Maternity Care Research Research Articles

Observational Data for Integrated Maternity Care: Experiences with a Data-Infrastructure for Parents and Children in the Netherlands.

Observational data are increasingly seen as a valuable source for integrated care research. Especially since the growing availability of routinely collected data and quasi-experimental methods. The aim of this paper is to describe the potentials and challenges when using observational data for integrated maternity care research, based on our experience from developing and working with the Data-InfrAstructure for ParEnts and childRen (DIAPER). We provide a description of DIAPER, which is a linked data-infrastructure on the individual level based on maternity care claims data, quality and utilization of maternity care and data from municipal registries, covering the life course from preconception to adulthood. We then discuss potentials and practical applications of DIAPER such as to evaluate alternative payment models for integrated maternity care, to set the policy agenda regarding postpartum care, to provide insights into value of care and into provider variation, and to evaluate (policy) interventions designed to promote and support integrated maternity care. This is relevant for several stakeholders: policy makers, payers, providers and clients/patients. Based on experiences with DIAPER, we identify remaining challenges: missing data sources (especially self-reported outcomes), suboptimal quality of data, privacy concerns and potential biases introduced during data linkage, and describe how these challenges were tackled within the applications of DIAPER. With DIAPER we demonstrated that using observational data can be of added value for integrated care research, but also that challenges remain. It is essential to keep exploring and developing the possibilities of observational data and continue the discussions in the scientific community. Learning from each other's successes and failures will be critical.

Business-Consumer Communication: A Qualitative Study on Brand Equity Approach Maternity Care

Maternity care communication is a generative topic both globally and nationally. Maternity care research has predominately dealt with mental health or physical environment issues, with little focus on healthcare providers’ innovative business-consumer communication or brand management. With the application of brand equity in maternity care communication in social media cases, the purpose of the present study to investigate matching between organizational identity and the represented image. Theoretical grounding elucidates the evidence of digital innovation in action. Qualitative methodology allows eliciting further research directions with relevant research instruments. Two Lithuania-based healthcare sector organization cases with equal value parameters (time, place, activities, and context) are researched. Quantitative and qualitative data analysis, based on virtual observation, is performed. The gap between what organizations want to communicate and what they actually communicate is identified. Managerial and communication actions creating premises for collaborative behaviour and value creation by specific communication tools across such issues as medical influencers, community managers, or readiness for managing healthcare during the pandemic are surveyed. Research limitations due to the narrowness in scope, investigating only two cases within a specific field, are counterbalanced by the completeness of the quantitative and qualitative inquiry into social media data. Despite this, this innovatory study not only expands academic knowledge, suggests an instance of methodology and a research sample, possibly adaptable to varying contexts, but also implies potential issues for communication and management practitioners at healthcare institutions, suggesting apprehensible solutions. DOI : https://doi.org/10.54663/2182-9306.2022.v10.n19.184-205

Birth integrity through the lens of medicalization, risk, embodiment and intersectionality

Abstract Background Women globally report suboptimal conditions during facility-based childbirth. Most approaches that capture abuse, violence or mistreatment in epidemiology do not reflect a theoretical perspective in their measurement. In order to contribute to a more valid consideration of the cultural drivers, institutional conditions, direct expressions and individual perceptions that violate or preserve what we define as “birth integrity”, we developed a new theory-informed approach and an accompanying multilevel framework. Methods We theoretically substantiated birth integrity, referring to medical anthropology, sociology, social epidemiology and a critical-feminist theory, in particular: risk and medicalization of childbirth, social embodiment and intersectionality. We then contextualized birth integrity within a multilevel framework to operationalize its potential for epidemiological research. Results We present a six-field theoretical framework to operationalise and measure birth integrity violations, from institutional discrimination, to gender norms structuring labour room interactions and restrictions on autonomy. It allows to measure birth integrity violations that women experience at the macro-to-micro level as implicit, invisible and normalized, or explicit, visible and societally accepted. Conclusions Our new multilevel framework, based on a theory-informed construct of birth integrity, allows to measure drivers of health inequality and gender-based violence in more dimensions than so far represented in epidemiological research. Key messages The birth integrity concept integrates theories of medicalization, risk, embodiment and intersectionality into a multilevel framework. Our birth integrity framework is useful in epidemiological approaches to explicitly acknowledge and integrate cultural drivers of gender-based violence and inequalities in maternity care research.

The Importance of Patient-Centered Research in the Promotion of Postpartum Mental Health.

