The Mother's Autonomy in Decision Making (MADM) scale: Patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care

Shared decision-making in maternity care in Saudi Arabia: A cross-sectional study

BACKGROUND

Shared decision-making (SDM) in maternity care involves women actively in decisions, thereby reducing decisional conflicts and enhancing satisfaction with care.

AIM

To investigate SDM and the factors associated with it, and its correlation with respect in maternity care in Saudi Arabia.

METHODS

A comprehensive, nationwide online questionnaire-based study was conducted between January to May 2023, involving women aged 18 years and above who were either pregnant or had experienced pregnancy/childbirth in the past 12 months. The Mothers' Autonomy in Decision-Making (MADM) scale and the Mothers of Respect Index (MORi) were used. Low to very low SDM was defined as a score of ≤ 24 on the MADM and low to very low respected was defined as a score of ≤ 49 on the MORi.

RESULTS

A total of 505 women completed the survey. Low to very low SDM was reported by 137 (34.1 %, 95 confidence interval (CI), 29.6 % - 38.9 %) women. Factors significantly associated with low to very low SDM included seeing different obstetricians of different gender at each visit (adjusted odds ratio (AOR) 2.0, 95 % CI, 1.0 - 3.9), not meeting the same obstetrician throughout the pregnancy (AOR 2.6, 95 % CI, 1.2 - 5.6) and having an instrumental vaginal birth (AOR 6.67, 95 % CI, 1.6 - 28.1). There was a positive association between low to very SDM and feeling of low to very low respect ((χ2 = 83.8173, p < 0.001).

CONCLUSION

More than one-third of women experienced low to very low SDM in maternity care. This should alert healthcare providers to the importance of continuity of care in Saudi Arabia.

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.

Autonomy and Respect in Pregnancy Care for LGBTQIA+ Families: Evaluation of a Home Visiting Program

The purpose of this program evaluation was to gather information on proportions of LGBTQIA+ individuals and families, their needs, and care experiences in a county health department's home visiting programs for perinatal clients and to make recommendations for improving culturally competent care for LGBTQIA+ individuals and families. In this engaged scholarship partnership, home visiting nurses administered a questionnaire to perinatal clients including demographic information on sexual orientation and gender identity. Differences between LBGTQIA+ identifying individuals' perception of the perinatal care received and those of heterosexual, cisgender individuals were assessed. On the basis of these data, 10% of the 52 respondents identified as LGBTQIA+ and 4% identified with a gender other than "woman." Clients who identified as straight had similar mean scores to those who listed an LGBTQIA+ sexual orientation. Clients who chose a gender identity other than "woman" had scores that fell within the 50th to 75th percentile of the overall mean. Qualitative interviews with 2 respondents provided additional in-depth information on their experiences. Overall, clients served by these perinatal programs reported similar diversity in terms of gender identity and sexual orientation as compared with national averages. This project provided evidence of the diversity among the clientele served by this agency and the importance of expanding the focus on inclusionary language and practices.

Assessing patient autonomy in the context of TeamBirth, a quality improvement intervention to improve shared decision-making during labor and birth

BACKGROUND

Respectful maternity care includes shared decision-making (SDM). However, research on SDM is lacking from the intrapartum period and instruments to measure it have only recently been developed. TeamBirth is a quality improvement initiative that uses team huddles to improve SDM during labor and birth. Team huddles are structured meetings including the patient and full care team when the patient's preferences, care plans, and expectations for when the next huddle will occur are reviewed.

METHODS

We used patient survey data (n = 1253) from a prospective observational study at four U.S. hospitals to examine the relationship between TeamBirth huddles and SDM. We measured SDM using the Mother's Autonomy in Decision-Making (MADM) scale. Linear regression models were used to assess the association between any exposure to huddles and the MADM score and between the number of huddles and the MADM score.

RESULTS

In our multivariable model, experiencing a huddle was significantly associated with a 3.13-point higher MADM score. When compared with receiving one huddle, experiencing 6+ huddles yielded a 3.64-point higher MADM score.

DISCUSSION

Patients reporting at least one TeamBirth huddle experienced significantly higher SDM, as measured by the MADM scale. Our findings align with prior research that found actively involving the patient in their care by creating structured opportunities to discuss preferences and choices enables SDM. We also demonstrated that MADM is sensitive to hospital-based quality improvement, suggesting that future labor and birth interventions might adopt MADM as a patient-reported experience measure.

Pregnant women autonomy when choosing their method of childbirth: Scoping review

This paper has as its theme the autonomy of pregnant women in relation to choosing the method of birth for their child. The objective was to carry out a scoping review to study the literature and evidence of how autonomy is being offered to parturient women. Study design and location: In October 2023, a search was carried out using the terms "pregnant women" AND "delivery" AND "autonomy" in the following databases: PubMed, Web of Science, Scopus, Scielo and LILACS. The search included articles from 2016 to 2023. Of the 179 articles found, 15 met the criteria and were selected for this review. Results: the pregnant woman's autonomy in choosing the method of childbirth is influenced by several factors, such as the obstetrician's recommendation, the medical team, and negative and positive experiences. Thus, when this autonomy is shared with the obstetrician, the obstetrician recommends cesarean section as the safest route, but does not explain the benefits and harms of both routes (vaginal and cesarean section), causing the woman to accept the cesarean section. Midwives recommend vaginal birth because they believe it to be natural and safe and explain the benefits and harms of both methods, respecting the pregnant woman's choice of the method she prefers. Conclusion: women have the fundamental right to choose their method of birth and must be properly guided throughout prenatal care, whether by an obstetrician or a midwife, about the options, risks and benefits of each method of childbirth, respecting the ethical principle of beneficence.

Validation of the Greek version of Mother's Autonomy in Decision Making (MADM) scale

INTRODUCTION

Ensuring expectant mothers have the capacity to make well-informed decisions regarding their prenatal care, encompassing medical interventions, and birthing preferences are crucial for fostering favorable health outcomes for both mother and newborn. The Mother's Autonomy in Decision Making (MADM) scale serves as a commonly utilized tool for evaluating the autonomy of pregnant women in the decision-making processes related to prenatal care and childbirth. The aim of this study is to validate the MADM scale in women who had at least one home childbirth experience in Greece.

METHODS

A retrospective online survey collected data from Greek women with home childbirth experience (January 2010 - December 2023). We utilized a self-administered questionnaire and the Greek version of the MADM scale.

RESULTS

The study included 162 women, predominantly of Greek nationality (94.4%) and residing in Attica (54%). The MADM scale showed a median score of 38. The confirmatory factor analysis indicated acceptable fit and reliability (comparative fit index, CFI=0.92; Tucker-Lewis index, TLI=0.91; root mean square error of approximation, RMSEA=0.07; Cronbach's α=0.92). Age correlated weakly negatively with the MADM scale score (Spearman's rho= -0.166, p=0.035). Additionally, women attending antenatal preparation courses with a midwife before their first home birth had higher MADM scores (median 39 vs 35, p=0.037).

CONCLUSIONS

The study underscores the importance of the MADM scale, demonstrating its reliability and validity for women living in Greece. Younger age and attending antenatal preparation courses with a midwife were associated with higher MADM scores, highlighting education's role in maternal autonomy.

Dehumanized, Violated, and Powerless: An Australian Survey of Women's Experiences of Obstetric Violence in the Past 5 Years

Globally, significant numbers of women report obstetric violence (OV) during childbirth. The United Nations has identified OV as gendered violence. OV can be perpetrated by any healthcare professional (HCP) and is impacted by systemic issues such as HCP education, staffing ratios, and lack of access to continuity of care. The current study explored the experiences of OV reported in a national survey in 2021 by Australian women who had a baby in the previous 5 years. A content analysis of 626 open text comments found three main categories: "I felt dehumanised," "I felt violated," and "I felt powerless." Women reported bullying, coercion, non-empathic care, and physical and sexual assault. Disrespect and abuse and non-consented vaginal examinations were the subcategories with the most comments.

