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

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.

Maternity clinician use of shared decision-making in antenatal care: A scoping review

BACKGROUND

Implementation of shared decision-making in antenatal care has had limited exploration.

OBJECTIVE

To assess what is known about shared decision-making in antenatal care.

SEARCH STRATEGY

Five databases were searched (1997-2022) limited to English language studies from OECD countries.

DATA COLLECTION AND ANALYSIS

A data collection table was constructed with findings from 32 papers. A narrative synthesis was conducted with subsequent thematic analysis of included papers.

MAIN RESULTS

Four areas of decision-making were identified with six themes revealing enablers and barriers to shared decision-making in antenatal care.

CONCLUSION

Implementation of shared decision-making requires continuity, time and personalisation of care.

Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands

BACKGROUND

Informed consent for medical interventions is ethically and legally required; an important aspect of quality and safety in healthcare; and essential to person-centred care. During labour and birth, respecting consent requirements, including respecting refusal, can contribute to a higher sense of choice and control for labouring women. This study examines (1) to what extent and for which procedures during labour and birth women report that consent requirements were not met and/or inadequate information was provided, (2) how frequently women consider consent requirements not being met upsetting and (3) which personal characteristics are associated with the latter.

METHODS

A national cross-sectional survey was conducted in the Netherlands among women who gave birth up to 5 years previously. Respondents were recruited through social media with the help of influencers and organisations. The survey focused on 10 common procedures during labour and birth, investigating for each procedure if respondents were offered the procedure, if they consented or refused, if the information provision was sufficient and if they underwent unconsented procedures, whether they found this upsetting.

RESULTS

13 359 women started the survey and 11 418 met the inclusion and exclusion criteria. Consent not asked was most often reported by respondents who underwent postpartum oxytocin (47.5%) and episiotomy (41.7%). Refusal was most often over-ruled when performing augmentation of labour (2.2%) and episiotomy (1.9%). Information provision was reported inadequate more often when consent requirements were not met compared with when they were met. Multiparous women had decreased odds of reporting unmet consent requirements compared with primiparous (adjusted ORs 0.54-0.85). There was considerable variation across procedures in how frequently not meeting consent requirements was considered upsetting.

CONCLUSIONS

Consent for performing a procedure is frequently absent in Dutch maternity care. In some instances, procedures were performed in spite of the woman's refusal. More awareness is needed on meeting necessary consent requirements in order to achieve person-centred and high-quality care during labour and birth.

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.

Effect of childbirth experience on the psychological well-being of postpartum women in Accra, Ghana

BACKGROUND

Women's experience of childbirth can affect their mental health outcomes, many years after the delivery. Consequently, the World Health Organisation has provided recommendations to ensure women receive positive birth experiences during intrapartum care. Yet, negative childbirth experience is widespread in Ghana. This study examined the association between women's childbirth experience (i.e. own capacity, professional support, perceived safety, and participation) and their psychological well-being, and whether or not perceived social support and resilience moderate the childbirth experience - psychological well-being relationship.

METHODS

Mothers (N = 117) who had given birth in the past month and were receiving postnatal care at two health facilities in the Greater Accra Region of Ghana provided the data for the current analysis. Data were collected using the Childbirth Experience Questionnaire, WHO-5 Well-Being Index, Multidimensional Scale of Perceived Social Support, and Brief Resilience Scale. Hierarchical Linear Regression was used to analyse the data.

RESULTS

Results showed that childbirth experience domains of own capacity and perceived safety were significantly, and positively associated with psychological well-being. The domains of professional support and participation were not associated with psychological well-being in this sample. Perceived social support and resilience did not moderate the association between childbirth experience and psychological well-being.

