Different Models Of Maternity Care Research Articles

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

BackgroundPregnancy, birth, and early parenthood are significant life experiences impacting women and their families. Growing evidence suggests models of maternity care impact clinical outcomes and birth experiences. The aim of this study was to explore the strengths and limitations of different maternity models of care accessed by women in Australia who had given birth in the past 5 years.MethodsThe data analysed and presented in this paper is from the Australian Birth Experience Study (BESt), an online national survey of 133 questions that received 8,804 completed responses. There were 2,909 open-ended comments in response to the question on health care provider/s. The data was analysed using content analysis and descriptive statistics.ResultsIn models of fragmented care, including standard public hospital care (SC), high-risk care (HRC), and GP Shared care (GPS), women reported feelings of frustration in being unknown and unheard by their health care providers (HCP) that included themes of exhaustion in having to repeat personal history and the difficulty in navigating conflicting medical advice. Women in continuity of care (CoC) models, including Midwifery Group Practice (MGP), Private Obstetric (POB), and Privately Practising Midwifery (PPM), reported positive experiences of healing past birth trauma and care extending for multiple births. Compared across models of care in private and public settings, comments in HRC contained the lowest percentage of strengths (11.94%) and the highest percentage of limitations (88.06%) while comments in PPM revealed the highest percentage of strengths (95.93%) and the lowest percentage of limitations (4.07%).ConclusionsWomen across models of care in public and private settings desire relational maternity care founded on their unique needs, wishes, and values. The strengths of continuity of care, specifically private midwifery, should be recognised and the limitations for women in high risk maternity care investigated and prioritised by policy makers and managers in health services.Trial registrationThe study is part of a larger project that has been retrospectively registered with OSF Registries Registration DOI https://doi.org/10.17605/OSF.IO/4KQXP.

Project20: maternity care mechanisms that improve access and engagement for women with social risk factors in the UK – a mixed-methods, realist evaluation

ObjectivesTo evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how?DesignRealist...

Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study.

Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations. This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended. Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care. This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

Women\u2019s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

BackgroundVaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women’s experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women’s experiences when planning a VBAC in Australia.MethodsThe Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor.ResultsIn total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC.ConclusionThis study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

Women\u2019s experiences of decision-making and informed choice about pregnancy and birth care: a systematic review and meta-synthesis of qualitative research

BackgroundThe purpose of this systematic review (PROSPERO Ref: CRD42017053264) was to describe and interpret the qualitative research on parent’s decision-making and informed choice about their pregnancy and birth care. Given the growing evidence on the benefits of different models of maternity care and the prominence of informed choice in health policy, the review aimed to shed light on the research to date and what the findings indicate.Methodsa systematic search and screening of qualitative research concerning parents’ decision-making and informed choice experiences about pregnancy and birth care was conducted using PRISMA guidelines. A meta-synthesis approach was taken for the extraction and analysis of data and generation of the findings. Studies from 1990s onwards were included to reflect an era of policies promoting choice in maternity care in high-income countries.ResultsThirty-seven original studies were included in the review. A multi-dimensional conceptual framework was developed, consisting of three analytical themes (‘Uncertainty’, ‘Bodily autonomy and integrity’ and ‘Performing good motherhood’) and three inter-linking actions (‘Information gathering,’ ‘Aligning with a birth philosophy,’ and ‘Balancing aspects of a choice’).ConclusionsDespite the increasing research on decision-making, informed choice is not often a primary research aim, and its development in literature published since the 1990s was difficult to ascertain. The meta-synthesis suggests that decision-making is a dynamic and temporal process, in that it is made within a defined period and invokes both the past, whether this is personal, familial, social or historical, and the future. Our findings also highlighted the importance of embodiment in maternal health experiences, particularly when it comes to decision-making about care. Policymakers and practitioners alike should examine critically current choice frameworks to ascertain whether they truly allow for flexibility in decision-making. Health systems should embrace more fluid, personalised models of care to augment service users’ decision-making agency.