"I had no choice": A mixed-methods study on access to care for vaginal breech birth

INTRODUCTION

Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth.

METHODS

We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care.

RESULTS

Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system.

CONCLUSION

Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

When addressing resources is not enough: lessons learned from a respectful maternal and neonatal care provider training intervention evaluation in Kenya and Tanzania

BACKGROUND

Respectful Maternal and Neonatal Care (RMNC) maintains and respects a pregnant person's dignity, privacy, informed choice, and confidentiality free from harm and mistreatment. It strives for a positive pregnancy and post-pregnancy care experiences for pregnant people and their families, avoiding any form of obstetric violence. Though RMNC is now widely accepted as a priority in obstetric care, there is a gap in resources and support tools for healthcare wproviders to clearly understand the issue and change long-established practices such as non-humanized caesarean sections. MSI Reproductive Choices (MSI) manages 31 maternities across 7 countries with a zero-tolerance approach towards disrespectful maternity care and obstetric violence. MSI developed and implemented a hybrid training package, which includes an online module and 1-day in-person workshop that allows healthcare providers to explore their beliefs and attitudes towards RMNC. It leverages methodologies used in Values-Clarification-Attitudes-Transformation (VCAT) workshops and behaviour change approaches.

METHODS

The impact of this training intervention was measured from the healthcare providers' and patients' perspectives. Patient experience of (dis)respectful care was collected from a cross-sectional survey of antenatal and postnatal patients attending MSI maternities in Kenya and Tanzania before and following the RMNC training intervention. Healthcare providers completed pre- and post-workshop surveys at day 1, 90 and 180 to measure any changes in their knowledge, attitudes and perception of intended behaviours regarding RMNC.

RESULTS

The results demonstrate that healthcare provider knowledge, attitudes and perceived RMNC practices can be improved with this training interventions. Patients also reported a more positive experience of their maternity care following the training.

CONCLUSION

RMNC is a patient-centred care priority in all MSI maternities. The training bridges the gap in resources currently available to support changes in healthcare wproviders' attitudes and behaviours towards provision of RMNC. Ensuring health system infrastructure supports compassionate obstetric care represents only the first step towards ensuring RMNC. The results from the evaluation of this RMNC provider training intervention demonstrates how healthcare provider knowledge and attitudes may represent a bottleneck to ensuring RMNC that can be overcome using VCAT and behaviour change approaches.

Patient-centered respectful maternity care: a factor analysis contextualizing marginalized identities, trust, and informed choice

BACKGROUND

Increasing rates of maternal mortality and morbidity, coupled with ever-widening racial health disparities in maternal health outcomes, indicate that radical improvements need to be made in the delivery of maternity care. This study explored the provision of patient-centered maternity care from the perspective of pregnant and postpartum people; experiences of respect and autonomy were examined through the multi-dimensional contexts of identity, relational trust, and protection of informed choices.

METHODS

We conducted primary data collection among individuals who experienced a pregnancy in the five years preceding the survey (N = 484) using the validated Mothers on Respect Index (MORi) and Mothers Autonomy in Decision Making (MADM) scale. We conducted an exploratory factor analysis (EFA) which produced three factor variables: trust, informed choice, and identity. Using these factor variables as dependent variables, we conducted bivariate and multivariate analysis to examine the relationship between these factor variables and social marginalization, as measured by race, disability, justice-involvement, and other social risk factors, such as food and housing insecurity.

RESULTS

Results of our bivariate and multivariate models generally confirmed our hypothesis that increased social marginalization would be associated with decreased experiences of maternity care that was perceived as respectful and protective of individual autonomy. Most notably, AI/AN individuals, individuals who are disabled, and individuals who had at least one social risk factor were more likely to report experiencing identity-related disrespect and violations of their autonomy.

CONCLUSIONS

In light of the findings that emphasize the importance of patient identity in their experience in the healthcare system, patient-centered and respectful maternity care must be provided within a broader social context that recognizes unequal power dynamics between patient and provider, historical trauma, and marginalization. Provider- and facility-level interventions that improve patient experiences and health outcomes will be more effective if they are contextualized and informed by an understanding of how patients' identities and traumas shape their healthcare experience, health-seeking behaviors, and potential to benefit from clinical interventions and therapies.

Incorporating co-design principles and social media strategies to enhance cross-sectional online survey participation: The Birth Experience Study

AIM

To use co-design principles to design a nationwide maternity experiences survey and to distribute the survey through social media.

DESIGN

A co-designed, cross sectional, and national online survey.

METHODS

Using co-design principles from study design and throughout the research process a cross-sectional, online, national survey of Australian women's experiences of maternity care was designed. Four validated survey instruments were included in the survey design.

RESULTS

An extensive social media strategy was utilized, which included paid advertising, resulting in 8804 surveys for analysis and 54,896 comments responding to open text questions.

DISCUSSION

The inclusion of co-design principles contributed to a well-designed survey and consumer involvement in distribution and support of the online survey. The social media distribution strategy contributed to high participation rates with overall low marketing costs.

CLINICAL RELEVANCE

Maternity services should be designed to provide woman-centered, individualized care. This survey was co-designed with maternity users and maternity organizations to explore women's recent experiences of maternity care in Australia. The outcomes of this study will highlight the factors that contribute to positive and negative experiences in maternity services.

PATIENT OR PUBLIC CONTRIBUTION

As a co-designed study, there was consumer engagement from the design of the study, throughout the research process.

In search of respect and continuity of care: Hungarian women's experiences with midwifery-led, community birth

INTRODUCTION

To describe and compare intervention rates and experiences of respectful care when Hungarian women opt to give birth in the community.

METHODS

We conducted a cross-sectional online survey (N = 1257) in 2014. We calculated descriptive statistics comparing obstetric procedure rates, respectful care indicators, and autonomy (MADM scale) across four models of care (public insurance; chosen doctor or chosen midwife in the public system; private midwife-led community birth). We used an intention-to-treat approach. After adjusting for social and clinical covariates, we used logistic regression to estimate the odds of obstetric procedures and disrespectful care and linear regression to estimate the level of autonomy (MADM scale).

FINDINGS

In the sample, 99 (7.8%) saw a community midwife for prenatal care. Those who planned community births had the lowest rates of cesarean at 9.1% (public: 30.4%; chosen doctor: 45.2%; chosen midwife 16.5%), induced labor at 7.1% (public: 23.1%; chosen doctor: 26.0%; chosen midwife: 19.4%), and episiotomy at 4.44% (public: 62.3%; chosen doctor: 66.2%; chosen midwife: 44.9%). Community birth clients reported the lowest rates of disrespectful care at 25.5% (public: 64.3%; chosen doctor: 44.3%; chosen midwife: 38.7%) and the highest average MADM score at 31.5 (public: 21.2; chosen doctor: 25.5; chosen midwife: 28.6). In regression analysis, community midwifery clients had significantly reduced odds of cesarean (0.35, 95% CI 0.16-0.79), induced labor (0.27, 95% CI 0.11-0.67), episiotomy (0.04, 95% CI 0.01-0.12), and disrespectful care (0.36, 95% CI 0.21-0.61), while also having significantly higher average MADM scores (5.71, 95% CI 4.08-7.36).

CONCLUSIONS

Hungarian women who plan to give birth in the community have low obstetric procedure rates and report greater respect, in line with international data on the effects of place of birth and model of care on experiences of perinatal care.

Respectful Maternity Care : A Systematic Review

BACKGROUND

Severe maternal morbidity and mortality are worse in the United States than in all similar countries, with the greatest effect on Black women. Emerging research suggests that disrespectful care during childbirth contributes to this problem.

PURPOSE

To conduct a systematic review on definitions and valid measurements of respectful maternity care (RMC), its effectiveness for improving maternal and infant health outcomes for those who are pregnant and postpartum, and strategies for implementation.

