The perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women: An ethnographic study

BackgroundAcross the globe, many women including economic and humanitarian migrants receive inadequate antenatal care. Understanding the difficulties that migrant women encounter when accessing maternity care, including the approach of health professionals, is necessary because inadequate care is associated with increasing rates of morbidity and mortality. There are very few studies of migrant women’s access to and experience of maternity services when they have migrated from a low- to a middle-income country.AimTo examine the perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women, and to describe women’s experiences of their encounters with health professionals providing maternity care in Ranong Province in southern Thailand.MethodsEthnography informed the study design. Individual interviews were conducted with 13 healthcare professionals and 10 Burmese women before and after birth. Observations of interactions (130 h) between health care providers and Burmese women were also conducted. Data were analysed using thematic analysis.FindingsThe healthcare professionals’ practices differed between the antenatal clinics and the postnatal ward. Numerous barriers to accessing culturally appropriate antenatal care were evident. In contrast, the care provided in the postnatal ward was woman and family centered and culturally sensitive. One overarching theme, “The system is in control’ was identified, and comprised three sub-themes (1) ‘Being processed’ (2) ‘Insensitivity to cultural practices’ and, (3) ‘The space to care’.Discussion and conclusionsThe health system and healthcare professionals controlled the way antenatal care was provided to Burmese migrant women. This bureaucratic and culturally insensitive approach to antenatal care impacted on some women’s decision to engage in antenatal care. Conversely, the more positive examples of woman-centered care evident after birth in the postnatal ward, can inform service delivery.     

‘It requires something drastic’: Interviews with health care leaders about organisational responses to social disadvantage

ProblemPersisting disparities in maternal and child health outcomes in high income countries require new insights for health service response.BackgroundSignificant social hardship, including factors related to migration, are associated with perinatal morbidity and mortality. The universality of maternity and child health care offers opportunities to reduce health disparities. Process evaluation of health service initiatives to address refugee health inequalities in Melbourne, Australia, is the setting for the study.AimTo explore the views of health service leaders about health system and service capacity to tailor care to address social adversity and reduce disparities in maternal and child health outcomes.MethodsIn-depth interviews with leaders of maternity and maternal and child health services with questions guided by a diagram to promote discussion. Thematic analysis of transcribed interviews.FindingsHealth care leaders recognised the level of social complexity and diversity of their clientele. The analysis revealed three key themes: grappling with the complexity of social disadvantage; ‘clinical risk’ versus ‘social risk’; and taking steps for system change.DiscussionPriority given to clinical requirements and routine practices together with the rising demand for services is limiting service response to families experiencing social hardship and hampering individualised care. System change was considered possible only if health service decision makers engaged with consumer and community perspectives and that of front-line staff.ConclusionAchieving equity in maternal and child health outcomes requires engagement of all key stakeholders (communities, clinicians, managers) to facilitate effective system re-design.     

Maternity services and the discharge process: A review of practice in Queensland

BackgroundEfforts to increase postnatal support available to women and families are hampered by inadequate referral mechanisms. However, the discharge process in maternity services has received little research attention.AimTo review current discharge practices in Queensland, in order to identify mechanisms to minimise fragmentation in the care of women and families as they transition from hospital-based postnatal care to community-based health and other services.MethodsA survey of discharge practices in Queensland hospitals that offer birthing services (N = 55) and content analysis of discharge summary forms used by those hospitals.FindingsFifty-two Queensland birthing hospitals participated in the study. Discharge summaries were most commonly sent to General Practitioners (83%), less commonly to Child and Family Health Nurses (CFHNs; 52%) and rarely to other care providers. Discharge summaries were usually disseminated within one week of discharge (87%), but did not capture any information about care provided by domiciliary services. Almost one-fifth (19%) of hospitals did not seek women's consent for the disclosure of their discharge summary and only 10% of hospitals had processes for women to check accuracy. Significant gaps in the content of discharge summaries were identified, particularly in psychosocial and cultural information, and post-discharge advice. The format of discharge summaries diminished their readability.ConclusionDischarge summaries (format and content) should be consistent, comprehensive and specific to maternity services. Discharge summaries should be generated and disseminated electronically at the time of discharge from the maternity service. Women should review their discharge summaries and direct and consent to its dissemination.     

