‘Moving on’ Violence,wellbeing and questions about violence in antenatal care encounters. A qualitative study with Somali-born refugees in Sweden

BackgroundSomali-born women constitute one of the largest groups of childbearing refugee women in Sweden after more than two decades of political violence in Somalia. In Sweden, these women encounter antenatal care that includes routine questions about violence being asked. The aim of the study was to explore how Somali-born women understand and relate to violence and wellbeing during their migration transition and their views on being approached with questions about violence in Swedish antenatal care.MethodQualitative interviews (22) with Somali-born women (17) living in Sweden were conducted and analysed using thematic analysis.FindingsA balancing act between keeping private life private and the new welfare system was identified, where the midwife’s questions about violence were met with hesitance. The midwife was, however, considered a resource for access to support services in the new society. A focus on pragmatic strategies to move on in life, rather than dwelling on potential experiences of violence and related traumas, was prominent. Social networks, spiritual faith and motherhood were crucial for regaining coherence in the aftermath of war. Dialogue and mutual adjustments were identified as strategies used to overcome power tensions in intimate relationships undergoing transition.ConclusionsIf confidentiality and links between violence and health are explained and clarified during the care encounter, screening for violence can be more beneficial in relation to Somali-born women. The focus on “moving on” and rationality indicates strength and access to alternative resources, but needs to be balanced against risks for hidden needs in care encounters. A care environment with continuity of care and trustful relationships enhances possibilities for the midwife to balance these dual perspectives and identify potential needs. Collaborations between Somali communities, maternity care and social service providers can contribute with support to families in transition and bridge gaps to formal social and care services.     

Changing models of public antenatal care in Australia: Is current practice meeting the needs of vulnerable populations?

Objectiveto investigate women's views and experiences of public antenatal care.Designpopulation-based survey in two states.SettingSouth Australia and Victoria, Australia.Participants4366 women surveyed at 5–6 months post partum.Findingsof 8468 eligible women mailed the survey, 52% returned completed questionnaires. Fifty-seven per cent of women (2496/4339) received public antenatal care. Of these, half attended a GP for some/all antenatal visits, 38% attended a public hospital clinic or midwives clinic, and 12% had primary midwife care, mostly in a midwifery group practice. Women with complex needs – young women, those experiencing multiple social health problems, women of non-English speaking background, and women at higher risk of complications in pregnancy – were the least likely to say that care met their needs. Women attending a GP or midwife as a primary caregiver were the most positive about their antenatal care: 69% and 74% respectively describing their antenatal care as ‘very good’. Women attending a standard public hospital clinic were the least positive about their antenatal care with only 48% rating their care as ‘very good’. Women enroling in GP shared care or attending a midwives clinic at a public hospital gave intermediate ratings.Conclusion and implications for practiceModels of public antenatal care involving a designated lead primary caregiver (GP or midwife) came closest to meeting women's need for information, individualised care and support.     

Somali women's experience of childbirth in the UK: Perspectives from Somali health workers

Objective

to conduct a qualitative study of perceptions of experiences of childbirth from Somali health workers in the UK.

Design &; setting

in depth narrative interviews at community centres and places of work in London.

Participants

eight Somali women aged between 23 and 57 years. The interviewees worked within the health sector in the UK and/or as nurses or gynaecologists in Somalia. Six of the women had also given birth in the UK.

Key findings

mismanagement of care of female circumcision provided during pregnancy and labour leads to problems at birth for many Somali women. The importance of Somalia's oral culture is not recognised when addressing communication barriers and continuity of care is lacking but important. Somali women also felt that midwives held stereotyped and negative attitudes towards them. Existing pressures as a consequence of migration were compounded by these experiences of childbirth in the UK.

Key conclusions

issues concerning female circumcision, verbal communication, cultural aspects of care and pressures that were a consequence of migration play a part in the experience of childbirth in the UK for Somali women.

Implications for practice

midwives need to possess the necessary clinical knowledge and skills to deal with women who have been circumcised and the issue needs to be raised early in the pregnancy. Attention needs to be paid to ensure continuity of care, maximising verbal communications and challenging stereotypical views of Somali women.     