DATA SOURCES

Systematic searches of Ovid Medline, CINAHL, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, and SocINDEX for English-language studies (inception to July 2023).

STUDY SELECTION

Randomized controlled trials and nonrandomized studies of interventions of RMC versus usual care for effectiveness studies; additional qualitative and noncomparative validation studies for definitions and measurement studies.

DATA EXTRACTION

Dual data abstraction and quality assessment using established methods, with resolution of disagreements through consensus.

DATA SYNTHESIS

Thirty-seven studies were included across all questions, of which 1 provided insufficient evidence on the effectiveness of RMC to improve maternal outcomes and none studied RMC to improve infant outcomes. To define RMC, authors identified 12 RMC frameworks, from which 2 main concepts were identified: disrespect and abuse and rights-based frameworks. Disrespect and abuse components focused on recognizing birth mistreatment; rights-based frameworks incorporated aspects of reproductive justice, human rights, and antiracism. Five overlapping framework themes include freedom from abuse, consent, privacy, dignity, communication, safety, and justice. Twelve tools to measure RMC were validated in 24 studies on content validity, construct validity, and internal consistency, but lack of a gold standard limited evaluation of criterion validity. Three tools specific for RMC had at least 1 study demonstrating consistency internally and with an intended construct relevant to U.S. settings, but no single tool stands out as the best measure of RMC.

LIMITATIONS

No studies evaluated other health outcomes or RMC implementation strategies. The lack of definition and gold standard limit evaluation of RMC tools.

CONCLUSION

Frameworks for RMC are well described but vary in their definitions. Tools to measure RMC demonstrate consistency but lack a gold standard, requiring further evaluation before implementation in U.S. settings. Evidence is lacking on the effectiveness of implementing RMC to improve any maternal or infant health outcome.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42023394769).

A content analysis of women's experiences of different models of maternity care: the Birth Experience Study (BESt)

BACKGROUND

Pregnancy, birth, and early parenthood are significant life experiences impacting women and their families. Growing evidence suggests models of maternity care impact clinical outcomes and birth experiences. The aim of this study was to explore the strengths and limitations of different maternity models of care accessed by women in Australia who had given birth in the past 5 years.

METHODS

The data analysed and presented in this paper is from the Australian Birth Experience Study (BESt), an online national survey of 133 questions that received 8,804 completed responses. There were 2,909 open-ended comments in response to the question on health care provider/s. The data was analysed using content analysis and descriptive statistics.

RESULTS

In models of fragmented care, including standard public hospital care (SC), high-risk care (HRC), and GP Shared care (GPS), women reported feelings of frustration in being unknown and unheard by their health care providers (HCP) that included themes of exhaustion in having to repeat personal history and the difficulty in navigating conflicting medical advice. Women in continuity of care (CoC) models, including Midwifery Group Practice (MGP), Private Obstetric (POB), and Privately Practising Midwifery (PPM), reported positive experiences of healing past birth trauma and care extending for multiple births. Compared across models of care in private and public settings, comments in HRC contained the lowest percentage of strengths (11.94%) and the highest percentage of limitations (88.06%) while comments in PPM revealed the highest percentage of strengths (95.93%) and the lowest percentage of limitations (4.07%).

CONCLUSIONS

Women across models of care in public and private settings desire relational maternity care founded on their unique needs, wishes, and values. The strengths of continuity of care, specifically private midwifery, should be recognised and the limitations for women in high risk maternity care investigated and prioritised by policy makers and managers in health services.

TRIAL REGISTRATION

The study is part of a larger project that has been retrospectively registered with OSF Registries Registration DOI https://doi.org/10.17605/OSF.IO/4KQXP .

Autonomy in labour and delivery in a Latin American urban centre: a qualitative phenomenological analysis

The medicalisation of childbirth has diminished the role of labouring people. We conducted an exploratory phenomenological qualitative study, using purposive sampling, and then conducted 17 semi-structured interviews between December 2016 and October 2017 with people who had recently given birth in a public hospital in the Northern Metropolitan area of Santiago, Chile. The sufficiency of the study group was determined according to saturation criteria. Triangulated content analysis was applied to explore the clinical relationship and processes of autonomy and decision-making. The predominant clinical relationship observed was paternalism. The participation of labouring people in decision-making is scarce, with no evidence of ethically valid processes of informed consent.

Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review

BACKGROUND

Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.

METHODS

Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.

RESULTS

More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.

CONCLUSION

A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.

Validation of a measure to assess decision-making autonomy in family planning services in three low- and middle-income countries: The Family Planning Autonomous Decision-Making scale (FP-ADM)

BACKGROUND

Integrating measures of respectful care is an important priority in family planning programs, aligned with maternal health efforts. Ensuring women can make autonomous reproductive health decisions is an important indicator of respectful care. While scales have been developed and validated in family planning for dimensions of person-centered care, none focus specifically on decision-making autonomy. The Mothers Autonomy in Decision-Making (MADM) scale measures autonomy in decision-making during maternity care. We adapted the MADM scale to measure autonomy surrounding a woman's decision to use a contraceptive method within the context of contraceptive counselling. This study presents a psychometric validation of the Family Planning Autonomous Decision-Making (FP-ADM) scale using data from Argentina, Ghana, and India.

METHODS AND FINDINGS

We used cross-sectional data from women in four subnational areas in Argentina (n = 890), Ghana (n = 1,114), and India (n = 1,130). In each area, 20 primary sampling units (PSUs) were randomly selected based on probability proportional to size. Households were randomly selected in Ghana and India. In Argentina, all facilities providing reproductive and maternal health services within selected PSUs were included and women were randomly selected upon exiting the facility. Interviews were conducted with a sample of 360 women per district. In total, 890 women completed the FP-ADM in Argentina, 1,114 in Ghana and 1,130 in India. To measure autonomous decision-making within FP service delivery, we adapted the items of the MADM scale to focus on family planning. To assess the scale's psychometric properties, we first examined the eigenvalues and conducted a parallel analysis to determine the number of factors. We then conducted exploratory factor analysis to determine which items to retain. The resulting factors were then identified based on the corresponding items. Internal consistency reliability was assessed with Cronbach's alpha. We assessed both convergent and divergent construct validity by examining associations with expected outcomes related to the underlying construct. The Eigenvalues and parallel analysis suggested a two-factor solution. The two underlying dimensions of the construct were identified as "Bidirectional Exchange of Information" (Factor 1) and "Empowered Choice" (Factor 2). Cronbach's alpha was calculated for the full scale and each subscale. Results suggested good internal consistency of the scale. There was a strong, significant positive association between whether a woman expressed satisfaction with quality of care received from the healthcare provider and her FP-ADM score in all three countries and a significant negative association between a woman's FP-ADM score and her stated desire to switch contraceptive methods in the future.

CONCLUSIONS

Our results suggest the FP-ADM is a valid instrument to assess decision-making autonomy in contraceptive counseling and service delivery in diverse low- and middle-income countries. The scale evidenced strong construct, convergent, and divergent validity and high internal consistency reliability. Use of the FP-ADM scale could contribute to improved measurement of person-centered family planning services.

Measuring disrespect and abuse during childbirth in a high-resource country: Development and validation of a German self-report tool

INTRODUCTION

Increasing evidence on disrespect and abuse during childbirth has led to growing concern about the quality of care childbearing women are experiencing. To provide quantitative evidence of disrespect and abuse during childbirth services in Germany a validated measurement tool is needed.

RESEARCH AIM

The aim of this research project was the development and psychometric validation of a survey tool in the German language that measures disrespect and abuse of women during childbirth.