CONCLUSION

The results suggest that efforts by birth practitioners (i.e. midwives, obstetricians, and gynaecologists) to give Ghanaian women positive childbirth experiences through the encouragement of personal control over the birthing process as well as ensuring the safety of the birthing procedure and environment would provide women with optimal mental health outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Informational support and information-seeking during transition to parenthood: Baby Buddy Forward's focus groups with pregnant women and new mothers in Cyprus

INTRODUCTION

Relevant and accurate information during the transition to parenthood is vital for active participation in decision-making. The aim of the study was to gain an in-depth understanding of informational support and information-seeking practices among women in Cyprus during the transition to parenthood with a focus on the use of the internet and informed decision making.

METHODS

Qualitative descriptive exploratory design of 12 focus groups with 64 participants representing different language-cultural groups served by the Baby Buddy Cyprus app. A topic guide covering expectations, experiences and practices guided the discussions. Data were analyzed using inductive content analysis.

RESULTS

Seven themes and several subthemes emerged. In an 'unsupportive system', 'void' of informational support, pregnant women strive to have a 'confident voice'. They find themselves 'self-navigating in parallel worlds' of formal and informal information, where the internet holds a prominent place. 'Supplementing and filtering', instinctively and selectively, results in a state of 'doubt and faith' towards the trustworthiness of the information but also healthcare providers. Effective communication with providers is needed to break the cycle, but seems dependent on the self-efficacy of the women themselves ('art of communication'). Women 'deconstruct and reimagine' their experiences, often assigning responsibility on themselves for not having been better prepared.

CONCLUSIONS

Women want control over decisions affecting their pregnancy. While the internet is a prevalent source of information, they value communication with healthcare providers and want direction. A shift is needed from current practices of unguided information-searching. Maternity healthcare professionals need to recognize this phenomenon, offer appropriate guidance, and support active participation in informed decision-making.

Seeking a connection: Women's lived experience of the woman-midwife relationship in mainstream maternity services in Japan

PROBLEM

In Japan, women continue to suffer from mental health and other postpartum issues despite good clinical outcomes of maternity care.

BACKGROUND

As key care providers, midwives potentially affect women's overall birth experience. Most women in Japan give birth in hospitals or obstetric clinics where different midwives and nurses provide one woman with fragmented care. Women's lived experiences of the woman-midwife in these birth facilities are not well known in Japan.

AIM

To understand women's birth experience and relationship with midwives in the mainstream maternity care system in Japan to improve maternity care and women's birth experience.

METHODS

Face-to-face individual interviews with 14 mothers were conducted. The data were analysed using van Manen's hermeneutic phenomenological approach, which reveals the meaning of human experience in the everyday world.

FINDINGS

Four themes were derived from the hermeneutic phenomenological analysis; 1) Closed hearts and bodies in insecure relationships, 2) Alienation, 3) Hopelessness and helplessness, and 4) Women's vulnerability and desire for positive relationships.

DISCUSSION

In institutionalised and fragmented maternity care settings, it is difficult for women and midwives to develop a relationship. In such a care environment, women's birth experience with midwives is negative or even traumatic; yet, women still need and seek the midwife relationship. Respectful care-necessary for women's positive birth experience-requires positive relationship between women and midwives.

CONCLUSION

Women's negative birth experience may affect their mental health and parenting. Maternity and midwifery care in Japan needs to develop relationship-based care to improve women's birth experience.

Conceptualization of patient-centered care in Latin America: A scoping review

INTRODUCTION

Patient-centered care (PCC) has been declared as a desirable goal for health care in Latin American countries, but a coherent definition of what exactly PCC entails for clinical practice is missing. This article's aim was to identify how PCC is conceptualized in Latin American countries.

METHODS

Scientific databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Scielo, Scopus, Web of Science) and webpages of the ministries of health were searched, and experts were contacted for suggestions of literature. References were included if they contained one of a range of a priori defined keywords related to PCC in the title, were published between 2006 and 2021, and were carried out in or concerned Latin America. Definitions of PCC were extracted from the included articles and analyzed using deductive and inductive coding. Deductive coding was based on the integrative model of patient-centeredness, which unites the definitions of PCC in the international literature (mainly North America and Europe) and proposes 16 dimensions describing PCC.

