Spousal violence and receipt of skilled maternity care during and after pregnancy in Nepal

Objectivesa substantial number of Nepali women experience spousal violence, which affects their health in many ways, including during and after pregnancy. This study aimed to examine associations between women's experiences of spousal violence and their receipt of skilled maternity care, using two indicators: (1) receiving skilled maternity care across a continuum from pregnancy to the early postnatal period and (2) receiving any skilled maternity care in pregnancy, childbirth, or postpartum.Methodsdata were analysed for married women aged 15–49 from the 2011 Nepal Demographic and Health Survey. Data were included on women who completed an interview on spousal violence as part of the survey and had given birth within the five years preceding the survey (weighted n=1375). Logistic regression models were developed for analyses.Resultsthe proportion of women who received skilled maternity care across the pregnancy continuum and those who received any skilled maternity care was 24.1% and 53.7%, respectively. Logistic regression analyses showed that spousal violence was statistically significantly associated with receiving low levels of skilled maternity care, after adjusting for accessibility of health care. However, after controlling for women's sociodemographic backgrounds (age, number of children born, educational level, husband's education level, husband's occupation, region of residence, urban/rural residence, wealth index), these significant associations disappeared. Better-educated women, women whose husbands were professionals or skilled workers and women from well-off households were more likely to receive skilled maternity care either across the pregnancy continuum or at recommended points during or after pregnancy.Conclusionspousal violence and low uptake of skilled maternity care are deeply embedded in a society in which gender inequality prevails. Factors affecting the receipt of skilled maternity care are multidimensional; simply expanding geographical access to maternity services may not be sufficient to ensure that all women receive skilled maternity care.     

‘No more strangers’: Investigating the experiences of women,midwives and others during the establishment of a new model of maternity care for remote dwelling aboriginal women in northern Australia

Objectiveto describe the experiences of women, midwives and others during the establishment of a new model of maternity care for remote dwelling Aboriginal women transferred to a regional centre in northern Australia for maternity care and birth.Designa mixed method design within a Participatory Action Research approach was used. Qualitative findings are presented here. Data for this paper were collected from semi-structured interviews, field notes and observations and analysed thematically.Settingthe ‘top end’ of the Northern Territory of Australia.Participantsa total of 66 participants included six MGP midwives, two Aboriginal Health Workers and one Senior Aboriginal Woman working in the new model; eight hospital midwives; 34 Department of Health staff, three staff from other agencies; and 12 remote dwelling Aboriginal women who used the service.Findingsthe study generated one overarching theme, it's not a perfect system but it's changing. This encompassed improvements to the services evident to all participants. Core themes related to the previous maternity service which was described as the arduous journey, the new model was seen as a new way of working and a resultant very different journey occurred for Aboriginal women using the service.Key conclusions and implications for practicethere was a dissonance between the previous culture of maternity services and the woman centred focus of the new model. Over 12 months initial resistance to the new model diminished and it became highly valued. The transfer of information between the regional service and remote community health centres improved as did the safety and quality of care. Aboriginal women can access continuity of carer in the regional centre for the first time and reported a more positive experience with maternity services. The new model appears to have changed the cultural responsiveness of the regional maternity service; and care provided for remote dwelling women within this service. The qualitative findings inform others seeking to implement a similar model of care for remote dwelling women transferred to a regional centre for birth.     

The impact of human trafficking in relation to maternity care: A literature review

ObjectiveTo map the relevant literature and inform future research on the issues related to and experiences of pregnancy and maternity care for women who have been trafficked.DesignA scoping review was undertaken to identify literature on the issues and experiences of pregnancy and maternity care for women who have been trafficked.Results45 papers were identified and six key themes were derived from the literature: the impact of trafficking on health; access to maternity care; experiences of maternity care; social factors; knowledge and experience of staff; and identification and referral.Key ConclusionsWomen who have been trafficked are at risk of physical and emotional health issues that may affect maternal and fetal outcomes. Multiple barriers to care exist for women who have been trafficked, and social factors including housing, poverty and dispersal policies may impact upon both health and access to care. Healthcare staff do not feel adequately prepared to respond to the needs of this vulnerable group and no midwifery-specific guidance exists.Implications for PracticeMidwives need awareness of the complex range of health and social factors that may affect women who have been trafficked. Midwives and maternity care professionals require more specialised training to better identify, refer and support women who have been trafficked.     

