Maternal Care Delivery Research Articles

Maternity-care: measuring women's perceptions.

Achieving maternity-care outcomes that align with women's needs, preferences and expectations is important but theoretically driven measures of women's satisfaction with their entire maternity-care experience do not appear to exist. The purpose of this paper is to outline the development of an instrument to assess women's perception of their entire maternity-care experience. A questionnaire was developed on the basis of previous research and informed by a framework of standard service quality categories covering the spectrum of typical consumer concerns. A pilot survey with a sample of 195 women who had recent experience of birth was undertaken to establish valid and reliable scales pertaining to different stages of maternity care. Exploratory factor analysis was used to interpret scales and convergent validity was assessed using a modified version of the Client Satisfaction Questionnaire. Nine theoretically informed, reliable and valid stand-alone scales measuring the achievement of different dimensions of women's expectancies of public maternity care were developed. The study scales are intended for use in identifying some potential areas of focus for quality improvement in the delivery of maternity care. Reliable and valid tools for monitoring the extent to which services respond to women's expectations of their entire maternity care form part of the broader toolkit required to adequately manage health-care quality. This study offers guidance on the make-up of such tools. The scales produced from this research offer a means to assess maternity care across the full continuum of care and are brief and easy to use.

Perinatal deaths of migrant mothers: Adverse outcomes from unrecognised risks and substandard care factors

Migrant mothers have a high rate of perinatal mortality. We set out to investigate the reasons through a confidential enquiry of babies born to mothers who were themselves born outside of the UK. The cohort consisted of 36 perinatal deaths from three large hospitals in the West Midlands, including 30 stillbirths and six early neonatal deaths from 34 weeks' gestation, with 18 normally formed babies and 18 with congenital anomalies. The case notes were anonymised and reviewed by independent multi-professional panels to assess standard care factors and avoidability of outcome. Of the normally formed babies, nine (50%) deaths were considered potentially avoidable. The majority of cases had one or more medical (78%) or social (81%) risk factors, most of which were not identified by care providers during pregnancy. Key substandard care themes included poor translation services, inadequate information-sharing with mothers and within the multi-disciplinary team, inappropriate management planning as well as an ad hoc approach to social care and support. In addition, the majority of the perinatal deaths had not been reviewed in the Trust where they had occurred. We conclude that many migrant mothers have medical and social risks that are currently not recognised or acted on, which can result in perinatal deaths that are potentially avoidable. Good risk assessment and communication with the mother as well as within the multidisciplinary team underpins high-quality and safe delivery of maternity care.

Women's expectations and experiences of maternity care in NSW--what women highlight as most important.

Although surveys have identified that women are generally highly satisfied with maternity care provision, those aspects of care that women highlight as most important for achieving satisfaction and a satisfactory maternity care experience have not been reported. The aim of this study was to investigate how women understand and experience their maternity care and to report which aspects of care women highlight as most important. This large qualitative study explored women's expectations and experiences of maternity care provision. In-depth semi-structured interviews were conducted with 53 women experiencing maternity care in a range of tertiary, regional, rural, remote hospitals and midwife-led practices in the state of New South Wales, Australia during 2011-2012. Included in the interview schedule was the question 'What 3 aspects would you see as most important for delivery of maternity care?' Descriptive analyses of entire transcripts and responses to the question on most important aspects of care were undertaken. Descriptive analyses of women's responses identified 5 important aspects of care: woman-focused care, staff qualities, systems and facilities, family-focused care and continuity of care/information. First-time mothers were more likely to identify woman-focused care, staff qualities and continuity of care/information as important aspects than multiparous mothers. Urban and regional mothers highlighted staff qualities as having greater importance for satisfaction with their care while rural and particularly remote women nominated systems and facilities as important. Our study showed that women from a range of settings are more concerned with staff and relational issues than facilities. Differences in perceptions among primiparous versus multiparous women, at different stages of pregnancy and among women from rural and remote compared to urban settings highlight the need to include women with a diversity of experience when trying to understand the aspects of maternity care most important to women.