Lived experiences of routine antenatal dietetic services among women with obesity: A qualitative phenomenological study

Objectiveto understand the lived experiences and views of being referred to an antenatal dietetic service from the perspective of pregnant women with obesity.Designa qualitative, interpretive approach using one-to-one in-depth interviews to explore the lived experience of pregnant women with obesity following referral to an antenatal dietetics service. Thematic content analysis was carried out by two researchers independently to develop data-driven themes.Settingone NHS Trust maternity and dietetic services, North East England, UK.Participantsfifteen pregnant women with a booking body mass index ≥30 kg/m² attending an obesity-specific antenatal dietetic service. All women were White, parity between 0 and 2, and BMI range 30–51 kg/m².Findingsfour themes were identified. (1) Women's overall experience of the service: experiences were predominately positive with only two negative cases identified. (2) Process of referral: women placed importance on informative and in-person communication about the service, with health professionals, at the point of referral. (3) Delivery of the service: dietitians were considered to be the experts and women wanted more frequent contact. (4) Content of the service: tailored advice enabled behaviour change, and women desired increased physical activity support and weight monitoring.Key conclusionswomen reported an overall positive experience and thought that dietitians were the expert health professionals to support them. Women in this study felt that tailoring advice specific to their personal circumstances helped them implement changes, and had a strong interest in the nutritional benefits for fetal development. Women considered weight monitoring to be a positive element of the service; however, further research is required given the limited and conflicting evidence-base.Implications for practiceit is important to incorporate women's experiences in the development and delivery of antenatal weight management services to facilitate person-centred care. Communication by health professionals at the point of referral is particularly important to provide accurate expectations of services and to reduce anxieties. Dietitians are considered to be appropriate experts to deliver these services, although they may need additional support to address women's physical activity needs in pregnancy.     

What Is It About Antenatal Continuity of Caregiver That Matters to Women?

ABSTRACT: Background: Continuity of care and of caregiver are thought to be important influences on women's experience of maternity care. The aim of this study was to analyze the influence of two aspects of continuity of caregiver in the antenatal period on women's overall rating of antenatal care: the extent to which women saw the same caregiver throughout pregnancy, and the extent to which women thought that their caregiver knew and remembered them and their progress from one visit to the next. Methods: An anonymous, population‐based postal survey was conducted of 1,616 women who gave birth in a 14‐day period in September 1999 in Victoria, Australia. Multivariate methods were used to analyze the data. Results: Most women saw the same caregiver at each antenatal visit (77%), and thought that caregivers got to know them (65%). This finding varied widely among different models of maternity care. Before adjustment, women were much more likely to describe their antenatal care as very good if they always or mostly thought the caregiver got to know them (OR 5.86, 95% CI 4.3, 7.9), and if they always or mostly saw the same caregiver at each visit (OR 2.91, 95% CI 2.0, 4.3). Adjusting for sociodemographic factors, parity, risk status of the pregnancy, and several specific aspects of antenatal care revealed that seeing the same caregiver was no longer associated with rating of care (adjusted OR 0.65, 95% CI 0.3,1.2), but women who thought that caregivers got to know and remember them remained much more likely to rate their care highly (adjusted OR 3.18, 95% CI 2.0, 5.1). Conclusions: These findings suggest that changing the delivery of antenatal care to increase women's chances of seeing the same caregiver at each visit is not by itself likely to improve the overall experience of care, but time spent personalizing each encounter in antenatal care would be well received. The analysis also confirmed the importance that women place on quality interactions with their doctors and midwives. (BIRTH 32:4 December 2005)     

Experiences with nutrition-related information during antenatal care of pregnant women of different ethnic backgrounds residing in the area of Oslo,Norway

