Antenatal Care Model Research Articles

Better together: A qualitative exploration of women’s perceptions and experiences of group antenatal care

ProblemChildbearing women from socio-economically disadvantaged communities and minority ethnic groups are less likely to access antenatal care and experience more adverse pregnancy outcomes. BackgroundGroup antenatal care aims to facilitate information sharing and social support. It is associated with higher rates of attendance and improved health outcomes. AimsTo assess the acceptability of a bespoke model of group antenatal care (Pregnancy Circles) in an inner city community in England, understand how the model affects women’s experiences of pregnancy and antenatal care, and inform further development and testing of the model. MethodsA two-stage qualitative study comprising focus groups with twenty six local women, followed by the implementation of four Pregnancy Circles attended by twenty four women, which were evaluated using observations, focus groups and semi-structured interviews with participants. Data were analysed thematically. FindingsPregnancy Circles offered an appealing alternative to standard antenatal care and functioned as an instrument of empowerment, mediated through increased learning and knowledge sharing, active participation in care and peer and professional relationship building. Multiparous women and women from diverse cultures sharing their experiences during Circle sessions was particularly valued. Participants had mixed views about including partners in the sessions. ConclusionsGroup antenatal care, in the form of Pregnancy Circles, is acceptable to women and appears to enhance their experiences of pregnancy. Further work needs to be done both to test the findings in larger, quantitative studies and to find a model of care that is acceptable to women and their partners.

Use of a Facilitated Group Process to Design and Implement a Group Antenatal and Postnatal Care Program in Rwanda.

IntroductionThe government of Rwanda is exploring strategies that may reduce the incidence of prematurity and low birth weight. Large‐scale implementation of group antenatal care (ANC) and postnatal care (PNC) within the context of the Rwanda national health care system is under consideration. To launch a cluster randomized controlled trial of group ANC and PNC in 5 districts in Rwanda, the implementation team needed a customized group care model for this context and trained health care workers to deliver the program.ProcessAdapting the group ANC and group PNC model for the Rwandan context was accomplished through a group process identical to that which is fundamental to group care. A technical working group composed of 10 Rwandan maternal‐child health stakeholders met 3 times over the course of 3 months, for 4 to 8 hours each time. Their objectives were to consider the evidence on group ANC, agree on the priorities and constraints of their ANC delivery system, and ultimately define the content and structure of a combined group ANC and PNC model for implementation in Rwanda. The same group process was employed to train health care workers to act as group ANC facilitators.OutcomesA customized group ANC and PNC model and guidelines for its introduction were developed in the context of a cluster randomized controlled trial in 36 health centers. Descriptions of this model and the implementation plan are included in this article.DiscussionOur experience suggests that the group process fundamental to successful group ANC and PNC is an effective method to customize and implement this innovative health services delivery model in a new context and is instrumental in achieving local ownership.

The Mexican Experience Adapting CenteringPregnancy: Lessons Learned in a Publicly Funded Health Care System Serving Vulnerable Women.

Group antenatal care is an innovative model of health care in which all components of antenatal care—clinical, educational, and supportive—happen in a group context with health care professionals as facilitators. CenteringPregnancy is the most studied model of group antenatal care, now widely implemented in the United States. This model has been shown to be effective in improving health and behavioral outcomes in the United States, but there is less known about the experience adapting group antenatal care in settings outside the US health care system. This article describes the adaptation of the CenteringPregnancy model to a Mexican context. We describe the Mexican health care context and our adaptation process and highlight key factors to consider when adapting the content and modality of the CenteringPregnancy model for diverse populations and health systems. Our findings are relevant to others seeking to implement group antenatal care in settings outside the US health care system.

English

Focused antenatal care has been viewed to be a better option to the previously existing orthodox model of antenatal care. The orthodox antenatal care otherwise known as traditional model of antenatal care requires a number of routine and frequent visits by pregnant women to the healthcare facility. This traditional model of antenatal care has been observed to require numerous materials such as financial and human resources for its continuous implementation. The observable cumbersome nature of the traditional model necessitates the recent exploration of alternative model of antenatal care referred to as focused antenatal care (FANC) model. The FANC model emanated during the era of evidenced based practice and evidence based approach to care. Evidence-based ensures that the care rendered are based on previous outcomes of care and are focused on what can be achieved during the less regular but specific visit, which is characterized by being client friendly with reduced cost of implementation. Despite this importance of FANC, antenatal care continues to be centered around clinical assessment, and regular attendance at the clinic. Thus, the objective of this paper is to review the traditional care model and the focused antenatal care model because antenatal care remains a mixture of both art and science, and to re-appraise current antenatal practices. Key words: Focused antenatal care, pregnancy, clinical assessment.