Navigating infant feeding supports after migration: Perspectives of Arabic and Chinese mothers and health professionals in Australia

Optimal feeding practices can establish lifelong, transgenerational and global health benefits. Migration and cultural factors impact infant feeding practices and the support mothers receive for optimal infant feeding. This qualitative study explored support for infant feeding among Arabic and Chinese speaking migrant mothers in Australia.Semi-structured focus groups were conducted in language with 24 Arabic and 22 Chinese-Mandarin speaking migrant mothers with children under five years of age. Individual interviews were conducted in English with 20 health professionals working with Arabic or Chinese speaking migrant families. Data were thematically analysed using the framework method.Traditional family networks and trusted bi-cultural doctors were influential infant feeding supports for mothers. Health professionals perceived maternal and child health services to be poorly understood, and some mothers who accessed services felt they were not always culturally sensitive. Mothers sought additional information and support through online sources and peers. Both mothers and health professionals recognised the challenges of managing conflicting infant feeding advice and seeking best-practice support.The findings of this study highlight opportunities for health professionals to better support migrant mothers’ infant feeding practices, for example through engaging families and working with doctors. There is a need for greater cultural sensitivity within maternal and child health services and culturally relevant programs to support healthy infant feeding practices among migrant communities.     

Factors affecting rural women's utilisation of continuum of care services in remote or isolated villages or Pakistan – A mixed-methods study

IntroductionAn effective continuum of care for pregnancy and childbirth connects women and girls with essential reproductive and maternity care services. This study aimed to estimate the continuum of care utilisation rate of women who lived in remote and isolated regions of Pakistan and explored factors that influence women's utilisation of reproductive and maternity care services.MethodsA mixed-methods study was conducted in five rural villages of Sindh, Pakistan. A cross-sectional survey with 669 women who gave birth between July 2010 and September 2014 investigated women's maternity-care service utilisation during pregnancy, childbirth, and in the postpartum period. In-depth interviews with 15 women explored their maternity-care experiences with health providers.ResultsOnly 6.4% of 669 women participants reported to have completed the continuum of care for their last pregnancy. Skilled birth attendants, including health professionals, were used by 56.1% for antenatal care, 40.8% for both antenatal and childbirth, 22.3% for antenatal, childbirth and postnatal, and only 6.4% reported using all pregnancy-related and postpartum services. Limited knowledge about affordable health services, poor health literacy, and access to health services was associated with women's fragmented utilisation of maternity care. A lack of respectful maternity-care was also identified as a major barrier to women's utilisation of primary health care facilities, especially for childbirth.ConclusionThe existing primary health structure in Pakistan provides a good foundation to deliver continuity of care services; however, health services utilisation for reproductive and maternity care remains suboptimal in women who live in geographically remote regions of Pakistan.     

‘No sugar’, ‘no junk food’, ‘do more exercise’ – moving beyond simple messages to improve the health of Aboriginal women with Hyperglycaemia in Pregnancy in the Northern Territory – A phenomenological study

BackgroundGlobally, rates of hyperglycaemia in pregnancy are highest among Indigenous women. The highest prevalence has been documented among Aboriginal women in the Northern Territory of Australia. Despite knowledge of this for over two decades, there has been very limited examination of the specific needs and experiences of Aboriginal women regarding this condition.QuestionHow do Aboriginal women with hyperglycaemia in pregnancy understand and experience this condition, and how can their care be improved?MethodsA phenomenological methodology underpinned semi-structured in-depth interviews with 35 Aboriginal women and seven health professionals across the Northern Territory. Data were inductively analysed.FindingsThe findings revealed that in general, participants in this study could recite simple health messaging regarding diabetes (e.g. ‘no sugar’), but many lacked in-depth knowledge and this affected the management of their condition. Nevertheless, many identified pregnancy as a powerful motivator for change, signalling scope to improve health messaging. Women consistently expressed the need for diabetes education that was culturally appropriate, a clear desire for maternity care that was family-centred, based on respectful relationships with the same care provider, and respected Aboriginal ways of knowing and being.ConclusionExisting health messaging around hyperglycaemia in pregnancy has limited reach with Aboriginal women in the Northern Territory. Reducing the burden of hyperglycaemia in pregnancy among these women requires a sustained commitment to redesign of maternity and diabetes care to incorporate the cultural and social context of women’s lives.     