Objectiveto explore experiences with nutrition-related information during routine antenatal care among women of different ethnical backgrounds.Designindividual interviews with seventeen participants were conducted twice during pregnancy. Data collection and analysis were inspired by an interpretative phenomenological approach.Settingparticipants were purposively recruited at eight Mother and Child Health Centres in the area of Oslo, Norway, where they received antenatal care.Participantsparticipants had either immigrant backgrounds from African and Asian countries (n=12) or were ethnic Norwegian (n=5). Participants were pregnant with their first child and had a pre-pregnancy Body Mass Index above 25 kg/m².Findingsparticipants experienced that they were provided with little nutrition-related information in antenatal care. The information was perceived as presented in very general terms and focused on food safety. Weight management and the long-term prevention of diet-related chronic diseases had hardly been discussed. Participants with immigrant backgrounds appeared to be confused about information given by the midwife which was incongruent with their original food culture. The participants were actively seeking for nutrition-related information and had to navigate between various sources of information.Conclusionsthe midwife is considered a trustworthy source of nutrition-related information. Therefore, antenatal care may have considerable potential to promote a healthy diet to pregnant women. Findings suggest that nutrition communication in antenatal care should be more tailored towards women's dietary habits and cultural background, nutritional knowledge as well as level of nutrition literacy.     

Role of receipt of antenatal care in subsequent contraceptive use at primary health care centres serving slum areas of Cairo,Egypt

Abstract

Objectives: Information on family planning and use of antenatal care services is vital for understanding the main influences on fertility and evaluating the success of national family planning programmes. This study aimed to explore contraceptive use and its relation to use of antenatal care services in Egypt.

Methods: A cross-sectional survey was conducted among women attending three primary health care centres serving different slum areas of Cairo.

Results: Most of women who used antenatal care services obtained contraception from the state sector. Although the number of antenatal care visits was not significantly associated with contraceptive use, it was a significant determining factor for the type of method used. Reasons given for non-use of contraception were related to reproductive health concerns or disapproval of contraceptive use.

Conclusion: Contraceptive use is widespread in Egypt, regardless of age and level of education. Antenatal care is no longer viewed with suspicion. Antenatal care visits are an opportunity for health care providers (HCPs) to encourage the use of contraception. Repeated antenatal care visits help to engender a relationship of trust between women and HCPs. Incorporation of family planning programmes into antenatal care programmes would be an opportunity to promote modern contraceptive use.     

Project 20: Midwives’ insight into continuity of care models for women with social risk factors: what works,for whom,in what circumstances,and how

IntroductionContinuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems.ObjectiveTo explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women’s outcomes.DesignRealist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London.FindingsThree main themes were identified: ‘Perceptions of the model of care, ‘Tailoring the service to meet women’s needs’, ‘Going above and beyond’. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women’s outcomes, and how women with different social risk factors respond to these mechanisms.Conclusions/implications for practiceOverall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women’s outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.     

‘From fragmented to interdisciplinary understanding of integrated antenatal and postnatal care’—An interprofessional project between public health nursing students and midwifery students

Backgroundin Norway, it is expected that public health nurses and midwives will collaborate in providing integrated antenatal and postnatal care. In practice, however, the extent of formal and informal collaboration between these two groups of health professionals appears limited. In this context, an interprofessional project was initiated, bringing together student public health nurses and midwives in a four-step programme. The objective was to develop the students' understanding of interdisciplinary collaboration in antenatal and postnatal care.Aimto gain knowledge of the students' experiences of the interprofessional project and their interdisciplinary understanding of integrated antenatal and postnatal care.Methodsthe students wrote reflective notes on their experiences, and this qualitative material was analysed through systematic text condensation.Findingsthe students gained awareness about each professional group's competence and responsibilities. They developed an interdisciplinary understanding, which is essential for continuity in antenatal and postnatal care. Changes in knowledge and attitudes during the project helped to develop the students' positive attitude towards future interdisciplinary collaborative practice.Conclusionsthe success of this project was due to the students' experiences during the four-step programme. They developed an interdisciplinary understanding in which loyalty to the family was more important than interprofessional disputes and boundaries. To enhance collaboration between the two professions it is essential that this programme is emphasised by the management and is integrated into the curriculum for both educational programmes.     