Adapting the Quality Maternal and Newborn Care (QMNC) Framework to evaluate models of antenatal care: A pilot study.

BackgroundRecent evidence indicates that continuity models of maternity care result in improved clinical and psychosocial outcomes, but their causal mechanisms are poorly understood. The recent Lancet Series on Midwifery’s Quality Maternal and Newborn Care Framework describes five components of quality care and their associated characteristics. As an initial step in developing this Framework into an evaluation toolkit, we transformed its components and characteristics into a topic guide to assess stakeholder perceptions and experiences of care provided and received. The main purpose of this study was to assess the feasibility of this process.MethodsWe conducted twelve focus groups in two Scottish health board areas with 13 pregnant women, 18 new mothers, 26 midwives and 12 obstetricians who had experience of a range of different models of maternity care. Transcripts were analysed using a six-phase approach of thematic analysis. We mapped the identified themes and sub-themes back to the Framework.ResultsThe emerging themes and sub-themes demonstrated the feasibility of using the QMNC framework as a data collection tool, and as a lens for analysing the data. Of the four emerging themes, only Organisation Culture / Work Structure’ mapped directly to a single Framework component. The others—‘Relationships’; ‘Information and support’; and ‘Uncertainty’–mapped to between two and five components, illustrating the interconnectedness of the Framework’s components. Some negative sub-themes mirrored positive Framework characteristics of care. Some re-phrasing and re-ordering of the topic guides in later focus groups ensured we could cover all aspects of the Framework adequately.ConclusionAdapting the Quality Maternal and Newborn Care Framework enabled us to focus on aspects of care which worked well and which didn’t work well for these key stakeholders. Identifying ‘what works for whom and why’ in different models of care is a necessary step in reinforcing and replicating the most effective models of care.

`It makes sense and it works': Maternity care providers' perspectives on the feasibility of a group antenatal care model (Pregnancy Circles)

AimTo test the feasibility of introducing a group antenatal care initiative (Pregnancy Circles) in an area with high levels of social deprivation and cultural diversity by exploring the views and experiences of midwives and other maternity care providers in the locality before and after the implementation of a test run of the group model. Design(i) Pre-implementation semi-structured interviews with local stakeholders. (ii) Post-implementation informal and semi-structured interviews and a reflective workshop with facilitating midwives, and semi-structured interviews with maternity managers and commissioners. Data were organised around three core themes of organisational readiness, the acceptability of the model, and its impact on midwifery practice, and analyzed thematically. SettingA large inner-city National Health Service Trust in the United Kingdom. ParticipantsSixteen stakeholders were interviewed prior to, and ten after, the group model was implemented. Feedback was also obtained from a further nine midwives and one student midwife who facilitated the Pregnancy Circles. InterventionFour Pregnancy Circles in community settings. Women with pregnancies of similar gestation were brought together for antenatal care incorporating information sharing and peer support. Women undertook their own blood pressure and urine checks, and had brief individual midwifery checks in the group space. FindingsDissatisfaction with current practice fuelled organisational readiness and the intervention was both possible and acceptable in the host setting. A perceived lack of privacy in a group setting, the ramifications of devolving blood pressure and urine checks to women, and the involvement of partners in sessions were identified as sticking points. Facilitating midwives need to be adequately supported and trained in group facilitation. Midwives derived accomplishment and job satisfaction from working in this way, and considered that it empowered women and enhanced care. Key conclusionsParticipants reported widespread dissatisfaction with current care provision. Pregnancy Circles were experienced as a safe environment in which to provide care, and one that enabled midwives to build meaningful relationships with women. Implications for practicePre-registration education inadequately prepared midwives for group care. Addressing sticking points and securing management support for Pregnancy Circles is vital to sustain participation in this model of care.