Experienced job autonomy among maternity care professionals in The Netherlands

ObjectiveHigh levels of experienced job autonomy are found to be beneficial for healthcare professionals and for the relationship with their patients. The aim of this study was to assess how maternity care professionals in the Netherlands perceive their job autonomy in the Dutch maternity care system and whether they expect a new system of integrated maternity care to affect their experienced job autonomy.DesignA cross-sectional survey. The Leiden Quality of Work Life Questionnaire was used to assess experienced job autonomy among maternity care professionals.SettingData were collected in the Netherlands in 2015.Participants799 professionals participated of whom 362 were primary care midwives, 240 obstetricians, 93 clinical midwives and 104 obstetric nurses.FindingsThe mean score for experienced job autonomy was highest for primary care midwives, followed by obstetricians, clinical midwives and obstetric nurses. Primary care midwives scored highest in expecting to lose their job autonomy in an integrated care system.Key conclusionsThere are significant differences in experienced job autonomy between maternity care professionals.Implications for practiceWhen changing the maternity care system it will be a challenge to maintain a high level of experienced job autonomy for professionals. A decrease in job autonomy could lead to a reduction in job related wellbeing and in satisfaction with care among pregnant women.     

The experiences of midwives in integrated maternity care: A qualitative metasynthesis

ObjectivesTo conduct a metasynthesis of eight qualitative studies of the experiences of midwives in integrated maternity practice; to identify common motifs among the eight studies through a thematic interpretive integration known as reciprocal translation; and to explore the effects on midwifery processes of care in the setting of integrated maternity practice.DesignA qualitative metasynthesis to analyze, synthesize, and interpret eight qualitative studies on the experiences of midwives and the effect on the midwifery processes of care in the setting of integrated maternity practice.Sample and SettingParticipants from the primary studies included a total of 160 midwives providing hospital-based intrapartum care. All primary studies were conducted in settings with midwives and obstetricians working together in an integrated or collaborative manner.FindingsThree overarching themes emerged from the data: professional dissonance, functioning from a position of risk, and practicing down.Key conclusionsThe findings indicated that integrated maternity practice affects the professional experience of midwives. Through a qualitative exploration, a clear process of deprofessionalization and deviation from the midwifery model of care is detailed. Midwives experienced decreasing opportunity to provide the quality woman-centered physiologic care that evidence shows benefits childbearing women.Implications for practiceIntegrated maternity practice, where low-risk and high-risk pregnancies are managed by midwife/physician teams, have proliferated as a solution to the need for quality, safe, and efficient health care. Insufficient evidence exists detailing the success or failure of this model of care. Qualitative studies suggest that the increasing medicalization occurring in integrated maternity practices minimizes the profession of midwifery and the ability to provide evidence-based quality midwifery care.     

Measuring the best outcome for the least intervention: can the Optimality Index-US be applied in the UK?

Objectiveto pilot the Optimality Index-US (OI-US) for the first time within a UK maternity setting in a sample of women at mixed risk.Designa multidisciplinary group reviewed the items and evidence base of the OI-US. A pilot study was undertaken to compare the availability and quality of data from maternity records to complete the OI-US. Data were collected from maternity records.Settinga maternity unit of an inner city teaching hospital in England.Participantsclinical midwives, research midwives, midwifery lecturers and consultant obstetricians (n=10) reviewed the items and evidence base of the OI-US. Data were collected from the maternity records of 97 women receiving caseload care and 103 women receiving standard care.Measurements and findingswhen the multidisciplinary group reviewed the items and evidence base of the OI-US, it was noted that some social and clinical factors should be considered for inclusion as part of the Perinatal Background Index (PBI) and OI. The results suggest that the inclusion of women at higher risk in this sample within the UK maternity setting has not been captured by the OI-US.Key conclusionsthe following social and clinical factors should be included as part of the PBI and OI for the UK setting: measure of social deprivation, woman's ability to speak and understand English in relation to accessing maternity care, mental health problems during pregnancy and history of domestic violence during pregnancyImplications for practiceavailability of items in electronic records is poor and it is recommended that the OI-UK version is a useful research tool in prospective data collection. The development of an international version would be valuable for comparision of background risk and outcomes across a range of care settings.     