Exploring health education with midwives,as perceived by pregnant women in primary care: A qualitative study in the Netherlands

Objectiveto explore the experiences, wishes and needs of pregnant women with respect to health education in primary care with midwives.Designqualitative semi-structured interview study, using thematic analysis and constant comparison.Setting and participantstwenty-two pregnant women in midwife-led primary care, varying in socio-demographic characteristics, weeks of pregnancy and region of residence in the Netherlands, were interviewed between April and December 2013.Findingswomen considered midwives to be the designated health caregivers for providing antenatal health education, and generally appreciated the information they had received from their midwives. Some women, however, believed the amount of verbal health information was insufficient; others that there was too much written information. Many women still had questions and expressed uncertainties regarding various health issues, such as weight gain, alcohol, and physical activity. They perceived their health education to be individualised according to their midwives' assessments of the extent of their knowledge, as well as by the questions they asked themselves. A few were concerned that midwives may make incorrect assumptions about the extent of their knowledge. Women also varied in how comfortable they felt about contacting their midwives for questions between antenatal visits. Women felt that important qualities for midwives underlying health education, were making them feel at ease and building a relationship of trust with them.Key conclusions and implications for practicehealth education was highly appreciated by women in general, suggesting that midwives should err on the side of providing too much verbal information, as opposed to too little. A more pro-active approach with information provision may be of value not only to those with a clear desire for more information, but also to those who are unsure of what information they may be missing. As midwives are the principal health care providers throughout pregnancy,they should ideally emphasise their availability for questions between antenatal visits.     

Does Team Midwife Care Increase Satisfaction with Antenatal,Intrapartum, and Postpartum Care? A Randomized Controlled Trial

Background: Although policymakers have suggested that improving continuity of midwifery can increase women's satisfaction with care in childbirth, evidence based on randomized controlled trials is lacking. New models of care, such as birth centers and team midwife care, try to increase the continuity of care and caregiver. The objective of this study was to evaluate the effect of a new team midwife care program in the standard clinic and hospital environment on satisfaction with antenatal, intrapartum, and postpartum care in low‐risk women in early pregnancy. Methods: Women at Royal Women's Hospital in Melbourne, Australia, were randomly allocated to team midwife care (n = 495) or standard care (n = 505) at booking in early pregnancy. Doctors attended most women in standard care, and continuity of the caregiver was lacking. Satisfaction was measured by means of a postal questionnaire 2 months after the birth. Results: Team midwife care was associated with increased satisfaction, and the differences between the groups were most noticeable for antenatal care, less noticeable for intrapartum care, and least noticeable for postpartum care. The study found no differences between team midwife care and standard care in medical interventions or in women's emotional well‐being 2 months after the birth. Conclusion: Conclusions about which components of team midwife care were most important to increased satisfaction with antenatal care were difficult to draw, but data suggest that satisfaction with intrapartum care was related to continuity of the caregiver.     

A multisite audit to assess how women with complex social factors access and engage with maternity services

Objectiveto audit women with socially complex lives’ documented access to and engagement with antenatal care provided by three inner city, UK maternity services in relation to birth and neonatal outcomes, and referral processes.Backgroundwomen living socially complex lives, including young mothers, recently arrived immigrants, non-English speaking, and those experiencing domestic violence, poor mental health, drug and alcohol abuse, and poverty experience high rates of morbidity, mortality and poor birth outcomes. This is associated with late access to and poor engagement with antenatal care.Methoddata was collected from three separate NHS trusts data management systems for a total of 182 women living socially complex lives, between January and December 2015. Data was presented by individual trust and compared to standards derived from NICE guidelines, local trust policy and national statistic using Excel and SPSS Version 22. Tests of correlation were carried out to minimise risks of confounding factors in characteristic differences.Findingsnon-English speaking women were much less likely to have accessed care within the recommended timeframes, with over 70% of the sample not booked for maternity care by 12 weeks gestation. On average 89% primiparous women across all samples had less than the recommended number of antenatal appointments. No sample met the audit criteria in terms of number of antenatal appointments attended. Data held on the perinatal data management systems for a number of outcomes and processes was largely incomplete and appeared unreliable.Conclusionthis data forms a baseline against which to assess the impact of future service developments aimed at improving access and engagement with services for women living with complex social factors. The audit identified issues with the completeness and reliability of data on the perinatal data management system.     