English

Late booking for antenatal care is a frequent occurrence among pregnant women in Nigeria unlike in most developed countries. The objective of the study was to determine the maternal, socio-cultural, religious, and institutional/systemic factors that determine late booking for antenatal care among pregnant women in Enugu, Nigeria. Descriptive, cross-sectional questionnaire based method was employed in the study. A proportionate stratified sampling technique was used to select 282 pregnant women from three selected hospitals for the study. A validated structured questionnaire constructed by the researchers was used for collection of data. Findings were analysed using both descriptive and inferential statistics. Respondents revealed that maternal factors such as health status in present pregnancy [205(70.7%)], ignorance of proper gestational age to register for antenatal [125(43.1%)] and experience from previous pregnancies [101(34.8%)] determine timing of booking among pregnant women. Socio-cultural factors such as husband’s decision [100(34.5%)] and preference for mother in-law/friends/other women’s advice during the early weeks of pregnancy [88(26.9%)] determine timing of booking. Religious factor which mostly determine late booking in the study was preference for prayer and faith healing [157(54.1%)]. Institutional/systemic factors such as long waiting time in hospitals [142(49.0%)] and very frequent antenatal care schedule [129(44.5%)] determine late booking for antenatal care among pregnant women. Health status in present pregnancy, husband’s decision, long waiting time at the clinic and frequent number of ante-natal visits are the major determinants of late booking in Enugu. There is need for transitioning from traditional approach of ANC to Focused Antenatal Care (FANC) model recommended by WHO. Key words: Determinants, Enugu, late ante natal booking.

Exploring perceptions of group antenatal Care in Urban India: results of a feasibility study

BackgroundMaking high-quality health care available to all women during pregnancy is a critical strategy for improving perinatal outcomes for mothers and babies everywhere. Research from high-income countries suggests that antenatal care delivered in a group may be an effective way to improve the provision, experiences, and outcomes of care for pregnant women and newborns. A number of researchers and programmers are adapting group antenatal care (ANC) models for use in low- and middle-income countries (LMIC), but the evidence base from these settings is limited and no studies to date have assessed the feasibility and acceptability of group ANC in India.MethodsWe adapted a “generic” model of group antenatal care developed through a systematic scoping review of the existing evidence on group ANC in LMICs for use in an urban setting in India, after looking at local, national and global guidelines to tailor the model content. We demonstrated one session of the model to physicians, auxiliary nurse midwives, administrators, pregnant women, and support persons from three different types of health facilities in Vadodara, India and used qualitative methods to gather and analyze feedback from participants on the perceived feasibility and acceptability of the model.ResultsProviders and recipients of care expressed support and enthusiasm for the model and offered specific feedback on its components: physical assessment, active learning, and social support. In general, after witnessing a demonstration of the model, both groups of participants—providers and beneficiaries—saw group ANC as a vehicle for delivering more comprehensive ANC services, improving experiences of care, empowering women to become more active partners and participants in their care, and potentially addressing some current health system challenges.ConclusionThis study suggests that introducing group ANC would be feasible and acceptable to stakeholders from various care delivery settings, including an urban primary health clinic, a community-based mother and child health center, and a private hospital, in urban India.

Are Kazakhstani Women Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services.

Women’s satisfaction is a part of the quality assurance process with potential to improve antenatal health services. The objective of this study was to assess the prevalence of women’s satisfaction with antenatal care in an urban Kazakhstani setting and investigate associated factors. A total of 1496 women who delivered in all maternity clinics from 6 February through 11 July 2013 in Semey, East Kazakhstan, filled out a standardized pretested questionnaire on satisfaction with antenatal care. Independent associations between dissatisfaction and its correlates were studied by logistic regression. Ninety percent of the women were satisfied with the antenatal care. Women who were dissatisfied had lower education. These women would have preferred more checkups, shorter intervals between checkups, more time with care providers, and shorter waiting times. The overall dissatisfaction was associated with long waiting times and insufficient information on general health in pregnancy, results of laboratory tests, treatment during pregnancy, and breastfeeding. Although most of the women in the study setting were satisfied with the new antenatal care model, we identified the main sources of dissatisfaction that should be addressed. Given that Semey is a typical Kazakhstani city, the results can be generalized to other Kazakhstani urban settings.

Antenatal care and opportunities for quality improvement of service provision in resource limited settings: A mixed methods study.