RESULTS

Thirty-two articles were included in the analysis and about half of them were from Brazil. Numerous similarities were found between the integrative model of patient-centeredness and the definitions of PCC given in the selected literature. The dimensions of the integrative model of patient-centeredness that were least and most prominent in the literature were physical support and patient information, respectively. A differentiation between PCC and family-centered care (FCC) was observed. Definitions of PCC and FCC as well as their cited references were diverse.

CONCLUSION

A considerable overlap between the conceptualization of PCC in Latin America and the integrative model of patient-centeredness has been identified. However, there are substantial differences between countries in Latin America regarding the emphasis of research on PCC versus FCC and diverse conceptualizations of PCC and FCC exist.

PATIENT CONTRIBUTION

This scoping review takes the patient's perspective based on the integrative model of patient-centeredness. Due to the study being a review, no patients, neither caregivers, nor members of the public, were involved.

Birth plans: definitions, content, effects, and best practices

The first written guide for birth plans was introduced in 1980 as a means for birthing people to document their choices in the child birthing experience. The birth plan offers an opportunity for the patient and the provider to discuss the birthing process and determine how to safely accommodate patient preferences. Patient satisfaction with birthing plans is variable and may depend on how many requests they have, how many of their plans are accomplished, route of delivery, and whether complications arise during or after delivery. Unmet expectations may lead to posttraumatic stress disorder, but following a birth plan may also be protective against it. Birthing people who use a birth plan may be less likely to use epidural anesthesia, have early amniotomy, or use oxytocin. The first stage of labor may be longer when a birth plan is used; however, there does not seem to be a decrease in the length of the second stage of labor among patients with a birth plan. Some providers believe that a disadvantage of birth plans is disappointment when birth plans are not able to be followed, and others consider that birth plans interfere with professional autonomy.

Women's negative childbirth experiences and socioeconomic factors: Results from the Babies Born better survey

OBJECTIVE

To investigate the association between women's socioeconomic status and overall childbirth experience and to explore how women reporting an overall negative birth experience describe their experiences of intrapartum care.

METHODS

We used both quantitative and qualitative data from the Babies Born Better (B3) survey version 2, including a total of 8317 women. First, we performed regression analyses to explore the association between women's socioeconomic status and labour and birth experience, and then a thematic analysis of three open-ended questions from women reporting a negative childbirth experience (n = 917).

RESULTS

In total 11.7% reported an overall negative labour and birth experience. The adjusted odds ratio (OR) of a negative childbirth experience was elevated for women with non-tertiary education, for unemployed, students and not married or cohabiting. Women with lower subjective living standard had an adjusted OR of 1.70 (95% CI 1.44-2.00) for a negative birth experience, compared with those with average subjective living standard. The qualitative analysis generated three themes: 1) Uncompassionate care: lack of sensitivity and empathy, 2) Impersonal care: feeling objectified, and 3) Critical situations: feeling unsafe and loss of control.

CONCLUSION

Important socioeconomic disparities in women's childbirth experiences exist even in the Norwegian setting. Women reporting a negative childbirth experience described disrespect and mistreatment as well as experiences of insufficient attention and lack of awareness of individual and emotional needs during childbirth. The study shows that women with lower socioeconomic status are more exposed to these types of experiences during labour and birth.

TWEETABLE ABSTRACT

Women with lower socioeconomic status are more exposed to negative experiences during labour and birth.

Using a scheduled caesarean birth plan: A cross-sectional exploration of women's perspectives

PROBLEM

There is minimal evidence regarding the role or impact of birth plans from the perspective of women experiencing scheduled caesarean birth.

BACKGROUND

Quality maternity care requires respect for women's preferences. Evidence suggests birth plans enable communication of women's preferences and may enhance agency when vaginal birth is intended, however there is limited evidence of how this translates in the perioperative environment where caesarean birth is the intended outcome.