METHODS

A survey tool was created including the following measures: German adaptations of the short and long form of the "Mothers on Respect" (MOR) index (MOR-7 and MOR-G); the "Mothers' Autonomy in Decision Making" (MADM) scale; a mistreatment-index (MIST-I) comprising indicators of mistreatment during childbirth; and a set of items that measure experiences of discrimination during maternity care. Internal consistency reliability and construct validity of the scales were assessed using Cronbach's alpha, unweighted least squares factor analysis and non-parametric correlation analysis with a scale that measures a related construct, the Posttraumatic Symptom Scale - Self Report (PSS-SR) scale. We distributed the survey online, recruiting through snowball sampling via social media. A selection bias towards women who had experienced disrespect and abuse during their birth was intended and expedient for tool validation. The final sample of participants (n = 2045) had given birth in Germany between 2009 and 2018.

FINDINGS

More than 77% of the study participants reported at least one form of mistreatment with non-consented care being the most commonly reported type of mistreatment, followed by physical violence, violation of physical privacy, verbal abuse and neglect. All included scales showed good psychometric properties with high Cronbach's alphas (0.95 for both MOR versions and 0.96 for MADM). Factor analysis generated one factor scales with high factor loadings (0.75 to 0.92 for MOR-7; 0.37 to 0.90 for MOR-G and 0.83 to 0.92 for MADM). MOR-7, MOR-G, MADM and MIST-I scores were significantly (p<0.001) correlated with PSS-SR scores (Spearman's rho -0.70, -0.61 and 0.68 for MOR-G, MADM and the MIST-I, respectively).

CONCLUSIONS

This study presents a valid and reliable instrument for the quantitative assessment of disrespect and abuse during childbirth in Germany. Childbearing women's experiences of disrespect and abuse are a relevant phenomenon in German hospital based maternity care. Disrespect and abuse during childbirth appear to contribute to post-traumatic symptoms and may be associated with severe mental health problems postpartum.

Development and psychometric properties of the Respectful Maternity Care Scale (RMCS)

AIMS/BACKGROUND

The Respectful Maternity Care Scale (RMCS) was developed specifically to assess the health care that women receive during pregnancy, labour and the postnatal period. The aim of this study was to investigate the validity and reliability of the RMCS.

DESIGN/METHODS

This study used a methodological design. The RMCS, a self-report instrument, was developed in consultation with professionals and women who had given birth, based on the literature. It was tested for content and construct validity. Reliability was assessed using Cronbach's alpha, test-retest method, and adjusted item-total correlation. The study sample consisted of 405 women between 6 weeks and 12 months postpartum who were admitted to a family health centre in Istanbul between April and June 2023.

RESULTS

The scale's content validity index is 0.92. The scale consists of 29 items and 3 sub-dimensions, which explain 61% of the total variance. χ2/df was less than 5 and RMSEA was less than 0.08, which confirms the validity of this model. The corrected item-total correlations were acceptable, and the Cronbach's alpha coefficient was 0.96.

CONCLUSION

The RMCS has been shown to be valid and reliable and can be used to assess respectful maternity care among Turkish women.

Measuring women's experiences during antenatal care (ANC): scoping review of measurement tools

BACKGROUND

The new WHO model for antenatal care (ANC) focuses on improving practice, organisation and delivery of ANC within health systems, which includes both clinical care and women's experiences of care. The goal of this review is to identify tools and measures on women's experiences of ANC.

METHODS

We conducted a scoping review to identify tools and measures on women's experiences of ANC. An iterative approach was used to review all tools in a series of four steps: (1) identify papers between 2007 and 2023; (2) identify the tools from these papers; (3) map relevant measures to conceptualizations of experiences of care, notably mistreatment of women and respectful maternity care and (4) identify gaps and opportunities to improve measures.

RESULTS

Across the 36 tools identified, a total of 591 measures were identified. Of these, 292/591 (49.4%) measures were included and mapped to the typology of mistreatment of women used as a definition for women's experiences care during ANC in this review, while 299/591 (44.9%) irrelevant measures were excluded. Across the included measures, the highest concentration was across the domains of poor rapport between women and providers (49.8%) followed by failure to meet professional standards of care (23.3%). Approximately, 13.9% of measures were around overall respectful care, followed by health systems (6.3%), and any  physical or verbal abuse, stigma and/or discrimination (4.8%) .

CONCLUSION

This analysis provides an overview of the existing tools, gaps and opportunities to measure women's experiences during ANC. Expanding beyond the childbirth period, these findings can be used to inform existing and future tools for research and monitoring measuring women's experiences of ANC.

Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts

OBJECTIVE

The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative.

METHODS

Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle.

RESULTS

Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle.

CONCLUSION

Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.

Multilevel Community Engagement to Inform a Randomized Clinical Trial

OBJECTIVE

To explore how patients, community-based perinatal support professionals, and health system clinicians and staff perceived facilitators and barriers to implementation of a randomized clinical trial (RCT) designed to optimize Black maternal heart health.

METHODS

This article describes the formative work that we believed needed to occur before the start of the Change of H.E.A.R.T (Here for Equity, Advocacy, Reflection and Transformation) RCT. We used a qualitative, descriptive design and community-based, participatory approach, the latter of which allowed our team to intentionally focus on avoiding harm and equalizing power dynamics throughout the research process. Data were collected between November 2021 and January 2022 through six semistructured focus groups that included attending physicians and midwives (n=7), residents (n=4), nurses (n=6), support staff (n=7), community-based perinatal support professionals (n=6), and patients (n=8).

RESULTS

Four primary themes emerged. The first three themes were present across all groups and included: 1) Trauma in the Community and Health System, 2) Lack of Trust, and 3) Desire to Be Heard and Valued. The fourth theme, Hope and Enthusiasm, was expressed predominantly by patients, community-based perinatal support professionals, residents, and support staff, and less so by the attending physician group.

CONCLUSION

Participants articulated a number of key sentiments regarding facilitators and barriers to implementing Change of H.E.A.R.T. We noted variability in perceptions from different groups. This has important implications for health equity efforts in similarly underresourced health systems where Black birthing people experience the greatest morbidity and mortality.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT05499507.

Development, woman-centricity and psychometric properties of maternity patient-reported experience measures: a systematic review

OBJECTIVE

Valid and reliable maternity patient-reported experience measures are critical to understanding women's experiences of care. They can support clinical practice, health service and system performance measurement, and research. The aim of this review is to identify and critically appraise the risk of bias, woman-centricity (content validity), and psychometric properties of maternity patient-reported experience measures published in the scientific literature.

DATA SOURCES

MEDLINE, CINAHL Plus, PsycINFO, and Embase were systematically searched for relevant records between January 1, 2010 and July 10, 2021.

STUDY ELIGIBILITY CRITERIA

We searched for articles describing the instrument development of maternity patient-reported experience measures and measurement properties associated with instrument validity and reliability testing. Articles that described patient-reported experience measures developed outside of the maternity context and articles that did not contribute to the instruments' development, content validation, and/or psychometric evaluation were excluded.

METHODS

Included articles underwent risk of bias, content validity, and psychometric properties assessments in line with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidance. Patient-reported experience measure results were summarized according to language subgroups. An overall recommendation for use was determined for each patient-reported experience measure language subgroup.

RESULTS

A total of 54 studies reported on the development and psychometric evaluation of 25 maternity patient-reported experience measures, grouped into 45 language subgroups. The quality of evidence underpinning the instruments' development was generally poor. Only 2 (4.4%) patient-reported experience measures reported sufficient content validity, and only 1 (2.2%) received a level "A" recommendation, required for real-world use.

CONCLUSION

Maternity patient-reported experience measures demonstrated poor-quality evidence for their measurement properties and insufficient detail about content validity. Future maternity patient-reported experience measure development needs to prioritize women's involvement in deciding what is relevant, comprehensive, and comprehensible to measure. Improving the content validity of maternity patient-reported experience measures will improve overall validity and reliability and facilitate real-world practice improvements. Standardized patient-reported experience measure implementation also needs to be prioritized to support advancements in clinical practice for women.