Maternal ability to take care of children exposed to HIV

to assess the ability of mothers to take care of children exposed to HIV, using the Assessment Scale of Care Skills for Children Exposed to HIV at Birth and to check the association between the scale dimensions and maternal characteristics. this cross-sectional study involved 62 HIV+ mothers whose children of up to one year old had been exposed to the virus at birth. The Assessment Scale of Care Skills for Children Exposed to HIV at Birth consists of 52 items and five dimensions, indicating high, moderate or low care ability. 72.7% of the mothers appropriately offered zidovudine syrup; 86.0% were highly skilled to prepare and administer milk formula; 44.4% were moderately able to prepare and administer complementary feeding; 76.5% revealed high ability to administer prophylactic treatment against pneumonia and 95.3% demonstrated high abilities for clinical monitoring and immunization. Significant associations were found between some maternal variables and the scale dimensions. the scale permits the assessment of maternal care delivery to these children and the accomplishment of specific child health interventions.

Implications for nurse managers arising from immigrant women’s experience of midwifery care in a hospital

This paper focuses on implications for nurse managers to support midwives in delivering nursing care to immigrant mothers in some government hospitals in Gauteng, South Africa. Immigration and poverty in Africa has led to midwives providing nursing care to immigrant mothers in a culturally sensitive environment. This necessitates an environment in which nurse managers should support midwives in caring for these mothers as unique individuals. An exploratory, descriptive phenomenological design was followed. The target population included nine immigrant mothers living in the inner centre of Johannesburg who, for the first time, attended, had antenatal clinics, laboured and gave birth at a Government Hospital in the Gauteng province of South Africa. After purposive sampling, phenomenological interviews were conducted until data saturation occurred. The findings indicate that nurse managers should ensure that midwifery care of immigrant mothers comply with the ethical-legal context of the South African constitution. Actions should be taken in combating issues related to impaired maternal-midwife relationship, lack of cultural sensitivity and psychological distress. The delivery of maternity care to immigrant mothers is below the standard expected in the South African context. The nurse manager should support midwives to ensure an environment to care for immigrant mothers in maternity wards.

Personal maternal care reflections of general practice physicians

As the number of female GPs increases, the need to understand delivery of maternity care to this group becomes increasingly important. Previous literature suggests doctors face additional barriers in utilizing health care compared to other patients, but little is known about GPs' maternal health care experiences and whether their occupation facilitates or compromises care. To explore female GPs' personal experiences of maternal health care and how occupation affects care received. Female GPs with children aged 6 months to 5 years were recruited from South Birmingham Primary Care Trust with subsequent snowballing. Data were obtained using semi-structured interviews and constant comparison analysis was applied to develop themes and categories. Fourteen GPs participated and no new themes emerged after interview 10 suggesting data saturation was achieved. Overall, GPs felt they received better care due to their occupation and where established relationships between the GP and the health care professional existed, communication and care satisfaction was enhanced. However, assumptions about knowledge led to reduced information provision and some problems in care provision, especially during labour and early motherhood when women were most vulnerable and unable to rely on work skills to address information deficits. This research supports the growing body of evidence that there are unique problems facing doctor-patients and clinicians treating them. However, contrary to expectations derived from anecdotal evidence, GPs indicated that care was enhanced due to their occupation. This study raises awareness of areas for consideration when female GPs approach pregnancy and health care professionals deliver maternal health care.