AIM

Explore the experiences and perspectives of women who had utilised a scheduled caesarean birth plan at an Australian tertiary maternity hospital.

METHODS

A cross-sectional design was used; 294 participants completed the survey within two weeks post-birth. Descriptive statistics were used to analyse quantitative data, qualitative responses were analysed using content analysis.

FINDINGS

Over half of the women requested lowering of the surgical-screen at birth, most requested immediate skin-to-skin with their babies; around two-thirds of these preferences were met. Use of a birth plan for scheduled caesarean section supported women's ability to communicate their desires and choices, enhancing agency and reinforcing the significance of the caesarean birth experience. Qualitative data revealed two main categories: Perceptions and experiences; and Recommendations for improvement, with corresponding sub-categories.

DISCUSSION

Findings provide unique opportunities to consider the provision of woman-centred care within the highly technocratic perioperative environment.

CONCLUSION

All women, regardless of birth mode, have a right to respectful maternity care that prioritises their wishes and agency. This study provides evidence for the positive utility of birth plans in caesarean birth, local adaptation is encouraged.

Efectividad de la autotoma del exudado vaginorrectal para el cribado prenatal de la infección por Streptococcus agalactiae. Estudio GALL

Objetivo

Evaluar la efectividad de la autotoma del exudado vaginorrectal para el cribado prenatal de la infección por EGB e identificar barreras y facilitadores que encuentra la gestante para esta intervención.

Diseño

Estudio transversal de pruebas diagnósticas.

Participantes y emplazamiento

Participaron 213 gestantes que acudieron a la consulta de la matrona de atención primaria en 6 centros de salud del Servicio Vasco de Salud/Osakidetza en Bizkaia, que cumplían los criterios de inclusión y aceptaban participar en el estudio.

Mediciones principales

Se comparó el resultado del cultivo vaginorrectal obtenido por la gestante con el resultado del cultivo vaginorrectal tomado por la matrona en consulta el mismo día, y se recogieron barreras y facilitadores encontrados por las mujeres en la autotoma.

Resultados

Se ha observado que la autotoma como prueba para detectar el EGB tiene una sensibilidad del 93,3% (IC 95%, 78,7-98,2), una especificidad del 99,4% (IC 95%, 96,5-99,9), un valor predictivo positivo del 96% (IC 95% 82,8-99,4) y un valor predictivo negativo del 98,8% (IC 95%, 95,6-99,7). El 27,3% de los encuestadas encontraron alguna dificultad en la recogida, solo el 4,8% no se vieron capacitadas, el 84,2% se sintieron cómodas, el 99,5% consideraron la información proporcionada adecuada y completa, al 94,7% no le resultaron complicados los pasos a seguir, y el 96% están satisfechas con el estudio.

Conclusiones

La autotoma del exudado vaginorrectal para la detección del EGB ha resultado ser válida y fiable, lo que permitiría ofrecer esta opción a las gestantes en el cribado sistemático de la infección por EGB.

The Birth Plan Experience—A Pilot Qualitative Study in Southern Spain

Background: Healthcare systems advocate for quality care and humanized relations in routine birth care, and have therefore created the Birth Plan, a document available to pregnant women to state their preferences in relation to the birth process. Methods: This qualitative research with a phenomenological design was carried out to record the experiences of women who presented a Birth Plan. Sample selection was carried out using non-probabilistic, intentional and convenience sampling, selecting seven participants who were willing to participate and share their experiences. Results: After analyzing the content of the interviews, four categories emerged: “respecting the woman’s wishes: humanizing the birth process”, “information and primary Care”, “expectations regarding the care received” and “results of using the birth plan”, with their corresponding subcategories. Conclusion: Women consider it beneficial to present a Birth Plan, because it informs them about the process and gives them the opportunity to have a better experience, which takes into account their preferences for making the delivery less instrumental. In addition, they state the importance of having trained professionals involved, and call for more attention to be paid to the birth process in general.