Antenatal care is essential to improve maternal and newborn health and wellbeing. The majority of pregnant women in Tanzania attend at least one visit. Since implementation of the focused antenatal care model, quality of care assessments have mostly focused on utilization and coverage of routine interventions for antenatal care. This study aims to assess the quality of antenatal care provision from a holistic perspective in a rural district in Tanzania. Structure, process and outcome components of quality are explored. This paper reports on data collected over several periods from 2012 to 2015 through facility audits of supplies and services, ANC observations and exit interviews with pregnant women. Additional qualitative methods were used such as interviews, focus group observations and participant observations. Findings indicate variable performance of routine ANC services, partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client’s wellbeing, basic physical examination and adequate counseling and education. Achieving quality improvement for ANC requires increased attention for the process of care provision beyond coverage, including attention for response-based services, which should be assessed based on locally determined criteria.

Randomized controlled pilot of a group antenatal care model and the sociodemographic factors associated with pregnancy-related empowerment in sub-Saharan Africa

BackgroundThe links between empowerment and a number of health-related outcomes in sub-Saharan Africa have been documented, but empowerment related to pregnancy is under-investigated. Antenatal care (ANC) is the entry point into the healthcare system for most women, so it is important to understand how ANC affects aspects of women’s sense of control over their pregnancy. We compare pregnancy-related empowerment for women randomly assigned to the standard of care versus CenteringPregnancy-based group ANC (intervention) in two sub-Saharan countries, Malawi and Tanzania.MethodsPregnant women in Malawi (n = 112) and Tanzania (n = 110) were recruited into a pilot study and randomized to individual ANC or group ANC. Retention at late pregnancy was 81% in Malawi and 95% in Tanzania. In both countries, individual ANC, termed focused antenatal care (FANC), is the standard of care. FANC recommends four ANC visits plus a 6-week post-birth visit and is implemented following the country's standard of care. In group ANC, each contact included self- and midwife-assessments in group space and 90 minutes of interactive health promotion. The number of contacts was the same for both study conditions. We measured pregnancy-related empowerment in late pregnancy using the Pregnancy-Related Empowerment Scale (PRES). Independent samples t-tests and multiple linear regressions were employed to assess whether group ANC led to higher PRES scores than individual ANC and to investigate other sociodemographic factors related to pregnancy-related empowerment.ResultsIn Malawi, women in group ANC had higher PRES scores than those in individual ANC. Type of care was a significant predictor of PRES and explained 67% of the variation. This was not so in Tanzania; PRES scores were similar for both types of care. Predictive models including sociodemographic variables showed religion as a potential moderator of treatment effect in Tanzania. Muslim women in group ANC had a higher mean PRES score than those in individual ANC; a difference not observed among Christian women.ConclusionsGroup ANC empowers pregnant women in some contexts. More research is needed to identify the ways that models of ANC can affect pregnancy-related empowerment in addition to perinatal outcomes globally.

Prevalence and Accuracy of Screening Test of Asymptomatic Bacteriuria During Pregnancy in Siriraj Hospital

BackgroundThe early detection and treatment asymptomatic bacteriuria (ASB) during pregnancy prevents maternal and fetal complication. Thus the American College of OB-GYN recommends urine culture should be obtained at the first prenatal visit and the U.S. Preventive Services Task Force obtains urine culture during 12–16 weeks of gestation. The new antenatal care (ANC) model of Thai Ministry of Public Health uses screening at first ANC by urine dipstick. However, neither research nor routine ASB screen in Siriraj Hospital because there was low prevalence and all pregnancy been screened by the obstetricians.MethodsProspective cohort study was performed at the ANC clinic, OB-GYN department, Siriraj Hospital. Pregnancies of first antenatal care visit during January to December 2015 were enrolled. Urine culture (UC), Urine dipstick for nitrite (UDN), and Urine dipstick for leukocyte esterase (UDL), were performed. Subjects’ baseline characteristics until birth delivery were collected.ResultsTotal 702 subjects were enrolled; median age, 28 yrs (range 16–45) and body mass index, 24.1 (range 14.0–44.3). The ASB prevalence was 2.3% (16 from 702) without significant difference between first, second, and thirdtrimester, P = 0.185. The most common organism was E. coli. Factors related to ASB were heart disease, P < 0.001 and having sexual intercourse during pregnancy, P = 0.005. The sensitivity and specificity of UDN and UDL were 37.5% and 99.0% and 56.3% and 55.7%, respectively. Positive predictive value and negative predictive value of UDN and UDL were 46.2% and 2.9% and 98.5% and 98.2%, respectively. No abnormal maternal and fetal outcomes were reported.ConclusionAccording to very low prevalence of ASB in Siriraj hospital, routine urine culture may be unnecessary for all antenatal pregnancy. However, heart disease and sexual intercourse during pregnancy should be considered for screening and treatment. However, further evaluation of outcome, i.e. UTI, maternal and fetal complication of non-screening for ASB should be studied.Disclosures All authors: No reported disclosures.