What women want if they were to have another baby: the Australian Birth Experience Study (BESt) cross-sectional national survey

OBJECTIVES

To explore if Australian women would do anything differently if they were to have another baby.

DESIGN AND SETTING

The Birth Experience Study (BESt) online survey explored pregnancy, birth and postnatal experiences for women who had given birth during 2016-2021 in Australia.

PARTICIPANTS

In 2021, 8804 women responded to the BESt survey and 6101 responses to the open text responses to the survey question 'Would you do anything different if you were to have another baby?' were analysed using inductive content analysis.

RESULTS

A total of 6101 women provided comments in response to the open text question, resulting in 10 089 items of coding. Six categories were found: 'Next time I'll be ready' (3958, 39.2%) described how women reflected on their previous experience, feeling the need to better advocate for themselves in the future to receive the care or experience they wanted; 'I want a specific birth experience' (2872, 28.5%) and 'I want a specific model of care' (1796, 17.8%) highlighted the types of birth and health provider women would choose for their next pregnancy. 'I want better access' (294, 2.9%) identified financial and/or geographical constraints women experience trying to make choices for birth. Two categories included comments from women who said 'I don't want to change anything' (1027, 10.2%) and 'I don't want another pregnancy' (142, 1.4%). Most women birthed in hospital (82.9%) and had a vaginal birth (59.2%) and 26.7% had a caesarean.

CONCLUSION

Over 85% of comments left by women in Australia were related to making different decisions regarding their next birth choices. Most concerningly women often blamed themselves for not being more informed. Women realised the benefits of continuity of care with a midwife. Many women also desired a vaginal birth as well as better access to birthing at home.

Childbirth experience questionnaire 2 - Icelandic translation and validation

OBJECTIVE

The aim of this study was to translate the Childbirth Experience Questionnaire (CEQ2) to Icelandic and assess its psychometric characteristics.

METHODS

The CEQ2 was translated to Icelandic using forward-to-back translation and tested for face-validity (n = 10). Then data was collected in an online survey to test validation in terms of reliability and construct validity (n = 1125). Reliability was assessed by calculating Cronbach's alpha for the total scale and subscales. Cronbach's alpha > 0.7 was regarded as satisfactory. Construct validity was measured using known-groups validation with data collected on women's birth outcomes known to be associated with more positive birth experiences. A comparison was made of CEQ2 subscale scores and total CEQ2 score for country of origin, social complications, parity, pregnancy complications, birthplace, mode of birth, maternal autonomy and decision making (MADM), and mothers on respect index (MORi). Mann WhitneyUand Kruskal Wallis H tests were used to compare scale scores between the groups. Principal components analysis with varimax rotation was chosen to determine whether the Icelandic version of the CEQ had similar psychometric properties as the original version.

RESULTS

The face validity and internal consistency reliability (Cronbach's alpha > 0.85 for the total scale and all subscales) of the Icelandic version of CEQ2 was good. Our findings indicate that two of the items in the 'own capacity' domain were not sufficiently related to other items of the scale to warrant inclusion.

CONCLUSIONS

The Icelandic CEQ2 is a valid and reliable measure of childbirth experience but further work is needed to determine the optimal number of items and domains of the Icelandic CEQ2.

Person-centred sexual and reproductive health: A call for standardized measurement

Person-centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person-centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person-centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person-centred care across the SRH continuum. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.

WHEN REPRODUCTION IS NO LONGER AUTONOMOUS: FEELING RESPECTED BY MATERNITY CARE PROVIDERS MODERATES THE ASSOCIATION BETWEEN AUTONOMY IN DECISION MAKING AND BIRTH-RELATED PTSD SYMPTOMS IN A COMMUNITY SAMPLE OF POSTPARTUM BLACK WOMEN

Black individuals are at particularly high risk for birth-related posttraumatic stress disorder (PTSD) symptoms, in part due to a lack of opportunity to lead maternity care decisions. Maternal care providers need evidence-based ways to reduce pregnant persons' risk for birth-related PTSD symptoms despite reduced autonomy in decision making resulting from heightened restrictions on reproductive rights. We investigated whether a potential relation between autonomy in decision making and birth-related PTSD symptoms would be moderated by being mistreated or feeling respected by maternity care providers in a community sample of Black women (N = 52; Mage = 28.2 years, SDage = 5.7 years) seeking maternity care at a public hospital in the southeastern United States. At six weeks postpartum, participants completed measures assessing autonomy in decision making, current birth-related PTSD symptoms, number of mistreatment events, and feelings of respect from providers during pregnancy, childbirth, and the postpartum period. Autonomy in decision making was negatively correlated with birth-related PTSD symptoms, r=-.43, p < .01. An interaction between autonomy in decision making and mistreatment by providers was trending toward significance, B=-.23, SE=.14, p = .10. Autonomy in decision making and feeling respected by maternity care provider interacted to predict birth-related PTSD symptoms, B = .05, SE=.01, p < .01. Feeling respected by providers may buffer against the negative effects of lack of autonomy in decision making on birth-related PTSD symptoms, highlighting the importance of providers' ability to convey respect to pregnant patients when they cannot lead care decisions.

Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter?

BACKGROUND

Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality.

METHODS

We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains.

RESULTS

Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28).

CONCLUSION

Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

Midwifery care during labor and birth in the United States

The intrapartum period is a crucial time in the continuum of pregnancy and parenting. Events during this time are shaped by individuals' unique sociocultural and health characteristics and by their healthcare providers, practice protocols, and the physical environment in which care is delivered. Childbearing people in the United States have less opportunity for midwifery care than in other high-income countries. In the United States, there are 4 midwives for every 1000 live births, whereas, in most other high-income countries, there are between 30 and 70 midwives. Furthermore, these countries have lower maternal and neonatal mortality rates and have consistently lower costs of care. National and international evidences consistently report that births attended by midwives have fewer interventions, cesarean deliveries, preterm births, inductions of labor, and more vaginal births after cesarean delivery. In addition, midwifery care is consistently associated with respectful care and high patient satisfaction. Midwife-physician collaboration exists along a continuum, including births attended independently by midwives, births managed in consultation with a physician, and births attended primarily by a physician with a midwife acting as consultant on the normal aspects of care. This expert review defined midwifery care and provided an overview of midwifery in the United States with an emphasis on the intrapartum setting. Health outcomes associated with midwifery care, specific models of intrapartum care, and workforce issues have been presented within national and international contexts. Recommendations that align with the integration of midwifery have been suggested to improve national outcomes and reduce pregnancy-related disparities.

Respectful maternity care and women's autonomy in decision making in Iceland: Application of scale instruments in a cross-sectional survey

OBJECTIVE

To explore how maternal factors are associated with women's experiences of respect and autonomy in Icelandic maternity care.

DESIGN

An online survey was developed including two measures assessing the quality of perinatal care: the Mothers on Respect Index and the Mothers' Autonomy in Decision Making Scale. Median and interquartile ranges were calculated for both scales. Logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals to investigate the relationship between maternal factors and perceived low levels of respectful care and perceived low levels of autonomy in decision making.

PARTICIPANTS AND SETTING

A total of 1,402 women participated. Requirements were: Age ≥ 18 years; antenatal care and childbirth in Iceland 2015-2021; and fluency in Icelandic, English or Polish.

MEASUREMENTS AND FINDINGS

Perceived lower levels of respect were reported by migrant women [aOR 2.16 (1.55-3.00)], women with at least one social complication [aOR 2.52 (1.92-3.31)], primiparous women [aOR 1.72 (1.26-2.36)], women with at least one pregnancy complication [aOR 1.63 (1.22-2.18)] and those who gave birth by caesarean section [aOR 1.75 (1.25-2.45)]. Perceived lower levels of autonomy were reported by migrant women [aOR 1.42 (1.02-1.97)], women who had at least one social complication [aOR 2.12 (1.63-2.74)] and those who gave birth in a hospital setting [aOR 1.62 (1.03-2.55)].