Though individuals, foundations, and governments have economically invested in improving maternal-child health for decades, the advancement of newborn and family health outcomes has proved elusive in multiple regions of the globe (1).1 Additionally, though researchers often seek the perspective of pregnant and postpartum patients concerning their experience of healthcare or specific models of care (2), the maternity care research issues which mothers believe ought to be prioritized are understudied (3). There is also substantial evidence of a mismatch between postpartum healthcare offerings and the support desired by mothers, particularly with regard to a relative neglect of the maternal psychosocial experience (4–7). It thus is becoming increasingly clear that mothers' experiences must be central to research aimed at improving maternal postpartum mental health. This opinion article therefore echoes calls for increased patient-centered research efforts in postpartum care (8), while emphasizing the value of this mode of inquiry for the promotion of maternal mental health specifically.

Phenomenology as a political position within maternity care.

In this article, the authors use the context of childbirth to consider the power that is endemic in certain forms of evidence within maternity care research. First, there is consideration of how the current evidence hierarchy and experimental-based studies are the gold standard to determine and direct women's maternity experiences, although this can be at the detriment of care and irrespective of women's needs. This is followed by a critique of how the predominant means to assess women's experiences via satisfaction surveys is of limited utility, offering impartial and restricted insights to assess the quality of care provision. A counter position of hermeneutic phenomenology as research method is then described. This approach offers an alternative perspective by penetrating the taken-for-granted ordinariness of an event (such as childbirth) to elicit rich emic meanings. Whilst all approaches to understanding maternity care have a place, depending on the question(s) being asked, the contribution of phenomenology is how it can uncover a depth of contextual understanding into what matters to women and to inform and transform care delivery.

Shared decision-making in maternity care: Acknowledging and overcoming epistemic defeaters.

Shared decision‐making involves health professionals and patients/clients working together to achieve true person‐centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision‐making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision‐making for caesarean section. The team concluded that shared decision‐making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision‐making (defeaters) are disclosed. Informed consent is not shared decision‐making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision‐making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required.

Protocol for the development of a salutogenic intrapartum core outcome set (SIPCOS)

BackgroundMaternity intrapartum care research and clinical care more often focus on outcomes that minimise or prevent adverse health rather than on what constitutes positive health and wellbeing (salutogenesis). This was highlighted recently in a systematic review of reviews of intrapartum reported outcomes where only 8% of 1648 individual outcomes, from 102 systematic reviews, were agreed as being salutogenically-focused. Added to this is variation in the outcomes measured in individual studies rendering it very difficult for researchers to synthesise, fully, the evidence from studies on a particular topic. One of the suggested ways to address this is to develop and apply an agreed standardised set of outcomes, known as a ‘core outcome set’ (COS). In this paper we present a protocol for the development of a salutogenic intrapartum COS (SIPCOS) for use in maternity care research and a SIPCOS for measuring in daily intrapartum clinical care.MethodsThe study proposes three phases in developing the final SIPCOSs. Phase one, which is complete, involved the conduct of a systematic review of reviews to identify a preliminary list of salutogenically-focused outcomes that had previously been reported in systematic reviews of intrapartum interventions. Sixteen unique salutogenically-focused outcome categories were identified. Phase two will involve prioritising these outcomes, from the perspective of key stakeholders (users of maternity services, clinicians and researchers) by asking them to rate the importance of each outcome for inclusion in the SIPCOSs. A final consensus meeting (phase three) will be held, bringing international stakeholders together to review the preliminary SIPCOSs resulting from the survey and to agree and finalise the final SIPCOSs for use in future maternity care research and daily clinical care.DiscussionThe expectation in developing the SIPCOSs is that they will be collected and reported in all future studies evaluating intrapartum interventions and measured/recorded in future intrapartum clinical care, as routine, alongside other outcomes also deemed important in the context of the study or clinical scenario. Using the SIPCOSs in this way, will promote and encourage standardised measurements of positive health outcomes in maternity care, into the future.