Improving antenatal engagement for Aboriginal women in Australia: A scoping review

BackgroundAboriginal women have an increased risk of poor antenatal engagement in pregnancy in comparison with Caucasian women, due to inequalities in health care provision. The Pregnancy Outcome in South Australia reports Aboriginal women having 10 times the risk of non-attendance of antenatal care throughout their pregnancy, 3 times the risk of attending the initial booking appointment later than recommended in their pregnancy, and Aboriginal women have an increased risk of attending significantly less antenatal appointments than Caucasian women.ObjectiveThe primary purpose of the scoping review is to map the body of literature known about Aboriginal women engaging with antenatal care in Australia, and the factors that facilitate or cause barriers to this engagement. Secondary to this, the review will describe how culturally safe care influences antenatal engagement.MethodsScoping reviews utilise a broad range of literature, encompassing all types of studies. An online search of 6 databases was conducted to identify and critically analyse sources discussing antenatal engagement for Aboriginal women in Australia. Using the JBI framework for Scoping Reviews, the researcher was able to strengthen the rigour of the methodology.FindingsThe search produced 9 articles, relating to 6 studies addressing antenatal engagement for Aboriginal women in Australia. Several themes were prevalent in the research that impact antenatal engagement including: Smoking, Relocation, Continuity of Care, Aboriginal maternity infant care workers, home visits, birthing on country, age, family and culturally safe care.ConclusionAboriginal women have identified continuity of care, Aboriginal workforce, home visits, family involvement, birthing on country and cultural safety as factors that improve antenatal engagement. Aboriginal women have reported smoking, rural and remote location, cultural incompetence and young age as factors that deter them from engaging with antenatal care.In order to improve antenatal engagement for Aboriginal women in South Australia, culturally safe care is essential. In order to determine the factors that facilitate and/or deter Aboriginal women from antenatal engagement, further research is required.     

Developing and introducing a post birth care plan (PBCP): An action research project

ObjectiveThere is ongoing poor evaluation of post-birth care and an urgent need to improve women's satisfaction. To develop and evaluate an acceptable and useable post-birth care plan template through collaboration with women and community midwives.DesignQualitative methodology using an action research design. Setting and participants: North East Scotland. 10 pregnant women and 6 community midwives.FindingsSeven themes emerged from thematic analysis that informed the format of the PBCP template: being prepared for transitions, physical needs, psychosocial needs, cultural, religious and spiritual needs, organisation of care information, knowledge transfer, financial information and guidance.Key conclusionsWomen and midwives recognised the benefit of using a PBCP to ensure all information is covered and that care is individualised and organised according to cultural, social and physical needs, especially when there is fragmentation of services. The open conversational style of the PBCP provides opportunity to explore post-birth needs and how they develop over time.Implications for practicePBCPs provide an opportunity for women to explore their post-birth needs with their midwife, enabling them to have meaningful, respectful conversations with their midwives during the antenatal and post-birth period. This has the potential to increase women's satisfaction with their care and is particularly pertinent in regions where fragmentary systems of care are prevalent.     

The influence of gender roles on health seeking behaviour during pregnancy in Turkey

Objectives To explore the impact of gender roles in relation to health seeking behaviour during pregnancy and childbirth.

Methods The study was conducted in neighbourhoods with low antenatal care rates in three provinces of Turkey. The study population consisted of pregnant women who never got or discontinued antenatal care and their peers, families and community leaders. Sixteen focus group discussions and 125 in-depth interviews were conducted with a total of 239 participants.

Results Pregnancy and childbirth are interwoven strongly with gender roles. Since the patriarchal system acknowledges women through the means of childbirth, women are expected to have many children. Hence women experience pregnancy as a burden and are not motivated to seek antenatal care. During pregnancy, only ‘serious’ conditions are considered as legitimate reasons for accessing care. However, the decision regarding whether a pregnant woman is seriously sick or not belongs to the responsibilities of elder women, which delays service use.

Conclusions Providing information regarding the value of antenatal care also to elder women is essential in increasing the demand to the services. Incorporating gender perspectives into daily health practice and maintaining access to high quality reproductive care services are vital in reducing the gender based barriers to care.