Experience with and amount of postpartum maternity care: Comparing women who rated the care they received from the maternity care assistant as ‘good’ or ‘less than good care’

ObjectiveThe postpartum period is an important time in the lives of new mothers, their children and their families. The aim of postpartum care is ‘to detect health problems of mother and/or baby at an early stage, to encourage breastfeeding and to give families a good start’ (Wiegers, 2006). The Netherlands maternity care system aims to enable every new family to receive postpartum care in their home by a maternity care assistant (MCA). In order to better understand this approach, in this study we focus on women who experienced the postpartum care by the MCA as ‘less than good’ care. Our research questions are; among postpartum women in the Netherlands, what is the uptake of MCA care and what factors are significantly associated with women’s rating of care provided by the MCA. Design and setting This study uses data from the ‘DELIVER study’, a dynamic cohort study, which was set up to investigate the organization, accessibility and quality of primary midwifery care in the Netherlands. Participants In the DELIVER population 95.6% of the women indicated that they had received postpartum maternity care by an MCA in their home. We included the responses of 3170 women.Measurements and findingsTo assess the factors that were significantly associated with reporting ‘less than good (postpartum) care’ by the MCA, a full cases backward logistic regression model was built using the multilevel approach in Generalized Linear Mixed Models.FindingsThe mean rating of the postpartum care by the MCA was 8.8 (on a scale from 1-10), and 444 women (14%) rated the postpartum maternity care by the MCA as ‘less than good care’. In the full cases multivariable analysis model, odds of reporting ‘less than good care’ by the MCA were significantly higher for women who were younger (women 25-35 years had an OR 1.32, CI 0.96-1.81 and women 35 years), multiparous (OR 1.27, CI 1.01-1.60) and had a higher level of education (women with a middle level had an OR 1.84,CI 1.22-2.79, and women with a high level of education had an OR 2.11, CI 1.40-3.18 compared to women with a low level of education). Odds of reporting ‘less than good care’ were higher for women who, received the minimum amount of hours (OR 1.86, CI 1.45-2.38), in their opinion received not enough or too many hours maternity care assistance (OR 1.47, CI 1.01-2.15 and OR 5.15, CI 3.25-8.15, respectively), received care from two or more different MCAs (2 MCAs OR 1.61 CI 1.24-2.08, ≥3 MCAs OR 3.01, CI 1.98-4.56 compared to 1 MCA) and rated the care of the midwife as less than good care (OR 4.03, CI 3.10-5.25) . The odds of reporting ‘less than good care’ were lower for women whose reason for choosing maternity care assistance was to get information and advice (OR 0.52, CI 0.41-0.65).Key conclusionsWe conclude that (the postpartum) MCA care is well utilised, and highly rated by most women. Implications for practice:The approach to care in the Netherlands addresses the needs as outlined by NICE and WHO. Although no data exists around the impact of use on maternal infant outcomes, this approach might be useful in other jurisdictions. MCA care might be improved if the hours of MCA care were tailored, and care by multiple MCAs minimised.     

Unauthorised pregnancies and use of maternity care in rural China

ABSTRACT

Objectives To describe the use of maternity care in rural China by the legal status of the pregnancy.

Methods Cross-sectional survey wherein information was obtained about 2576 women who gave birth in 2006. Logistic regression was used to compare women having an unauthorised pregnancy with those having an authorised second birth, adjusting for confounding factors.