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.

The development of a classification system for maternity models of care.

A lack of standard terminology or means to identify and define models of maternity care in Australia has prevented accurate evaluations of outcomes for mothers and babies in different models of maternity care. As part of the Commonwealth-funded National Maternity Data Development Project, a classification system was developed utilising a data set specification that defines characteristics of models of maternity care. The Maternity Care Classification System or MaCCS was developed using a participatory action research design that built upon the published and grey literature. The study identified the characteristics that differentiate models of care and classifies models into eleven different Major Model Categories. The MaCCS will enable individual health services, local health districts (networks), jurisdictional and national health authorities to make better informed decisions for planning, policy development and delivery of maternity services in Australia.

The effect of midwifery care on rates of cesarean delivery

ObjectiveTo examine whether changing to a midwifery-led maternity service model was associated with a lower national rate of cesarean delivery. MethodsWe analyzed trends in the rate of cesarean delivery per 1000 live births between 1996 and 2010 in New Zealand. Estimates of relative increases in rate were calculated via Poisson regression for several maternal age groups over the study period. ResultsRates of cesarean delivery increased over the study period, from 156.9 per 1000 live births in 1996 to 235 per 1000 in 2010: a crude increase of 49.8%. Increasing trends were apparent in each age group, with the largest increases occurring before 2003 and relatively stable rates in the subsequent period. The smoothed estimate showed that the increase in cesarean rate across all age groups was 43.7% (95% confidence interval, 41.6–45.8) over the 15-year period. ConclusionA national midwifery-led care model was not associated with a decreased rate of cesarean delivery but, instead, with an increase similar to that in other high-resource countries. This indicates that other factors may account for the increase. Further research is needed to examine maternity outcomes associated with different models of maternity care.

Women's Experience of Discrimination in Australian Perinatal Care: The Double Disadvantage of Social Adversity and Unequal Care

Discrimination in women's health care, particularly perinatal care, has received minimal attention. The aim of this study is to describe women's experience of discrimination in different models of maternity care and to examine the relationship between maternal social characteristics and perceived discrimination in perinatal care. A population-based postal survey was mailed 6 months postpartum to all women who gave birth in two Australian states in September and October 2007. Perceived discrimination was assessed using a five-item measure designed to elicit information about experiences of unequal treatment by health professionals. A total of 4,366 eligible women completed the survey. Women attending public models of maternity care were significantly more likely to report perceived discrimination compared with women attending a private obstetrician (30.7% vs 19.7%, OR 1.79, 95% CI 1.5-2.1). Compared with women reporting no stressful life events or social health issues in pregnancy, those reporting three or more stressful life events or social health issues had a twofold increase in adjusted odds of perceived discrimination (41.1% vs 20.4%, adj OR 2.27, 95% CI 1.8-2.8). Young women (< 25 yr) and women who were smoking in pregnancy were also at increased risk of experiencing perceived discrimination. Discrimination is an unexplored factor in how women experience perinatal care. Developing approaches to perinatal care that incorporate the capacity to respond to the needs of vulnerable women and families requires far-reaching changes to the organization and provision of care.

Models of antenatal care and obstetric outcomes in Sydney South West

To assess obstetric outcomes of different models of antenatal care. The study was historical cohort analysis of population birth data of 67,675 singleton births delivered in all public hospitals in Sydney South-west. Maternal and neonatal outcomes were compared for different models of antenatal care received. The care was provided within the hospitals in doctor's clinic, midwives' clinic, birth centre, or by a team of midwives in the caseload midwifery. In the non-hospital settings, the care was provided by private obstetricians or by the general practitioner (GP) as part of the GP Shared Care program. The data for those women who received no antenatal care were also analysed. This study provided information that the obstetric outcomes were very similar regardless of whether a woman received her antenatal care in the midwives' clinic, the birth centre, under the GP Shared Care program or in the doctor's clinic in Sydney South-west hospitals. This study provides evidence for the view that different models of maternity care can be provided with good outcomes.