Longitudinal perspective is needed to improve postpartum health

Our attention in maternity care research and practice is focused primarily on short-term outcomes. A systematic review of randomised controlled trials evaluating perinatal interventions concluded that only a minority of trials reported offspring outcomes following hospital discharge (Teune et al. BJOG 2013;120:15–22). A parallel analysis would perhaps yield an even lower proportion of studies measuring medium to longer term maternal outcomes. This is troubling, as frameworks such as epigenetics, developmental origins of health and disease, life-course health development, and the human microbiome highlight the importance of long-term impacts of exposures during early sensitive windows of most rapid human development, with long-term impacts on childbearing women increasingly identified as well. When we shine the light on just a small area, what are we missing out there in the dark? McDonald and colleagues' Maternal Health Study investigated first-time mothers' experience of postpartum dyspareunia and the results are illuminating. Experiences of dyspareunia soared above baseline prepregnancy levels, with more than one in four participants reporting persistent dyspareunia. In the adjusted analysis emergency caesarean section was associated with persistent dyspareunia. Professional recognition of the overuse of caesarean section, calls for safely preventing such procedures, and identification of well-supported ways to do so point to opportunities to prevent persistent dyspareunia (American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine Obstet Gynecol 2014;123:693–711). Mothers and babies have the rest of their lives ahead of them, and high performing healthcare systems cannot rely primarily on myopic knowledge. With a longer view, notable proportions of women experience a range of new-onset morbidities in the weeks after giving birth, persisting in many to 6 months and beyond (Declercq et al. Listening to Mothers III: New Mothers Speak Out. New York: Childbirth Connection; 2013). We need long-term follow up in randomised controlled trials and complementary well-conducted observational studies. It is important to monitor and treat postpartum morbidity in clinical practice. In a national survey in the USA, excluding infection, more than seven out of ten participants did not seek help from a health professional for various new-onset postpartum problems (Declercq et al. Listening to Mothers; Report of the First National U.S. Survey of Women's Childbearing Experiences. New York: Maternity Center Association, 2002). A high-quality patient-reported outcome measure of composite maternal morbidity captured 4–8 weeks postpartum could improve maternal health in several ways. It could engender discussion, counselling and treatment during postpartum care. Relevant information would be captured in the health record for continued attention within primary care in settings with the capacity to share health records from other providers. More generally, such a measure could inform professionals and the public regarding maternity-care outcomes, fostering quality improvement and patient choice. Better research, measurement, prevention and treatment are needed to address issues of great interest and consequence to women during a phase of maternity care and the life cycle that have received incommensurate attention. I am a co-investigator of the Listening to Mothers surveys. I have no financial interests in matters discussed in this commentary.

Introducing video into maternity care research: Lessons learned

The Australian Bureau of Statistics reports that of the 297,900 births in 2010, 1767 babies were stillborn and a further 842 babies died during the first 4 weeks of life. The ABS also estimates that in 2007, 150,000 parents experienced early pregnancy loss and this figure is ongoing and on the increase. Evidence in the literature recognises that the death of a baby is a traumatic life event and bereaved parents experience a unique grief that may result in complicated grief because of a lack of appropriate support and understanding of the response needed. There is significant evidence that bereaved parents experience the most effective grief support through a response which includes: – ‘Permission to grieve’, recognising the significance and uniqueness of the loss; – Encourages the opportunities to create memories of their baby; – Facilitation of contact between bereaved parents in the form of peer support – delivered through one-on-one support or through support groups; and – The best maternal services by informed health professionals. At ACM 2015, SANDS would like to take the opportunity to deliver a workshop on the SANDSmodel whilst also highlighting the needs of bereaved parents in themedical situation after their baby dies. This will be a beneficial way for midwives who care for bereaved parents to learn about the bereaved parents’ grief and loss experiences around the death of their baby so that they can better anticipate and understand the needs of the bereaved parents, and how best to care and support them. Workshop outcomes: A greater understanding of SANDS’ peer support model and its benefits to bereaved parents; a greater understandingof theneedsofbereavedparentswhentheirbabydies; an insight into how to give bereaved parents ‘permission to grieve’.

The use of salutogenesis theory in empirical studies of maternity care for healthy mothers and babies

BackgroundHealth care outcomes used in service evaluation and research tend to measure morbidity and mortality. This is the case even in maternity care, where most women and babies are healthy. Salutogenesis theory recognises that health is a continuum, with explicit inclusion of well-being as well as illness and pathology. This offers the potential to reframe the outcomes and therefore, the focus of, maternity care research and provision. AimThe aim of this study was to identify how salutogenesis has been defined and used in maternity care research undertaken with healthy women. MethodA scoping review was undertaken, using a formal pre-defined search strategy. Inclusion criteria encompassed research papers relating to the maternity episode up to 1 year after birth, using salutogenesis or any of its associated concepts, focused on healthy women, and written in a language which any of the members of the group could understand. The search was undertaken in two phases (database inception – April 2011 and May 2011–February 2013). Included studies were subject to narrative analysis. FindingsEight papers met the inclusion criteria. They covered seven topics, spanning the antenatal, intrapartum and postnatal periods. Only two papers employed both positive health orientation and explicit use of Antonovsky's theory. The remaining studies used discrete aspects of the theory. ConclusionSalutogenic framing is rarely used in maternity care research with healthy participants. An increase in research that measures salutogenically orientated outcomes could, eventually, provide a balance to the current over-emphasis on pathology in maternity care design and provision worldwide.

Integrating Women's Views into Maternity Care Research and Practice

The purpose of this paper is to consider the role of women's views in maternity care research and practice: what we mean by that, how and when women's views are sought (or not), and what we should do next. It is argued that women's views are not a stand-alone extra, but integral at every stage, including having an impact on clinical outcomes. Attending to "women's views" should not only mean a post hoc assessment of experiences but also needs to consider expectations and values. Importantly, this approach needs to apply not only to the care of individual women but also to the shaping of research and policy agendas. Recommendations are made for ways in which women's views can have a more central role in research and practice in the future.