The dual roles of rural midwives: The potential for role conflict and impact on retention

Nurses and midwives continue to make up the largest proportion of the health workforce. As a result, shortages of nurses and midwives have a significant impact on the delivery of effective health care. Shortages of nurses and midwives are known to be more pronounced in rural and remote areas where recruitment and retention remain problematic. However, rural nurses are often required to be multi-skilled, which has led to expectations that nurses who are also midwives, are required to work across areas of the hospital to help to address shortages. For midwives this issue is even more problematic as they may actually end up spending a very small percentage of their working day involved in the delivery of maternity care. This workforce strategy has the potential to seriously erode the skills of the midwives. Situations such as this are implicated in attrition of midwives because of the role stress that results when they are required to work in models of care where they experience the constant pull to work between departments and across roles. This paper addresses the requirement for midwives in some rural facilities to work across roles of general nurse and midwife and outlines the issues that arise as a result. In particular, the paper links the concepts of Role Theory to the requirement for midwives to work in dual roles and the potential for role stress to develop.

BARIATRIC SURGERY IN PREGNANCY: BENEFITS, RISKS AND OBSTETRIC MANAGEMENT

Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that 50% of women of childbearing age are either overweight (Body Mass Index [BMI] = 24.9–29.9kg/m2) or obese with 18% starting pregnancy as obese. Obesity prevalence has doubled over a decade from the early 1990’s. In the US it is estimated that 30% of reproductive-age women have a BMI greater than 30 kg/m while 7% have a BMI > 40 kg/m2. A recent report from the UK found that 5% of women had a BMI >35 kg/m2, 2% > 40 kg/m2 and 0.2% >50 kg/m2 with an association not only with social deprivation, but also with a higher prevalence of pre-existing medical disorders such as diabetes and hypertension and medical complications of pregnancy such as preeclampsia. Obesity was also associated with increased rates of macrosomia, operative delivery and postpartum haemorrhage. These data highlight the fact that obesity is an increasing health concern particularly in young women of childbearing age. Obesity will expose them to significant pregnancy complications ranging from miscarriage and fetal abnormality through to operative delivery and thromboembolism. There are also challenges for the delivery of maternity care to meet the needs of these women. As obesity is associated with significant pregnancy complications it is important that women enter pregnancy with an optimum body weight. Many complications, such as fetal abnormality occur in the first trimester and so pre-pregnancy weight reduction is preferred. Further, there is insufficient evidence to recommend specific dietary and/or physical activity interventions to reduce weight or moderate weight gain during pregnancy.

Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative

BackgroundAustralia's Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities.MethodsWe undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4) were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems.ResultsThe proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician.ConclusionParticipating services had both strengths and weaknesses in the delivery of maternal health care. Increasing access to evidence-based screening and health information (most notably around smoking cessation) were consistently identified as opportunities for improvement across services.

What are pregnant women in a rural Niger Delta community's perceptions of conventional maternity service provision? An exploratory qualitative study.

At present there is under utilization of maternity service provision in Nigeria, with only a third of childbearing women electing to deliver in healthcare facilities. This is relevant since Nigeria's maternal mortality rate is second highest in the world and is estimated at 1,100 per 100,000 live births. To date, studies have sought cause and effect and have neglected the opinion of the people about what they perceive to be problematic and what they believe constitutes satisfactory maternity service provision. An exploratory qualitative study was carried out to identify pregnant women in a rural Niger Delta community's perceptions of conventional maternity service provision. Participants included 8 pregnant Niger Delta women from differing sub-groups within the homogeneous population. Semi-structured interviews were conducted to explore informants' views of what constitutes satisfactory maternity service provision, what comprises inadequate care, barriers that obstruct delivery of maternity care, and what promotes positive outcomes. Five major themes emerged from the data. These included: (1) Women's requirements for information; (1a) nutritional and dietary advice, (1b) how to recognise developing complications, (1c) appropriate fetal development, (1e) importance of attending clinics; (2) Staff services required: (2a) availability, (2b) well managed, and (2c) good quality; (3) Apparatus: (3a) equipment available, (3b) adequate infrastructure; (4) Affordability; (5) Place of traditional and spiritual methods. The interviewed childbearing Niger Delta women voiced several factors that they considered altered their satisfaction with maternity service provision. Finding out more about what causes satisfaction/dissatisfaction in childbearing women facilitates maternity care professionals to improve standards of care and allocate resources more effectively. Policy changes are driven by initiatives that reinforce strengths of current specification and recognise weaknesses. In addition, the WHO recommends that working towards improving health related culture is important.