Experiences of Antenatal Care Among Women Who Are Socioeconomically Deprived in High-Income Industrialized Countries: An Integrative Review.

Socioeconomic deprivation in high-income industrialized countries is a key factor in poor perinatal outcomes. Limited access, utilization, and quality of antenatal care seem to play an important role in poor perinatal outcomes. This integrative review aimed to explore experiences of antenatal care among women who are socioeconomically deprived in high-income industrialized countries. A search was conducted using 5 databases for articles published from 2004 to 2014. Six qualitative and 3 quantitative articles were selected. These were systematically appraised for quality independently by 3 researchers. Relevant themes were identified and organized into categories. The disadvantages experienced in antenatal care by women who are socioeconomically deprived start before the first contact with health care services and are notable throughout the entire pregnancy. There is disparity in choice of medical or midwifery service provision models. Six categories emerged during review: choice of service provision model, feeling valued, various types of discrimination, structural and interpersonal accessibility, comprehensibility and trustworthiness of information, and engagement and sense of responsibility. Categories underscored the importance of the woman's relationship with the antenatal care provider. Antenatal care models with women-centered approaches and continuity of care, such as midwifery models, have potential to increase the satisfaction of women with low socioeconomic status with care; this may increase antenatal care utilization and improve perinatal outcomes.

Fathers’ satisfaction with two different models of antenatal care in Sweden – Findings from a quasi-experimental study

Fathers’ satisfaction with two different models of antenatal care in Sweden – Findings from a quasi-experimental study

The relationship between midwife-led group-based versus conventional antenatal care and mode of birth: a matched cohort study

BackgroundMidwife facilitated, group models of antenatal care have emerged as an alternative to conventional care both within Australia and internationally. Group antenatal care can be offered in a number of different ways, however usually constitutes a series of sessions co-ordinated by a midwife combining physical assessment, antenatal education and peer support in a group setting. Midwife-led group antenatal care is viewed positively by expectant mothers, with no associated adverse outcomes identified in the published literature for women or their babies when compared with conventional care. Evidence of an improvement in outcomes is limited. The aim of this study was to compare mode of birth (any vaginal birth with caesarean birth) between pregnant women accessing midwife-led group antenatal care and conventional individual antenatal care, in Queensland, Australia.MethodsThis was a retrospective matched cohort study, set within a collaborative antenatal clinic between the local university and regional public health service in Queensland, Australia. Midwife-led group antenatal care (n = 110) participants were compared with controls enrolled in conventional antenatal care (n = 330). Groups were matched by parity, maternal age and gestation to form comparable groups, selecting a homogeneous sample with respect to confounding variables likely to affect outcomes.ResultsThere was no evidence that group care resulted in a greater number of caesarean births. The largest increase in the odds of caesarean birth was associated with a previous caesarean birth (p < 0.001), no previous birth (compared with previous vaginal birth) (p < 0.003), and conventional antenatal care (p < 0.073). The secondary outcomes (breastfeeding and infant birth weight) which were examined between the matched cohorts were comparable between groups.ConclusionsThere is no evidence arising from this study that there was a significant difference in mode of birth (caesarean or vaginal) between group and conventional care. Group care was associated with a lower risk of caesarean birth after controlling for previous births, with the highest chance for a vaginal birth being a woman who has had a previous vaginal birth and was in group care. Conversely, the highest risk of caesarean birth was for women who have had a previous caesarean birth and conventional care.

Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models

BackgroundAntenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models.MethodsA protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions.ResultsOf 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted ‘lower-risk’-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted ‘higher-risk’-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.ConclusionsInterventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.

From Consultation to Application: Practical Solutions for Improving Maternal and Neonatal Outcomes for Adolescent Aboriginal Mothers at a Local Level.