Mother knows best: Developing a consumer led, evidence informed, research agenda for maternity care

The principles of evidence-based practice and involvement of consumers in healthcare are well established. However, consumers are rarely involved in decisions about what evidence is actually required and this may result in a mismatch between research undertaken and issues of importance to those who use the health services. This may be particularly evident in maternity care where disease focused research funding priorities may not address aspects of care which are important to the majority of women. Working with service users to generate possible future research questions may facilitate more women centred research. Aim1.to work with groups of mothers to develop questions for research that reflect issues of importance to them;2.to make these questions widely available to facilitate the development of women centred maternity care research. Methodthe project used a three stage participatory approach in a diverse sample of localities across Scotland. Twelve pre-existing, community-based groups of maternity service users participated with between 8 and 20 mothers in each. Each group met twice. At the first meeting group discussion identified topics and questions. A rapid literature review of each topic was conducted and used to develop a document summarising evidence to facilitate discussion at the second meeting. The group then prioritised topic areas and questions using a modified Nominal Group Technique. Findingsanalysis identified key topics and questions which were raised and prioritised by a number of the groups; a ‘top ten’ list of priority topics was readily identified, these included aspects of postnatal care, antenatal care, communication and information giving and risk. Approximately 200 individual questions were asked by women, for example: What is the impact of a bad birth experience on postnatal physical and psychological health? What is the best way of providing antenatal classes/preparation classes? What is the effect of women feeling not listened to in labour? How can fathers be given effective preparation for coping with labour and birth and supporting their partner? Discussionthis project demonstrates that women are well able to articulate researchable questions when given the opportunity and support to do so. Although a wide range of topics and questions were identified there were remarkable areas of consensus and clear areas of priority for women, these should be used to inform development of women centred research.

Creating consumer satisfaction in maternity care: the neglected needs of migrants, asylum seekers and refugees

AbstractAn estimated 190 million people are now living outside their countries of birth or citizenship, and the rate of this migration is expected to remain high. The resulting growing cultural and ethnic diversity in societies adds specific challenges to the requirement of delivering public services such as health care to consumers. Globally, about half of the migrant population are women. Migrants’ outcomes of pregnancy are known to be poor, showing significant disparities when compared with those of native populations. Although these disparities have been noted, knowledge is limited regarding the availability and accessibility of healthcare services, as well as the acceptability of maternity care for women with experiences of free and forced migration. Healthcare research in general, and maternity care research specifically, have often neglected this population. This paper examines the existing international guidelines intended to address inequities in health outcomes, policies which have been introduced at national levels, and the widely used concepts of ‘patient‐centred’ and ‘woman‐centred’ health services. The ideals implicit in those guidelines and concepts are contrasted with the available evidence of many overseas nationals’ experiences with healthcare provisions in general, and maternity care in particular. This is followed by reflections on deficiencies in current studies and on those methodological problems which make research on maternity care for migrant women particularly challenging. The conclusion considers the appropriateness and relevance of guidelines currently promoting equity in maternity care and suggests a future agenda for priority research.

Factors That Influence Women's Decisions About Whether to Participate in Research: An Exploratory Study

Women are increasingly being asked to consider participating in medical research. We sought to investigate views of women who participated in and declined to participate in a study that was part of a program of maternity care research. An exploratory study using focus group interviews and semistructured interviews was conducted. A purposive sample of 17 postnatal women who had participated in research, from a hospital in the North West of England, were interviewed. An open coding mechanism to identify emergent themes was used for the analysis of data. Of women who had not declined to participate in any research, the following themes were identified: altruism versus self-protection, enhanced versus inferior care, professional guidance versus self-direction, and welcome versus unacceptable methodology. Of women who had participated in some research but declined to participate in other research, the following themes were identified: feeling disempowered by the process, inability to believe equipoise existed, and practical inconvenience. These findings suggest that although health care researchers adopt an individualistic approach to care, they may fail to adopt a similar approach within research. What is important and acceptable to women needs to be ascertained to develop appropriate research strategies. This plan will ensure that research is carried out to the highest ethical standard, which may increase recruitment rates.

They were different and few: An Australian study of midwives' attitudes to research and computerised research findings

This study sought to determine factors influencing the utilisation of research findings by Australian midwives before and after exposure to an on-line research database within their practice setting. The setting was a large maternity hospital in South Australia and data were collected via pre and post intervention questionnaires. 14 midwives from the Delivery Suite and Birth Centre of this hospital participated in the study. Midwives showed an increased receptivity to the concept of computerised research findings after exposure to the database. They rated research as highly important to providing quality midwifery care and for the midwifery profession, and saw midwives as the key players in maternity care research. These findings are not in keeping with previous research — largely accounted for, we believe, by the particular, and small number of, midwives who volunteered to participate in the study (24% of those invited).