KEY CONCLUSION

The results shed light on inequity in Icelandic maternity care and suggest that data from such surveys can provide valuable information on the changes that must be made in maternity health care services to ensure equity.

IMPLICATIONS FOR PRACTICE

Action must be taken to increase provision of respectful, woman-centred maternity care with an emphasis on informed decision making. Strategies to improve services for groups that have been socially marginalized, such as migrant women and women affected by social determinants of health, should be implemented and monitored.

Measuring women's empowerment during the perinatal period in high income countries: A scoping review of instruments used

Empowerment is acknowledged as a process facilitating those who are less powerful to be engaged in their problem identification, decision making and actions to gain control over their life. This is an important goal for women during the perinatal period in their transition to motherhood. A concept analysis of women's empowerment during the perinatal period found that psychological and social dimensions play a role in women's perinatal empowerment and identified several defining attributes. The aim of this study was to identify robust validated instruments that measure all the attributes of women's empowerment during the perinatal period. We did a scoping review of scientific literature following the methodology of the JBI Reviewer's Manual. We searched the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES and SocINDEX and selected papers meeting the inclusion criteria. Instruments measuring empowerment or related concepts were identified in the selected papers. Two authors independently cross referenced the items of each instrument against the defining attributes for empowerment. Our search resulted in 9771 unique hits of which 36 papers were finally included. Studies were from various countries with a wide variety of aims, demographics of cohorts and timepoints across the perinatal period. Twenty-one different instruments were used to measure empowerment, of which 11 were validated among women during the perinatal period. However, no identified instrument was developed specifically for women during the perinatal period or included all the dimensions of empowerment and the defining attributes. There is a need for a theoretically sound valid and reliable instrument measuring all the dimensions of empowerment of women during the perinatal period. Once developed this instrument needs testing with a broad range of women. Results from such a study will inform the development of appropriate interventions that have a coherent theoretical basis and are empirically informed to enhance women's empowerment during the perinatal period.

Health engagement: a systematic review of tools modifiable for use with vulnerable pregnant women

OBJECTIVE

To examine available health engagement tools suitable to, or modifiable for, vulnerable pregnant populations.

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Original studies of tool development and validation related to health engagement, with abstract available in English, published between 2000 and 2022, sampling people receiving outpatient healthcare including pregnant women.

DATA SOURCES

CINAHL Complete, Medline, EMBASE and PubMed were searched in April 2022.

RISK OF BIAS

Study quality was independently assessed by two reviewers using an adapted COSMIN risk of bias quality appraisal checklist. Tools were also mapped against the Synergistic Health Engagement model, which centres on women's buy-in to maternity care.

INCLUDED STUDIES

Nineteen studies were included from Canada, Germany, Italy, the Netherlands, Sweden, the UK and the USA. Four tools were used with pregnant populations, two tools with vulnerable non-pregnant populations, six tools measured patient-provider relationship, four measured patient activation, and three tools measured both relationship and activation.

RESULTS

Tools that measured engagement in maternity care assessed some of the following constructs: communication or information sharing, woman-centred care, health guidance, shared decision-making, sufficient time, availability, provider attributes, discriminatory or respectful care. None of the maternity engagement tools assessed the key construct of buy-in. While non-maternity health engagement tools measured some elements of buy-in (self-care, feeling hopeful about treatment), other elements (disclosing risks to healthcare providers and acting on health advice), which are significant for vulnerable populations, were rarely measured.

CONCLUSIONS AND IMPLICATIONS

Health engagement is hypothesised as the mechanism by which midwifery-led care reduces the risk of perinatal morbidity for vulnerable women. To test this hypothesis, a new assessment tool is required that addresses all the relevant constructs of the Synergistic Health Engagement model, developed for and psychometrically assessed in the target group.

PROSPERO REGISTRATION NUMBER

CRD42020214102.

Birth includes us: Development of a community-led survey to capture experiences of pregnancy care among LGBTQ2S+ families

BACKGROUND

Limited research captures the intersectional and nuanced experiences of lesbian, gay, bisexual, transgender, queer, two-spirit, and other sexual and gender-minoritized (LGBTQ2S+) people when accessing perinatal care services, including care for pregnancy, birth, abortion, and/or pregnancy loss.

METHODS

We describe the participatory research methods used to develop the Birth Includes Us survey, an online survey study to capture experiences of respectful perinatal care for LGBTQ2S+ individuals. From 2019 to 2021, our research team in collaboration with a multi-stakeholder Community Steering Council identified, adapted, and/or designed survey items which were reviewed and then content validated by community members with lived experience.

RESULTS

The final survey instrument spans the perinatal care experience, from preconception to early parenthood, and includes items to capture experiences of care across different pregnancy roles (eg, pregnant person, partner/co-parent, intended parent using surrogacy) and pregnancy outcomes (eg, live birth, stillbirth, miscarriage, and abortion). Three validated measures of respectful perinatal care are included, as well as measures to assess experiences of racism, discrimination, and bias across intersections of identity.

DISCUSSION AND CONCLUSIONS

By centering diverse perspectives in the review process, the Birth Includes Us instrument is the first survey to assess the range of experiences within LGBTQ2S+ communities. This instrument is ready for implementation in studies that seek to examine geographic and identity-based perinatal health outcomes and care experiences among LGBTQ2S+ people.

USING THE DELPHI METHOD TO VALIDATE INDICATORS OF RESPECTFUL MATERNITY CARE FOR HIGH RESOURCE COUNTRIES

Background and Purpose: Consistent measurement of respectful maternity care (RMC) is lacking. This Delphi study assessed consensus about indicators of RMC. Methods: A multidisciplinary panel assessed items (n = 201) drawn from global literature. Over two rounds, the panel rated importance, relevance, and clarity, and ranked priority within 17 domains including communication, autonomy, support, stigma, discrimination, and mistreatment. Qualitative feedback supported the analysis. Results: In Round One, 191 indicators exceeded a content validation index of 0.80. In Round Two, Kendall's W ranged from 0.081 (p = .209) to 0.425 (p < .001) across domains. Fourteen indicators received strong support. Changes in indicator assessment between rounds prevented agreement stability assessment. Conclusion: The indicators comprise a registry of items for use in perinatal care research.

A national survey of Australian midwives' birth choices and outcomes

BACKGROUND

Maternity care in Australia is predominantly provided by midwives, many who give birth. There is a paucity of research on midwives' own childbearing preferences and experiences.

AIM

To explore midwives childbirth preferences and outcomes when giving birth to their first child in Australia, after qualifying as a midwife.

METHODS

An online national survey. Data were analysed using descriptive statistics.

FINDINGS

447 midwives responded, with the majority of midwives indicating a preference for a normal vaginal birth with a known care provider under a continuity of midwifery care model. For midwives who were first time mothers, 66% had normal vaginal births, 16.3% had an instrumental birth, and 16.8% had caesarean births. Over 85% of midwives received the model of care they wanted and 45% had continuity of midwifery care. While a quarter of midwives wanted a homebirth,11.2% achieved this. Over three quarters (75.4%) of midwives were cared for by a care provider of their choosing.

DISCUSSION

There was a difference in models of care accessed and birth outcomes between midwives and other women giving birth for the first-time in Australia. Australian midwives appear to have the advantage of clinical and scientific knowledge to navigate the maternity care system to get the birth care and outcomes they want.

CONCLUSION

It is possible that professional experience, insider knowledge, and existing relationships with other midwifery friends and colleagues, affords midwives a higher degree of agency and autonomy when it comes to getting the maternity care and birth outcomes that they want.