Parental experiences with changes in maternity care during the Covid-19 pandemic: A mixed-studies systematic review

BackgroundDuring the COVID-19 pandemic, pregnant women were identified as a high-risk and vulnerable group. To reduce risk of transmission, maternity healthcare services were modified to limit exposure but maintain services for pregnant women. However, the change in hospital practice may have compromised quality maternal care standards. Therefore, this review aims to explore parental experiences and views with maternity care received from healthcare institutions during the COVID-19 pandemic.MethodsA mixed studies systematic review was conducted. Six electronic databases (Medline, CINAHL, Embase, PsycInfo, Web of Science, and Maternity and Infant Care) were searched for qualitative, observational, and mixed method studies from the year 2019 to February 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Quantitative findings were converted to narrative findings. Data was synthesised thematically using a convergent synthesis design.ResultsFifty-eight articles were included. Four themes were generated: (1) Distress associated with COVID-19 regulations (perception of hospital restrictions, confusion with ever changing policies), (2) adaptability with maternity services (prenatal: changes in birth plans, prenatal: altered antenatal appointments, education, and care, intrapartum: medicalization of birth, postpartum: varied views on care received and Breastfeeding woes, postpartum: skin-to-skin contact and mother infant bonding) (3) importance of support persons, and (4) future direction for maternity services.ConclusionsParental experiences highlighted how maternity care during the COVID-19 pandemic did not adhere to WHO standards of quality maternity care. This calls for healthcare institutions to continuously appraise the implementation of restrictive practices that deviate from evidence-based frameworks underpinning quality care.     

Creating coherent perinatal care journeys: An ethnographic study of the role of continuity of care for Danish parents in a vulnerable position

BackgroundWhile continuity of care is a core element of high-quality maternity care, it is potentially even more important for pregnant women and their partners who are at risk of adverse health outcomes because of psychosocial vulnerability. However, little is known about how a coherent care journey can be ensured for women and families who may require interdisciplinary and inter-sectoral services during pregnancy and the postnatal period.AimTo explore the role of continuity of care in creating a coherent care journey for vulnerable parents during pregnancy and the postnatal period.MethodsAn ethnographic study conducted in Denmark based on interviews with, and field observations, of 26 mothers and 13 fathers receiving services due to mental health problems, young age, past substance abuse and/or adverse childhood experiences.FindingsThree key findings emerged: 1). Developing relationships allowed parents to know and feel known by care providers, which helped them feel secure and reach out for support. 2). Handover of information allowed parents to feel secure as their need for support was recognised by care providers; some parents, however, felt exposed when information was shared 3). Receiving relevant services allowed parents to have their needs for support addressed, which requires easy referral pathways and coordination of services.ConclusionAll forms of continuity of care should be prioritised in the organisation of maternity care services for women and families in vulnerable positions. While relational continuity is important, continuity of care must also reach across providers, sectors and services to ensure coherent care journeys.     

The maternal health-related issues that matter most to women in Ireland as they transition to motherhood - A qualitative study

BackgroundMany studies on women’s maternity care experiences reveal recurring issues that are poor or less than optimal. Women’s opinions on the maternal health-related issues that matter most to them are essential if care and services are to be improved.AimsTo identify the maternal health-related issues that matter most to women in Ireland, based on their own experiences of maternity care, services and motherhood.MethodsA qualitative exploratory study with 24 women. Following university ethical approval, audio-recorded one-to-one telephone interviews were conducted and thematically analysed.FindingsWe identified two themes, each with four subthemes, connected to a central concept of the invisible woman. Pendulum of care, and subthemes Inconsistent services, All about the baby, Induced anxiety and Information seesaw, illustrated the extremes of care and services that women experienced. Magnitude of motherhood, and subthemes Weight of responsibility, Real-time reassurance, Change of identity and Growth into advocacy, depicted the intensity of their new role while transitioning to motherhood.DiscussionFindings articulate the issues that mattered most to women in Ireland as they transitioned to motherhood. Some women identified specific research topics/areas, but all of the issues identified can be translated into researchable topics that seek to improve local care and service provision.ConclusionGiven the recurring nature of women’s less than satisfactory experiences of aspects of maternity care in many countries, it is likely that conducting research on issues that matters most to women will have the greatest impact on their health, wellbeing and lives as they transition to motherhood.     

Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework

ProblemMidwifery-led continuity of care has well documented evidence of benefits for mothers and babies, however uptake of these models by Australian maternity services has been slow.BackgroundIt is estimated that only 10% of women have access to midwifery-led continuity of care in Australia. The Quality Maternal Newborn Care (QMNC) Framework has been developed as a way to implement and upscale health systems that meet the needs of childbearing women and their infants. The Framework can be used to explore the qualities of existing maternity services.AimWe aimed to use the QMNC Framework to explore the qualities of midwifery-led continuity of care in two distinct settings in Australia with recommendations for replication of the model in similar settings.MethodsData were collected from services users and service providers via focus groups. Thematic analysis was used to develop initial findings that were then mapped back to the QMNC Framework.FindingsGood quality care was facilitated by Fostering connection, Providing flexibility for women and midwives and Having a sense of choice and control. Barriers to the provision of quality care were: Contested care and Needing more preparation for unexpected outcomes.DiscussionMidwifery-led continuity of carer models shift the power dynamic from a hierarchical one, to one of equality between women and midwives facilitating informed decision making. There are ongoing issues with collaboration between general practice, obstetrics and midwifery. Organisations have a responsibility to address the challenges of contested care and to prepare women for all possible outcomes to ensure women experience the best quality care as described in the framework.ConclusionThe QMNC Framework is a useful tool for exploring the facilitators and barriers to the widespread provision of midwifery-led continuity of care.     