Assessing the quality of maternal health care in Indigenous primary care services

TO THE EDITOR: Improving access to appropriate, good-quality care in the antenatal and postnatal period is a key part of closing the acknowledged gap between Indigenous and other Australians in perinatal outcomes. Previous research in a large Aboriginal medical service in Queensland demonstrated sustained improvements in perinatal outcome ssociated with a quality improvement approach. Here we describe patterns of the delivery of maternity care and service gaps on a broad scale, using data from baseline clinical audits in 34 Indigenous primary health centres participating in a national quality improvement intervention. Participating services were located across the Northern Territory (Top End and Central Australia), North Queensland, Far West New South Wales and Western Australia. Details of the audit methods have been described previously. Briefly, a random sample of up to 30 clinical records in each service was assessed to determine the degree of adherence to recommended protocols and procedures in the antenatal and postnatal periods. Records of women with an infant aged 2–14 months and who had been resident in the community for at least 6 months of the infant’s gestation were considered eligible for our study. The study was approved by the human research ethics committees in each region, and their Indigenous subcommittees where required. Clinical records of 535 women were assessed. Eighty-nine per cent of the women were Indigenous. However, compared with services in the NT, WA and North Queensland, services in Far West NSW had a higher proportion of nonIndigenous women presenting for antenatal or postnatal care (34% v 0–6%; P < 0.05). Overall, less than half of all women presented for care in the first trimester of pregnancy (Box, page 598). Documentation of routine antenatal investigations and brief interventions or advice regarding health behaviour varied, but generally these services appeared to be underutilised. There was relatively good documentation of follow-up of identified problems relating to hypertension or diabetes, with over 70% of identified women being referred to a general practitioner or obstetrician. However, follow-up of other identified problems, such as inadequate rubella immunity, was poor. Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors during the postnatal period was poor. For about half of all women there was documentation about breastfeeding advice and contraception. But advice about smoking, nutrition or mood (depression) was recorded for only 19%–21% of all women, and advice about sudden infant death syndrome prevention, injury prevention or infection/ hygiene was recorded for only 4%–5% of all women. The clinical audit data presented here indicate that participating services had both strengths and weaknesses in delivering maternal health care. Nevertheless, improving adherence to recommended screening investigations and brief interventions or advice about health behaviours, particularly smoking cessation, in the antenatal and postnatal period were identified as clear areas for improvement across all services. This information represents baseline data to inform the long-term monitoring of a quality improvement intervention. More broadly, it should be useful for informing local, regional and national efforts to promote and assess the quality of primary maternal health care for Indigenous women, and thus help address the persisting unacceptably high rates of poor Indigenous perinatal outcomes in Australia.

Mapping the emotional terrain of midwifery: What can we see and what lies ahead?

Greater understanding of midwives' emotion work could potentially improve practitioner/client and collegial relationships, and inform future organisation and delivery of maternity care. However, midwives' emotion work remains relatively unrecognised and under-investigated. Drawing on a previous paper (Hunter, 2001), I contrast previous and current knowledge in the field. Four key areas appear significant: impact of work context and organisation; midwife-woman relationships; collegial relationships; emotion work as coercion or gift? More research is needed into how midwives manage emotions and learn emotion management skills. Trends towards "high tech but low care solutions" (Kirkham, 2009, p.237) have implications for future emotion work study.