Results Almost all respondents had antenatal care and most deliveries occurred in hospitals. Women with unauthorised pregnancies were significantly less likely to have had maternity care, particularly prenatal care, postnatal care, to have been hospitalised during pregnancy, and to have been reimbursed for hospital delivery costs than women with an authorised second birth. They were also more likely to have been hospitalised for seven or more days after delivery. Primiparous women used maternity care services and received financial support more often than women with an authorised second birth. Among the women with an unauthorised pregnancy an important reason for not using hospital care during pregnancy or delivery was financial constraint.

Conclusions Women with unauthorised pregnancies use less maternity care, although pregnancy in such circumstances may adversely impact their health. Primiparous women benefit from more financial support than multiparous women.     

What Makes a Good Family‐Centered Partnership Between Women and Their Practitioners? A Qualitative Study

Abstract: Background : Family‐centered maternity care is an approach based on mutually beneficial partnerships between health care providers and families. It offers new ways of thinking about the relationship among childbearing women, their families, and health caregivers. This study was designed to identify health care practices that promoted or limited a family‐centered philosophy. Methods : A qualitative design, using reflexive interviews and focus groups, investigated the perspectives of 34, primarily African American women who used maternity services at a large urban hospital; some women traveled from rural areas for delivery. Inductive data analysis was conducted on the transcribed audiotapes of the interviews and groups. Results : Barriers to family‐centered maternity care were categorized as issues in coordination of services among health caregivers, patient‐health caregiver relationships and systems, and access to services. Facilitators of family‐centered maternity care were identified as perceived response to high‐risk patients, health‐related support outside the hospital, and special resources. Narratives, or personal stories told by the women, were used to illustrate barriers and facilitators. Conclusions : Education about family‐centered maternity care is vitally important for health caregivers. In clinical situations, each childbearing woman and her family should be treated as if they are extraordinary. In this way, practitioners can alter routines that cause the woman and her family to lose individualized care. (BIRTH 31:1 March 2004)     

The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care

Background

the maternity services reforms announced by the Australian government herald a process of major change. The primary maternity care reforms requires maternity care professionals to work collaboratively as equals in contrast to the current system which is characterised by unequal relationships.

Aim

critical discourse analysis (CDA) using neoliberalism as an interpretive lens was employed to determine the positions of the respective maternity care professionals on the proposed reform and what purpose was served by their representations to the national review of maternity services.

Method

a CDA framework informed by Fairclough, linking textual and sociological analysis in a way that foregrounds issues of power and resistance, was undertaken. Data were collected from selected written submissions to the 2008 national review of maternity services representing the position of midwifery, obstetrics, general practitioners including rural doctors and maternity service managers.

Findings

maternity care professionals yielded several discourses that were specific to the discipline with a number that were shared across disciplines. The rise in consumerism has changed historical positions of influence in maternity services policy. The once powerful obstetric position in determining the direction of policy has come under siege, isolated in the presence of a powerful alliance involving consumers, midwives, sympathetic maternity service managers and some medical professions. The midwifery voice has been heard, a historical first, supported by its presence as a member of the alliance.

Conclusion

the struggle for contested boundaries is entering a new phase as maternity care professionals struggle with different perceptions of what multidisciplinary collaboration means in the delivery of primary maternity care.     

Clinical handover practices in maternity services in Ireland: A qualitative descriptive study

Objectivethe objective was to examine and describe clinical handover practices in Irish maternity services.Designthe study design incorporated interviews and focus group discussions with a purposive sample of healthcare practitioners working in Irish maternity services.Settingfive maternity hospitals and fourteen co-located maternity units.Participantsmidwives, obstetricians and other healthcare professionals, specifically physiotherapists and radiologists, midwifery students and health care assistants working in maternity services.Findingsthe study participants provided nuanced and differentiated accounts of clinical handover practices, which indicated a general absence of formal policy and training on clinical handover and the practice of midwifery and medical teams holding separate clinical handovers based on their separate, respective needs for transferring information and clinical responsibility. Participants spoke of barriers to effective clinical handover, including unsuitable environments, lack of dedicated time and fatigue during duty shift clinical handover, lack of supportive information technology (IT) infrastructure, and resistance of some staff to the adoption of new technologies to support clinical handover.Key conclusionswhether internal and external to clinical handover events, the barriers to effective clinical handover represent threats to patient safety and quality of care, since effective clinical handover is essential to the provision of safe quality care.Implications for practiceclear and effective communication between collaborating professionals within maternity teams is essential.     

