers.

RESULTS

A geographically representative sample of Canadian women (n = 2051) reported on 3400 pregnancies. Most women (95.2%) preferred to be the lead decision-maker during care. Patients of physicians had significantly lower autonomy (MADM) scores than midwifery clients as did women who felt pressured to accept interventions. Women who had a difference in opinion with their provider, and those who felt their provider seemed rushed reported the lowest MADM scores.

CONCLUSION

Women's autonomy is significantly altered by model of maternity care, the nature of interactions with care providers, and women's ability for self-determination.

PRACTICE IMPLICATIONS

If health professionals acquire skills in person-centred decision-making experience of autonomy among pregnant women may improve.

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.

The patient experience of kidney disease and pregnancy

Achieving parenthood is often a priority and goal for women with chronic kidney disease (CKD). It can be challenging due to medical and emotional complexities around pregnancy planning and care, increased risk of adverse maternal and fetal outcomes, fears about medications such as immunosuppressants and fetal harm, and concerns regarding the impact of pregnancy on women's kidney health. Navigating the pathways for shared decision-making regarding parenthood requires an understanding of the patient's experiences, values, priorities, and needs. In this review, we describe the patient perspective of high-risk pregnancies including those complicated by CKD and outline recommendations for counseling that incorporate these perspectives to improve the patient experience.