Racial Disparities in Respectful Maternity Care During Pregnancy and Birth After Cesarean in Rural United States

OBJECTIVE

To describe the experiences of pregnancy and birth after cesarean of women who live in rural areas of the United States, including access to vaginal birth after cesarean (VBAC), type of maternity care provider, travel times, autonomy in decision making, and respectful maternity care.

DESIGN

Retrospective observational study.

SETTING

Online questionnaire of women who gave birth in the United States.

PARTICIPANTS

Women (N = 1,711) with histories of cesarean and subsequent births within 5 years of participating.

METHODS

We calculated descriptive and bivariate statistics by identified areas of residence and stratified measures of autonomy and respectful maternity care by self-identification as a member of a racialized group. We applied qualitative descriptive analysis to responses to an open-ended survey question.

RESULTS

A total of 299 (17.5%) participants identified their areas of residence as rural. Similar percentages of rural and metropolitan participants were able to plan VBAC (p = .88). More rural participants than metropolitan participants reported travel times of more than 60 minutes to give birth (p < .001), and fewer had obstetricians (p = .002) or doulas (p = .03). Rural participants from racialized groups experienced significantly less respectful maternity care than White, non-Hispanic rural participants and all metropolitan participants (p = .04). Qualitative data illustrating the main findings are included.

CONCLUSIONS

Our findings highlight challenges faced by rural residents accessing VBAC and help explain why rates of VBAC in rural areas remain low. We suggest a range of clinical and policy strategies to improve access to VBAC in rural areas and to improve the quality of maternity care for racialized women who live in rural areas.

The time is now: addressing implicit bias in obstetrics and gynecology education

Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.

A Qualitative Analysis on Sexual and Reproductive Health Needs and Issues During COVID-19 Using a Reproductive Justice Framework

The COVID-19 pandemic exacerbated existing health inequities, further exposing the challenges in meeting the sexual and reproductive health (SRH) needs, particularly for Black, Indigenous and People of Color (BIPOC). We interviewed 11 key informants through three focus groups to explore barriers and pathways to SRH care for BIPOC during COVID-19 in the United States. Reimagining reproductive health practices requires holistic practices and multisector pathways, a comprehensive reproductive justice approach. This includes interventions across the sexual and reproductive health continuum. Using a deductive-dominant approach grounded in reproductive justice values, we explore themes around SRH during COVID-19. Five themes for advancing reproductive justice were identified: "supremacy of birth"; police violence as a determinant of SR mental health; addressing quality of care outside of hospital settings; digital redlining; and centering joy, liberation, and humanity.

Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean

OBJECTIVE

High-quality, respectful maternity care has been identified as an important birth process and outcome. However, there are very few studies about experiences of care during a pregnancy and birth after a prior cesarean in the U.S. We describe quantitative findings related to quality of maternity care from a mixed methods study examining the experience of considering or seeking a vaginal birth after cesarean (VBAC) in the U.S.

METHODS

Individuals with a history of cesarean and recent (≤ 5 years) subsequent birth were recruited through social media groups to complete an online questionnaire that included sociodemographic information, birth history, and validated measures of respectful maternity care (Mothers on Respect Index; MORi) and autonomy in maternity care (Mother's Autonomy in Decision Making Scale; MADM).

RESULTS

Participants (N = 1711) representing all 50 states completed the questionnaire; 87% planned a vaginal birth after cesarean. The most socially-disadvantaged participants (those less educated, living in a low-income household, with Medicaid insurance, and those participants who identified as a racial or ethnic minority) and participants who had an obstetrician as their primary provider, a male provider, and those who did not have a doula were significantly overrepresented in the group who reported lower quality maternity care. In regression analyses, individuals identified as Black, Indigenous, and People of Color (BIPOC) were less likely to experience autonomy and respect compared to white participants. Participants with a midwife provider were more than 3.5 times more likely to experience high quality maternity care compared to those with an obstetrician.

CONCLUSION

Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Women’s experience of the decision-making process for home-based postnatal midwifery care when discharged early from hospital: A Swedish interview study

INTRODUCTION

Women and their families are often excluded from reproductive decision-making processes in postnatal care, and do not know which choices they have. Shared decision-making is a critical but challenging component of maternity care quality. The aim was to explore women’s experience of the decision-making process about early return from hospital with home-based postnatal midwifery care.

METHODS

This is a descriptive qualitative study. In total, 24 women participated in a semi-structured telephone interview, averaging 58 minutes. Data were analyzed using thematic analysis according to Braun and Clarke.

RESULTS

The main theme explored was ‘The supremacy of giving new mothers autonomy to decide on the postnatal care model they would prefer’. Important aspects of the women’s decision-making process were the time-point for receiving information about the home-based midwifery model of care, to receive sufficient time for consideration about the model, to have a rationale for choosing home-based care, and to comprehend the concept.

CONCLUSIONS

Women must be given sufficient time for consideration and necessary information about postnatal care models, which is essential for making an informed decision. Parents’ readiness for discharge must be identified by midwives who need to facilitate shared decision-making by introducing early postnatal care model choices, describe these options, and support women to explore their preferences. Midwives must ensure parents’ participation in decision-making for the time of discharge from hospital.

Agency in Contraceptive Decision-Making in Patient Care: a Psychometric Measure

BACKGROUND

Patient agency in contraceptive decision-making is an essential component of reproductive autonomy.

OBJECTIVE

We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist.

DESIGN

For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory-based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale.

PARTICIPANTS

A racially/ethnically diverse sample of 338 individuals, aged 15-34 years, receiving contraceptive care across nine California clinics in 2019-2020.

MAIN MEASURES

Contraceptive Agency Scale (CAS) of patient agency in preventive care.

KEY RESULTS

Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black, 10% Asian/Native Hawaiian/Pacific Islander. Scale items covered the domains of freedom from coercion, non-judgmental care, and active decision-making, and loaded on to a single factor, with a Cronbach's α of 0.80. Item responses fit a unidimensional partial credit item response model (weighted mean square statistic within 0.75-1.33 for each item), met criteria for internal structure validity, and showed no meaningful differential item functioning. Most participants expressed high agency in their contraceptive visit (mean score 9.6 out of 14). One-fifth, however, experienced low agency or coercion, with the provider wanting them to use a specific method or to make decisions for them. Agency scores were lowest among Asian/Native Hawaiian/Pacific Islander participants (adjusted coefficient: -1.5 [-2.9, -0.1] vs. White) and among those whose mothers had less than a high school education (adjusted coefficient; -2.1 [-3.3, -0.8] vs. college degree or more).

CONCLUSIONS

The Contraceptive Agency Scale can be used in research and clinical care to reinforce non-coercive service provision as a standard of care.

Integrating women's voices in quality improvement for maternity care: A qualitative study

INTRODUCTION

Improving the quality of maternity care is high on the national agenda in the Netherlands. One aspect gaining significant attention is integrating women's experiences - as users of maternity care - in this quality improvement. The aim of this study was to gain deeper insights into how maternity care professionals in Dutch Maternity Care Collaborations integrate women's voices into quality improvement as part of integrated maternity care and what role midwives can have in this.

METHODS

This was a descriptive qualitative study, using semi-structured individual interviews and content analysis for an in-depth exploration of maternity care professionals' experiences and opinions on integrating women's voices in quality improvement. Participants were twelve maternity care professionals involved in quality improvement activities from eight Dutch Maternity Care Collaborations.

RESULTS

Four themes emerged: 'Quality improvement based on women's voices is still in its infancy' and was experienced as an important but challenging topic; 'Collecting women's voices' was conducted, but needed more facilitation; Using women's voices' was hindered by a lack of expertise and a structured feedback and feedforward system; and 'Ensuring listening to women's voices' and integrating them in quality improvement required further facilitation.

CONCLUSIONS

Care professionals emphasized that listening to women's voices for quality improvement is important but challenging due to the lack of expertise, organizational structure, time, and financial resources. A feasible implementation strategy including concrete support is recommended by maternity care professionals to boost action.