Is Your Perinatal Practice Mother‐Friendly? A Strategy for Improving Maternity Care

Abstract: The purpose of the questionnaire, “Is Your Perinatal Practice Mother‐Friendly?” is to provide health practitioners with an evidence‐based tool that can be used to improve maternity care. The Mother‐Friendly Childbirth Initiative is a consensus document promoting a wellness model of maternity care that was developed by the Coalition for Improving Maternity Services (CIMS) and ratified by major childbirth organizations and leading authorities in maternity care. By complying with the “Ten Steps of Mother‐Friendly Care,” a hospital or practice can be designated as “mother‐friendly.” The questionnaire enables health care providers to apply the Ten Steps to their maternity practice or services.     

Knowledge,attitude and practice of emergency contraception among health care providers in Ismailia,Egypt

ObjectiveTo explore the knowledge, attitude and practice of health care providers in Ismailia, Egypt regarding emergency contraception.Participants and methodA structured questionnaire was distributed to a total of 270 health care providers (obstetrics and gynecology specialists and general practitioners or family physicians). The questionnaire contained four main domains: demographic characteristics; knowledge about EC; attitude toward EC; and practice of EC.ResultsKnowledge of specialists was significantly higher than general practitioners/family physicians regarding the three most commonly used methods of EC, viz; combined oral contraceptive (Yuzpe) method, progesterone only pills (plan B) method and IUCD. Only 39.5% of specialists and 24.0% of GPs/family physicians had good knowledge of EC (p = 0.01). 45.7% of specialists and 42.6% of GPs/family physicians had favorable attitude toward EC with no significant difference. 39.5% of specialists and 26.6% of GPs/family physicians reported ever prescribing EC. Yuzpe method was the most commonly prescribed method by specialists (31.5%) and GPs/family physicians (27.0%) with no significant difference. Knowledge and favorable attitude were significantly associated in both groups. Age and years of experience significantly affected the three outcome measures.ConclusionA deficit in knowledge and a negative attitude shown by health care providers lead to an insufficient use of EC methods.     

The experiences of women,midwives and obstetricians when women decline recommended maternity care: A feminist thematic analysis

Backgroundpregnant women, like all competent adults, have the right to refuse medical treatment, although concerns about maternal and fetal safety can make doing so problematic. Empirical research about refusal of recommended maternity care has mostly described the attitudes of clinicians, with women's perspectives notably absent.Designfeminist thematic analysis of in-depth, semi-structured interviews with women's (n=9), midwives’ (n=12) and obstetricians’ (n=9) about their experiences of refusal of recommended maternity care.Findingsthree major interrelated themes were identified. “Valuing the woman's journey”, encapsulated care experiences that women valued and clinicians espoused, while “The clinician's line in the sand” reflected the bounded nature of support for maternal autonomy. When women's birth intentions were perceived by clinicians to transgress their line in the sand, a range of strategies were reportedly used to convince the woman to accept recommended care. These strategies formed a pattern of “Escalating intrusion”.Key conclusions and implications for practicedeclining recommended care situated women at the intersection of two powerful normative discourses: medical dominance and the patriarchal institution of motherhood. Significant pressures on women's autonomy resulted from an apparent gap between clinicians’ espoused and reported practices. Implications for policy and practice include a need for specific guidance for clinicians providing care in situations of maternal refusal, the potential value of an independent third-party for advice and advocacy, and the development of models that support reflexive practice amongst clinicians.