Women's maternity care needs and related service models in rural areas: A comprehensive systematic review of qualitative evidence

BackgroundUnderstanding the needs of rural women in maternity care and service models available to them is significant for the development of effective policies and the sustainability of rural communities. Nevertheless, no systematic review of studies addressing these needs has been conducted.ObjectivesTo synthesise the best available evidence on the experiences of women's needs in maternity care and existing service models in rural areas.MethodsLiterature search of ten electronic databases, digital theses, and reference lists of relevant studies applying inclusion/exclusion criteria was conducted. Selected papers were assessed using standardised critical appraisal instruments from JBI-QARI. Data extracted from these studies were synthesised using thematic synthesis.Findings12 studies met the inclusion criteria. There were three main themes and several sub-themes identified. A comprehensive set of the maternity care expectations of rural women was reported in this review including safety (7), continuity of care (6) and quality of care (6), and informed choices needs (4). In addition, challenges in accessing maternity services also emerged from the literature such as access (6), risk of travelling (9) and associated cost of travel (9). Four models of maternity care examined in the literature were medically led care (5), GP-led care (4), midwifery-led care (7) and home birth (6).ConclusionThe systematic review demonstrates the importance of including well-conducted qualitative studies in informing the development of evidence-based policies to address women's maternity care needs and inform service models. Synthesising the findings from qualitative studies offers important insight for informing effective public health policy.     

“I knew there has to be a better way”: Women’s pathways to freebirth in Poland

BackgroundEach year a small number of women decide to birth at home without midwifery and medical assistance despite the availability of maternity services in the country. This phenomenon is called freebirth and can be used as a lens to look into shortcomings of maternity care services.AimBy exploring women’s pathways to freebirth, this article aims to examine the larger context of maternity services in Poland and identify elements of care contributing to women’s decision to birth without midwifery and medical assistance.MethodsA qualitative methodology was used employing elements of ethnographic fieldwork, including digital ethnography. Semi-structured interviews with twelve women who freebirth, analysis of online support groups, secondary sources of information and elements of participant observation were used.FindingsWomen’s decisions to freebirth were born out of their previous negative experiences with maternity care. Persistent use of medical technology and lack of respect from maternity care providers played a major role in pushing women away from available Polish maternity services. While searching for a better environment for themselves and their babies for the subsequent births, women experienced a rigidity of both mainstream and homebirth services and patchy availability of the latter that contributed to their decisions to freebirth.ConclusionsFreebirth appears to be a consequence of inadequate maternity services both mainstream and homebirth rather than a preference. Women’s freebirth experiences can be used to improve maternity care in Poland and inform similar contexts globally.     

Guilty until proven innocent? – The Assumption of Care of a baby at birth

BackgroundThis paper provides an overview of the history of child protection, the associated law and the 2008 amendments to the Child and Young Persons (Care and Protection) Act 1998 in relation to the Assumption of Care at birth Practice.ObjectiveTo explore the current practice of an Assumption of Care (AOC) where a newborn baby is removed from his/her mother at the time of birth, particularly focussing on the impact of the AOC on midwives.DiscussionAssumption of Care practices in NSW raise significant issues for midwives in relation to the midwifery codes of ethics and conduct and importantly, to their ability to work in ways that honour a “woman-centred care” philosophy. When midwives are exposed to conflict between workplace and personal or professional values such as the practice of AOC cognitive dissonance can occur.ConclusionsFurther research is required to understand the impact of current Assumption of Care. Broader research to not only look at effect on the midwife but also on other health professionals involved and the women who personally experience the removal of their baby at the time of birth. Consideration must also be given to ways of working with vulnerable families to enhance the acceptability and efficacy of maternity services and with associated agencies will decrease the need for Assumption of Care at birth.     

Demographic Research in Britain 1936–1986

We use data from the nationally representative 1997 Demographic and Reproductive Health Survey to examine use of maternity services in rural China. The data indicate that roughly 60 per cent of women had at least one prenatal visit, while 40 per cent had a professionally assisted birth over the period 1988–97. Despite China's shift from a more socialist to a more privatized health care system, use of maternity services increased over this period. These increases are consistent with the push toward integration of reproductive health into family planning that emerged after the 1994 International Conference on Population and Development and the 1995 Fourth World Women's Conference held in Beijing. At the same time, we find indirect evidence that the target-based population policy may well have exerted downward pressure on use of maternity services; differences by parity are marked and multilevel models predicting use of maternity services indicate underdispersion at the individual level.     