Ontario Care Providers’ Considerations Regarding Models of Maternity Care

ObjectiveThere is currently a crisis in the delivery of maternity care in Canada, in part due to the significant decline in the number of professionals who provide intrapartum care. This study was undertaken (1) to elicit care providers’ opinions regarding seven proposed models of maternity care, (2) to explore barriers to collaborative interprofessional practice, and (3) to identify factors that would encourage the practice of intrapartum care. MethodsA survey seeking opinions about models of care, perceived barriers to interprofessional collaboration, and factors that might encourage practising intrapartum care was mailed to all registered midwives (N = 322) and obstetricians (N = 647) in Ontario and to a stratified random sample of family physicians (N = 750) in Ontario. ResultsCompleted questionnaires were received from 80% of midwives, 64% of obstetricians, and 66% of family physicians. Midwives and obstetricians endorsed uniprofessional models and indicated an interest in multiprofessional practice. Family physicians were reluctant to choose any models that would have them practising intrapartum care. However, family physicians currently providing intrapartum care would consider the uniprofessional model in which they delivered the babies of the women they were caring for unless they were signed out. Midwives identified different philosophies of care as the main barrier to collaborative interprofessional maternity care (60.7%); obstetricians and family doctors identified liability and insurance issues (60.3% and 38.7%, respectively). An adequate on-call arrangement was the key factor potentially encouraging midwives and obstetricians to provide intrapartum care (70.3% and 70.0%, respectively). For family physicians, good medical and obstetrical back-up was the first priority (70.8%), followed by on-call arrangements. ConclusionA variety of models for providing intrapartum care must be available, as no single model meets the needs of all maternity providers. Attention must be given to eliminating barriers to collaborative interprofessional practice, coupled with enhancing factors that facilitate the delivery of intrapartum care.

Community-based delivery of maternal care in conflict-affected areas of eastern Burma: Perspectives from lay maternal health workers

In settings where active conflict, resource scarcity, and logistical constraints prevail, provision of maternal health services within health centers and hospitals is unfeasible and alternative community-based strategies are needed. In eastern Burma, such conditions necessitated implementation of the “Mobile Obstetric Maternal Health Worker” (MOM) project, which has employed a community-based approach to increase access to essential maternal health services including emergency obstetric care. Lay Maternal Health Workers (MHWs) are central to the MOM service delivery model and, because they are accessible to both the communities inside Burma and to outside project managers, they serve as key informants for the project. Their insights can facilitate program and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality. Focus group discussions ( n = 9), in-depth interviews ( n = 18), and detailed case studies ( n = 14) were collected from MHWs during centralized project management meetings in February and October of 2007. Five case studies are presented to characterize and interpret the realities of reproductive health work in a conflict-affected setting. Findings highlight the process of building supportive networks and staff ownership of the MOM project, accessing and gaining community trust and participation to achieve timely delivery of care, and overcoming challenges to manage and appropriately deliver essential health services. They suggest that some emergency obstetric care services that are conventionally delivered only within healthcare settings might be feasible in community or home-based settings when alternatives are not available. This paper provides an opportunity to hear directly from community-based workers in a conflict setting, perspectives seldom documented in the scientific literature. A rights-based approach to service delivery and its suitability in settings where human rights violations are widespread is highlighted.

Trends and factors associated with maternal mortality in Abakaliki, Nigeria.

Maternal health indices are poor in Nigeria. Regular audit of maternal deaths is vital to planning and maternal care delivery. The aim of the study was to evaluate and determine the trend of maternal mortality ratio in a Federal Medical Centre and analyze associated factors. A retrospective review of available data on all maternal deaths between January 2000 and December 2005 at the Federal Medical Centre Abakaliki was carried out.The 38 maternal deaths recorded out of 4193 deliveries during the study period resulted in a maternal mortality ratio (MMR) of 906 per 100,000 live births. In the two triennial intervals (Jan.2000- Dec.2002 and Jan.2003-Dec.2005) reviewed the MMR were 1017 and 799 per 100,000 live births respectively. The unbooked parturient accounted for over 74% of the deaths. Grandmultiparity, primigravidity, poor educational background, extremes of reproductive age and economic adversity were major factors associated with such deaths. Haemorrhage was the commonest cause of mortality during the period. Women\'s education and empowerment, provision of adequate and subsidized maternal care especially immediate postpartum are advocated to reduce maternal mortality to the barest minimum in Nigeria. Keywords : trend, maternal death, delay, unbooked, referral. Ebonyi Medical Journal Vol. 6 (1) 2007 pp. 30-36