Psychometric validation of a patient-reported experience measure of obstetric racism© (The PREM-OB Scale™ suite)

BACKGROUND

Perinatal quality improvement lacks valid tools to measure adverse hospital experiences disproportionately impacting Black mothers and birthing people. Measuring and mitigating harm requires using a framework that centers the lived experiences of Black birthing people in evaluating inequitable care, namely, obstetric racism. We sought to develop a valid patient-reported experience measure (PREM) of Obstetric Racism^© in hospital-based intrapartum care designed for, by, and with Black women as patient, community, and content experts.

METHODS

PROMIS© instrument development standards adapted with cultural rigor methodology. Phase 1 included item pool generation, modified Delphi method, and cognitive interviews. Phase 2 evaluated the item pool using factor analysis and item response theory.

RESULTS

Items were identified or written to cover 7 previously identified theoretical domains. 806 Black mothers and birthing people completed the pilot test. Factor analysis concluded a 3 factor structure with good fit indices (CFI = 0.931-0.977, RMSEA = 0.087-0.10, R²  > .3, residual correlation < 0.15). All items in each factor fit the IRT model and were able to be calibrated. Factor 1, "Humanity," had 31 items measuring experiences of safety and accountability, autonomy, communication, and empathy. A 12-item short form was created to ease respondent burden. Factor 2, "Racism," had 12 items measuring experiences of neglect and mistreatment. Factor 3, "Kinship," had 7 items measuring hospital denial and disruption of relationships between Black mothers and their child or support system.

CONCLUSIONS

The PREM-OB Scale™ suite is a valid tool to characterize and quantify obstetric racism for use in perinatal improvement initiatives.

Reliability and Validity of a Perinatal Shared Decision-Making Measure: The Childbirth Options, Information, and Person-Centered Explanation

OBJECTIVE

To develop and test the psychometric properties of a shared decision-making tool: Childbirth Options, Information, and Person-Centered Explanation (CHOICEs).

DESIGN

Multiphase instrument development study beginning with item development through a cross-sectional postpartum survey.

SETTING

The cross-sectional postpartum survey was distributed online through convenience and snowball sampling methods.

METHODS

We developed instrument items through an iterative process with key stakeholders. We evaluated reliability based on internal consistency and differential item functioning analysis. We evaluated validity on evidence of construct validity. We used criterion-related item mapping to evaluate whether the measure addressed the full spectrum of shared decision making related to maternity care.

RESULTS

Surveys were completed by 1,171 participants. A Cronbach's αcoefficient of .99 supported internal consistency reliability. Infit and outfit statistics that ranged from 0.92 to 1.55 supported item fit. Differential item functioning analysis showed that CHOICEs scores were invariant between different demographic groups. Significant positive correlations between scores on CHOICEs and the Mothers on Respect index (r = 0.75, p = .01) and the Mothers Autonomy in Decision-Making scale (r = 0.75, p = .01) supported criterion-related validity. Item mapping suggested more items were needed to capture the full spectrum of shared decision making.

CONCLUSION

We recommend using CHOICEs to evaluate shared decision making in maternity care for research and quality improvement projects.

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.

Development of a scale to measure shared problem-solving and decision-making in mental healthcare

OBJECTIVES

The aim of this study was to create a measure of collaborative processes between healthcare team members, patients, and carers.

METHODS

A shared decision-making scale was developed using a qualitative research derived model and refined using Rasch and factor analysis. The scale was used by staff in the hospital for four consecutive years (n = 152, 121, 119 and 121) and by two independent patients' and carers' samples (n = 223 and 236).

RESULTS

Respondents had difficulty determining what constituted a decision and the scale was redeveloped after first use in patients and carers. The initial focus on shared decision-making was changed to shared problem-solving. Two factors were found in the first staff sample: shared problem-solving and shared decision-making. The structure was confirmed on the second patients' and carers' sample and an independent staff sample consisting of the first data-points for the last three years. The shared problem-solving and decision-making scale (SPSDM) demonstrated evidence of convergent and divergent validity, internal consistency, measurement invariance on longitudinal data and sensitivity to change.

CONCLUSIONS

Shared problem-solving was easier to measure than shared decision-making in this context.

PRACTICE IMPLICATIONS

Shared problem-solving is an important component of collaboration, as well as shared decision-making.

Birth during the Covid-19 pandemic: What childbearing people in the United States needed to achieve a positive birth experience

BACKGROUND

The COVID pandemic exposed many inadequacies in the maternity care system in the United States. Maternity care protocols put in place during this crisis often did not include input from childbearing people or follow prepandemic guidelines for high-quality care. Departure from standard maternity care practices led to unfavorable and traumatic experiences for childbearing people. This study aimed to identify what childbearing people needed to achieve a positive birth experience during the pandemic.

METHODS

This mixed-methods, cross-sectional study was conducted among individuals who gave birth during the COVID pandemic from 3/1/2020 to 11/1/2020. Participants were sampled via a Web-based questionnaire that was distributed nationally. Descriptive and bivariate statistics were analyzed. Thematic and content analyses of qualitative data were based on narrative information provided by participants. Qualitative and convergent quantitative data were reported.

RESULTS

Participants (n = 707) from 46 states and the District of Columbia completed the questionnaire with 394 contributing qualitative data about their experiences. Qualitative findings reflected women's priorities for (a) the option of community birth, (b) access to midwives, (c) the right to an advocate at birth, and (d) the need for transparent and affirming communication. Quantitative data reinforced these findings. Participants with a midwife provider felt significantly better informed. Those who gave birth in a community setting (at home or in a freestanding birth center) also reported significantly higher satisfaction and felt better informed. Participants of color (BIPOC) were significantly less satisfied and more stressed while pregnant and giving birth during the pandemic.

CONCLUSIONS

High-quality maternity care places childbearing people at the center of care. Prioritizing the needs of childbearing people, in COVID times or otherwise, is critical for improving their experiences and delivering efficacious and safe care.

WHO Standards-based questionnaire to measure health workers' perspective on the quality of care around the time of childbirth in the WHO European region: development and mixed-methods validation in six countries

OBJECTIVES

Develop and validate a WHO Standards-based online questionnaire to measure the quality of maternal and newborn care (QMNC) around the time of childbirth from the health workers' perspective.

DESIGN

Mixed-methods study.

SETTING

Six countries of the WHO European Region.

PARTICIPANTS AND METHODS

The questionnaire is based on lessons learnt in previous studies, and was developed in three sequential phases: (1) WHO Quality Measures were prioritised and content, construct and face validity were assessed through a Delphi involving a multidisciplinary board of experts from 11 countries of the WHO European Region; (2) translation/back translation of the English version was conducted following The Professional Society for Health Economics and Outcomes Research guidelines; (3) internal consistency, intrarater reliability and acceptability were assessed among 600 health workers in six countries.

RESULTS

The questionnaire included 40 items based on WHO Standards Quality Measures, equally divided into four domains: provision of care, experience of care, availability of human and physical resources, organisational changes due to COVID-19; and its organised in six sections. It was translated/back translated in 12 languages: Bosnian, Croatian, French, German, Italian, Norwegian, Portuguese, Romanian, Russian, Slovenian, Spanish and Swedish. The Cronbach's alpha values were ≥0.70 for each questionnaire section where questions were hypothesised to be interrelated, indicating good internal consistence. Cohen K or Gwet's AC1 values were ≥0.60, suggesting good intrarater reliability, except for one question. Acceptability was good with only 1.70% of health workers requesting minimal changes in question wording.

CONCLUSIONS

Findings suggest that the questionnaire has good content, construct, face validity, internal consistency, intrarater reliability and acceptability in six countries of the WHO European Region. Future studies may further explore the questionnaire's use in other countries, and how to translate evidence generated by this tool into policies to improve the QMNC.

TRAIL REGISTRATION NUMBER

NCT04847336.