Afghan families and health professionals’ access to health information during and after pregnancy

BackgroundHaving a baby in a new country can be challenging, especially if unable to communicate in a preferred language. The aim of this paper is to explore the provision of health information for Afghan women and men during pregnancy, childbirth and the first year after birth in Melbourne, Australia.MethodsCommunity engagement underpinned the study design. Qualitative study with bicultural researchers conducting semi-structured interviews. Interviews and focus groups were also conducted with health professionals.ResultsSixteen Afghan women and 14 Afghan men with a baby aged 4–12 months participated. Thirty four health professionals also participated. Verbal information provided by a health professional with an interpreter was the most common way in which information was exchanged, and was generally viewed favourably by Afghan women and men. Families had limited access to an interpreter during labour and some families reported difficulty accessing an interpreter fluent in their dialect. Availability of translated information was inconsistent and health professionals occasionally used pictures to support explanations. Women and men were unsure of the role of health professionals in providing information about issues other than pregnancy and infant wellbeing.ConclusionBoth individual and health system issues hinder and enable the availability and use of information. Consistent, understandable and ‘actionable’ information is required to meet the needs of diverse families. Health professionals need to be supported with adequate alternatives to written information and access to appropriate interpreters. Inconsistent provision of information is likely to contribute to low health literacy and poor maternal and child health outcomes.     

Developing a Core Competency Model and Educational Framework for Primary Maternity Services: a national consensus approach

BackgroundAn appropriately educated and competent workforce is crucial to an effective health care system. The National Health Workforce Taskforce (now Health Workforce Australia) and the Maternity Services Inter-Jurisdictional Committee funded a project to develop Core Competencies and Educational Framework for Primary Maternity Services in Australia. These competencies recognise the interdisciplinary nature of maternity care in Australia where care is provided by general practitioners, obstetricians and midwives as well as other professionals.ParticipantsKey stakeholders from professional organisations and providers of services related to maternity care and consumers of services.MethodsA national consensus approach was undertaken using consultation processes with a Steering Committee, a wider Reference Group and public consultation.FindingsA national Core Competencies and Educational Framework for Primary Maternity Services in Australia was developed through an iterative process with a range of key stakeholders. There are a number of strategies that may assist in the integration of these into primary maternity service provider professional groups’ education and practice.ConclusionsThe Core Competencies and Educational Framework are based on an interprofessional approach to learning and primary maternity service practice. They have sought to value professional expertise and stimulate awareness and respect for the roles of all primary maternity service providers. The competencies and framework described in this paper are now a critical component of Australian maternity services as they are included in actions in the newly released National Maternity Services Plan and thus have relevance for all providers of Australian maternity services.     

Identifying and dismantling racism in Australian perinatal settings: Reframing the narrative from a risk lens to intentionally prioritise connectedness and strengths in providing care to First Nations families

IntroductionThe perinatal period is a time when provision of responsive care offers a life course opportunity for positive change to improve health outcomes for mothers, infants and families. Australian perinatal systems carry the legacy of settler-colonialism, manifesting in racist events and interactions that First Nations parents encounter daily.ObjectiveThe dominance of a western risk lens, and conscious and unconscious bias in the child protection workforce, sustains disproportionately high numbers of First Nations infants being removed from their parents’ care. Cascading medical interventions compound existing stressors and magnify health inequities for First Nations women.DesignCritical discourse was informed by Indigenous ways of knowing, being and doing via targeted dialogue with a group of First Nations and non-Indigenous experts in Australian perinatal care who are co-authors on this paper. Dynamic discussion evolved from a series of yarning circles, supplemented by written exchanges and individual yarns as themes were consolidated.ResultsFirst Nations maternity services prioritise self-determination, partnership, strengths and communication and have demonstrated positive outcomes with, and high satisfaction from First Nations women. Mainstream perinatal settings could be significantly enhanced by embracing similar principles and models of care.Conclusions and relevanceThe Australian Anti-racism in Perinatal Practice (AAPP) Alliance calls for urgent transformations to Australian perinatal models of care whereby non-Indigenous health policy makers, managers and clinicians take a proactive role in identifying and redressing ethnocentrism, judgemental and culturally blind practices, reframing the risk narrative, embedding strength-based approaches and intentionally prioritising engagement and connectedness within service delivery.