The inverse care law in antenatal midwifery care

The material in this series of papers is derived from a Department of Health funded evaluation of the MIDIRS Informed Choice leaflets (Kirkham and Stapleton, 2001). The ‘inverse care law’ was first described over 30 years ago (Hart, 1971) and this paper reveals how little has changed in respect to the pregnancy and related health needs of the poorest and most marginalised women. Inequalities in the delivery of maternity care are examined and examples of midwifery practices which support, rather than challenge, service-related inequity are described. The assumed correlation, made by many midwives in this study, between a woman's social class and her knowledge base was not supported by data from the randomised, controlled trial. The stereotyped assumptions midwives made, however, had a direct and negative impact on the care of materially deprived women. The pressures upon midwives' time and the organisational constraints on their practice hindered the development of trusting relationships with those women most in need of strong midwifery support.

The less we do, the more we give

Across the country cost improvements in maternity care are beginning to bite deeply, just as areas with pilot continuity-of-carer schemes begin to contemplate the costs of roll-out. The effect of these resource restraints is causing some hard thinking. On the one hand, it seems that the door is open to us as midwives to regain what many have argued is our rightful place in the delivery of maternity care.

Enough work for everyone

There has always been a competitive element among the different professional groups involved in the delivery of maternity care. While midwives, GPs and obstetricians would all accept that each professional group has a contribution to make, it often seems that each group believes that the particular expertise they bring is the key tenet of good maternity care. This belief comes to light when discussion takes place about who should play the key role in the provision of maternity care. Each group will normally put up a robust argument as to why women would be best advised (within the context of informed choice) to seek at least some care from them. At a time when resources appear to be limited, and in some instances decreasing, this approach seems somewhat perverse.

Further Notes on Record Taking and Making in Maternity Care: The Case of South Asian Descent Women

This paper draws on data from a small-scale ethnographic study of the delivery of maternity care to South Asian descent women in a hospital in Southern England during 1988. Stereotyped views of these women which related to their customs and culture as well as their typification as patients were commonly expressed by staff, particularly midwives. The paper examines the role of medical records and record making in stereotyping Asian women: the ways in which stereotyped views of women may affect the record making process; and how that process itself may reinforce and create stereotypes. The utility of records for ‘rate production’ purposes is also discussed. The focus of the paper is the creation of a woman's maternity records which occurs in the antenatal clinic. The transformation of stigmatised views of a client into ‘facts’ about a client is common among bureaucrats, in this setting health service staff. This process affects the client's future encounters with the bureaucracy. In medical settings records (ie the case notes) help to create, transmit and reify negative stereotypes of health service users. These stereotypes can affect the kind of care given to individual patients.

Maternal deaths from haemorrhage double in UK

Maternal deaths due to haemorrhage have doubled in the United Kingdom since the last report from the Confidential Enquiry into Maternal Deaths, which covered 1985-7. The inquiry's latest report, covering 1988-90, also shows that deaths from sepsis have nearly doubled. “Many of the overall favourable trends seen in previous reports have not been maintained,” says the report, published by the government. “There is a need for critical reappraisal of the administration and delivery of maternity care.” The assessors for the inquiry - one in obstetrics, anaesthetics, and pathology from each health region - found evidence of substandard care in almost half of all the cases of maternal death. The report draws attention to the “significant number of cases where major problems were handled by junior doctors, a recurring theme of recent reports.” The inquiry found that 238 women died during pregnancy …