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

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. 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. 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). 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.

‘Multidisciplinary collaboration’ and ‘team work’: misnomers for subjugation?

Rhetoric in the maternity services is easy to sign up to when meaning and application remain open to individual interpretation. Who would argue against a general principle of 'choice' or 'a woman-centred service' underpinning provision? But then apply that to the woman with two previous caesarean sections who now wants a vaginal birth and the rhetoric's limitations are plain to see. It is all about how the rhetoric is understood and applied at the service delivery level. So it is with 'multidisciplinary collaboration' and 'team work'. Denis Walsh (DW) worked as a team leader midwife in a UK maternity hospital in the 1990s when 'team' was the buzzword. The midwives understood it as having an egalitarian dimension. We were equal but with different skills/experience which we bought to the table to create a synergy. Not so our 'linked obstetrician' who saw himself as in charge of the team, in effect his 'team of midwives'. From there his application degenerated into a benign paternalism at best and an intransigent despot at worst. Team for him was intrinsically hierarchical. For the rest of us it was fundamentally a democratic, consensual model. In a similar way, many a midwifery-led initiative has faltered on the altar of 'multi-disciplinary collaboration' where essentially an obstetric veto has operated. The rhetoric in 'Re-Birthing': Report of the Review of Maternity Services in Queensland is specific about carers working together and communicating. It suggests this will be fostered by joint training programs and the encouragement of open communication channels. It acknowledges that two contrasting paradigms represent obstetric interests (mechanical model) and midwifery interests (organic model), believing these can be reconciled on the ground. Getting down to the nitty-gritty of multi-disciplinary dynamics reminded us of an experience one of us (DW) had last year in the UK at a multidisciplinary forum. It is described here in full to illustrate some of the dysfunctional dynamics that can operate at this level. DW was asked to be a keynote speaker at the forum examining different models of maternity care. The topic was about the emerging evidence base for free-standing birth centres and midwifery-led services and the benefits of small scale facilities as opposed to the mega-unit. Other invited speakers gave their perspectives on the birth centre model. The session was then thrown open to general questions and discussions. There appeared to be a predominantly lay audience of maternity service users and a lively discussion ensued. Towards the end of the session, a question was taken from one of the few mate members of the audience. He stood up, introduced himself by professional group and spoke fluently and assertively on his particular perspective. In fact, he was not asking a question at all. Rather he was stating his view on the issue of birth centres. Some of what he said was critical of DW's earlier address. It was clear that he had used tried and tested strategies to further his agenda and undermine alternative views. They are detailed here: • If you want to be heard in a group, stand up rather than sit. This tiny gesture projects your voice, makes you visible to all present and enables you to scan the room as you address the group. • If you have a position of authority within your profession and work place, state it at the outset. In this particular case, it was a consultant neonatologist. This immediately establishes an authoritative impression. • Speak in absolutes and proclaim rather than express a view: 'As a paediatrician, you are never going to convince me of the safety of birth centres...' • Quote an obscure paper. 'Among your research references, you made no mention of the Australian paper that found high perinatal mortality among small rural maternity units in northwest, Western Australia'. • Finally, close with the 'worse case anecdote': 'I wonder whether everyone here heard of the small district general hospital that was closed this month after the death of four babies...'

Multidisciplinary forums: not all voices are equal

Recently, I was asked to be a keynote speaker at a multidisciplinary forum examining different models of maternity care.

Development of a multidimensional labour satisfaction questionnaire: dimensions, validity, and internal reliability

Background—No published quantitative instrument exists to measure maternal satisfaction with the quality of different models of labour care in the UK. Methods—A quantitative psychometric multidimensional maternal satisfaction questionnaire, the Women's...