Adolescent pregnancy has been typically linked to a range of adverse outcomes for mother and child. In Australia, Aboriginal and Torres Strait Islander women have a higher proportion of adolescent births compared with other adolescent Australian women, and are at greater risk of poorer psychosocial and clinical outcomes if they are not well supported during pregnancy and beyond. Drawing on existing literature and consultations with young Aboriginal women and health professionals supporting pregnant Aboriginal women in Western Australia, this paper discusses the importance of creating models of antenatal care using a “social determinants of health” framework. Destigmatizing young parenthood and providing continuity of caregiver in culturally safe services, with culturally competent health professionals provides a means to encourage engagement with the health system and improve health outcomes for young mothers and their babies.

Influences on vaginal birth after caesarean section: A qualitative study of Taiwanese women.

Vaginal birth is a safe mode of birth for most women who have had a prior caesarean with a transverse incision. Despite the evidence, most Taiwanese women who have had a previous caesarean are rarely offered the opportunity to consider any possibility other than a repeat caesarean. This study explored factors affecting Taiwanese women's decisionmaking regarding vaginal birth after cesarean. Ajzen's Theory of Planned Behaviour provided the theoretical framework to underpin the study, which adopted an interpretive descriptive methodology. Sequential semi-structured interviews were conducted with 29 women who had a previous caesarean and were pregnant between 34 and 38 weeks gestation, ten women who attempted vaginal birth in the third to fifth day postpartum, and 25 women in the fourth week postpartum. Boyatzis' method of thematic analysis was used to identify themes and codes. This paper reports the findings of the prenatal interviews with 29 participants. The major factor influencing women's decision-making was to avoid negative outcomes for themselves and their babies. Three thematic codes describe influences on the women's decisions: 'past experience of childbirth', 'anticipating the next experience of normal birth' and 'contemplation on the process of childbirth'. Women who have had a previous caesarean section are prepared to have a vaginal birth but are not always supported to carry out this decision. Changing the models of antenatal care is recommended as a strategy to overcome this difficulty therefore empowering women to make a meaningful choice about VBAC after a CS.

New WHO antenatal care model—quality worth paying for?

The 2016 WHO guidelines on antenatal care 1 were published earlier this month and are widely welcomed because they are not only academically robust, but also relevant to end-users and patients. The guidelines cover antenatal care for normal pregnancies and have adopted a woman-centred, holistic approach to care. They cover nutritional interventions, maternal and fetal assessment, preventive measures, interventions for common physiological pregnancy symptoms, and health systems interventions to improve the use and quality of antenatal care. The guidelines address antenatal evidence-based practices that improve outcomes and detail how these practices should be delivered. In addition to standard antenatal medical advice, the 49 recommendations include guidance on psychological support, nutrition, and domestic violence screening. Each recommendation is backed up with an evidence review, generally based upon systematic reviews conducted by the Cochrane Collaboration. But even with the most rigorous analyses of the evidence, there are conflicting opinions as to how to deal with some of the results, and what to recommend when there is very limited evidence to support or reject common practice. The WHO antenatal care Guideline Development Group (GDG) is to be congratulated for putting into practice the old adage that “no evidence of benefit is not the same as evidence of no benefit”. So in symphysis-fundal height measurement, for example, where there is limited evidence for its benefit, they do not discard it but recommend that clinicians continue whatever is their current practice.

Elements of cultural competence in an Australian Aboriginal maternity program.

Pregnancy, labour and neonatal health outcomes for Australian Aboriginal women and their infants are frequently worse than those of the general population. Provision of culturally competent services may reduce these differences by improving access to timely and regular antenatal care. In an effort to address these issues, the Aboriginal Maternity Group Practice Program commenced in south metropolitan Perth, Western Australia, in 2011. The program employed Aboriginal Grandmothers, Aboriginal Health Officers and midwives working in a partnership model with pre-existing maternity services in the area. To identify elements of the Aboriginal Maternity Group Practice Program that contributed to the provision of a culturally competent service. The Organisational Cultural Competence Assessment Tool was used to analyse qualitative data obtained from surveys of 16 program clients and 22 individuals from partner organisations, and interviews with 15 staff. The study found that the partnership model positively impacted on the level of culturally appropriate care provided by other health service staff, particularly in hospitals. Two-way learning was a feature. Providing transport, team home visits and employing Aboriginal staff improved access to care. Grandmothers successfully brought young pregnant women into the program through their community networks, and were able to positively influence healthy lifestyle behaviours for clients. Many elements of the Aboriginal Maternity Group Practice Program contributed to the provision of a culturally competent service. These features could be considered for inclusion in antenatal care models under development in other regions with culturally diverse populations.