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.     

Experiences and needs of women from ethnic minorities in maternity healthcare: A qualitative systematic review and meta-aggregation

ObjectivesTo consolidate the available evidence around ethnic minority women’s experiences and needs when accessing maternity care.MethodsA qualitative systematic review and meta-aggregation of qualitative data were conducted. Nine electronic databases were searched for qualitative or mixed-methods studies from the inception of each database until January 2022. Using the Nested-Knowledge software, meta-aggregation was conducted according to the Joanna Briggs Institute (JBI) data synthesis approach to identify all potential intersections between different themes. Methodological quality of included studies was assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) and the mixed-methods appraisal tool (MMAT) checklists for qualitative and mixed-methods studies, respectively.ResultsTwenty-two studies (nineteen qualitative and three mixed-methods) were included. All studies were of good methodological quality. An overarching theme ‘the struggles and fears of ethnic minority women’ was identified. The negative experiences with maternity care were attributed to barriers including ineffective communication, cultural and religious insensitivity, inattentiveness and disregard for women’s needs, and isolation-related impact due to the COVID pandemic.ConclusionsOverall, our review highlighted several significant gaps between the care provided and the expected care among ethnic minority women accessing maternity care services. This mismatch between their expectations and care resulted in negative experiences, as the women reported being discriminated against and disrespected. There is an urgent need to develop and implement maternity care policies that are inclusive of needs of the ethnic minority women to optimize their maternity care experience.     

Women from migrant and refugee backgrounds’ perceptions and experiences of the continuum of maternity care in Australia: A qualitative evidence synthesis

BackgroundWomen who were born overseas represent an increasing proportion of women giving birth in the Australian healthcare system.ProblemWomen from migrant and refugee backgrounds have an increased risk of poor pregnancy and birth outcomes, including experiences of care.AimTo understand how women from migrant and refugee backgrounds perceive and experience the continuum of maternity care (pregnancy, birth, postnatal) in Australia.MethodologyWe conducted a qualitative evidence synthesis, searching MEDLINE, CIHAHL, and PsycInfo for studies published from inception to 23/05/2020. We included studies that used qualitative methods for data collection and analysis, that explored migrant/refugee women’s experiences or perceptions of maternity care in Australia. We used a thematic synthesis approach, assessed the methodological limitations of included studies, and used GRADE-CERQual to assess confidence in qualitative review findings.Results27 studies met the inclusion criteria, representing women in Australia from 42 countries. Key themes were developed into 24 findings, including access to interpreters, structural barriers to service utilisation, experiences with health workers, trust in healthcare, experiences of discrimination, preferences for care, and conflicts between traditional cultural expectations and the Australian medical system.ConclusionThis review can help policy makers and organisations who provide care to women from migrant and refugee backgrounds to improve their experiences with maternity care. It highlights factors linked to negative experiences of care as well as factors associated with more positive experiences to identify potential changes to practices and policies that would be well received by this population.     

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.     

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.     

Remote access and care: A comparison of Queensland women's maternity care experience according to area of residence

BackgroundThis study fills a gap in the literature with a quantitative comparison of the maternity care experiences of women in different geographic locations in Queensland, Australia.MethodData from a large-scale survey were used to compare women's care experiences according to Australian Standard Geographical Classification (major city, inner regional, outer regional, remote and very remote).ResultsCompared to the other groups, women from remote or very remote areas were more likely to be younger, live in an area with poorer economic resources, identify as Aboriginal and/or Torres Strait Islander and give birth in a public facility. They were more likely to travel to another city, town or community for birth. In adjusted analyses women from remote areas were less likely to have interventions such as electronic fetal monitoring, but were more likely to give birth in an upright position and be able to move around during labour. Women from remote areas did not differ significantly from women from major cities in their satisfaction with interpersonal care. Antenatal and postpartum care was lacking for rural women. In adjusted analyses they were much less likely to have booked for maternity care by 18 weeks gestation, to be telephoned or visited by a care provider in the first 10 days after birth. Despite these differences, women from remote areas were more likely to be breastfeeding at 13 weeks and confident in caring for their baby at home.ConclusionsFindings support qualitative assertions that remote and rural women are disadvantaged in their access to antenatal and postnatal care by the need to travel for birth, however, other factors such as age were more likely to be significant barriers to high quality interpersonal care. Improvements to maternity services are needed in order to address inequalities in maternity care particularly in the postnatal period.     

Socially disadvantaged women's views of barriers to feeling safe to engage in decision-making in maternity care

BackgroundAlthough midwifery literature suggests that woman-centred care can improve the birthing experiences of women and birth outcomes for women and babies, recent research has identified challenges in supporting socially disadvantaged women to engage in decision-making regarding care options in order to attain a sense of control within their maternity care encounters.ObjectiveThe objective of this paper is to provide an understanding of the issues that affect the socially disadvantaged woman's ability to actively engage in decision-making processes relevant to her care.Research designThe qualitative approach known as Interpretative Phenomenological Analysis was used to gain an understanding of maternity care encounters as experienced by each of the following cohorts: socially disadvantaged women, registered midwives and student midwives. This paper focuses specifically on data from participating socially disadvantaged women that relate to the elements of woman-centred care-choice and control and their understandings of capacity to engage in their maternity care encounters.FindingsSocially disadvantaged women participants did not feel safe to engage in discussions regarding choice or to seek control within their maternity care encounters. Situations such as inadequate contextualised information, perceived risks in not conforming to routine procedures, and the actions and reactions of midwives when these women did seek choice or control resulted in a silent compliance. This response was interpreted as a consequence of women's decisions to accept responsibility for their baby's wellbeing by delegating health care decision-making to the health care professional.ConclusionThis research found that socially disadvantaged women want to engage in their care. However without adequate information and facilitation of choice by midwives, they believe they are outsiders to the maternity care culture and decision-making processes. Consequently, they delegate responsibility for maternity care choices to those who do belong; midwives. These findings suggest that midwives need to better communicate a valuing of the woman's participation in decision-making processes and to work with women so they do have a sense of belonging within the maternity care environment. Midwives need to ensure that socially disadvantaged women do feel safe about having a voice regarding their choices and find ways to give them a sense of control within their maternity care encounters.     

South-Asian women’s experiences of earlier additional,fetal monitoring to reduce stillbirth: An exploratory qualitative study

BackgroundIn an attempt to reduce the rates of stillbirth at term among South-Asian born women, Victoria’s largest maternity service, Monash Health, implemented a new clinical guideline in 2017 that recommended additional earlier, twice weekly monitoring to assess fetal wellbeing from 39 weeks for South-Asian women. In acknowledging the importance of woman centred, culturally responsive care, this study aimed to understand South-Asian women’s, experiences, of the additional earlier fetal monitoring.MethodsAn exploratory qualitative study was conducted using semi-structured phone interviews six weeks postpartum, across June and July 2021, with South-Asian born women who underwent the earlier monitoring from 39 weeks. Women were asked questions regarding their understanding of the monitoring, their experiences of the monitoring process and any impact the monitoring or results had on their pregnancy, labour and birth. Interviews were recorded and transcribed verbatim. Data were analysed using a thematic approach and an inductive coding strategy.ResultsSeventeen women from India, Sri Lanka, Pakistan and Afghanistan were interviewed. the main themes were i: gaining peace of mind, need for better communication, did the women really have a choice? and comparisons to maternity care in the country of origin. Women experienced positive reassurance of their baby’s well-being from the monitoring and were happy with the earlier, extra care. However, women described receiving variable explanations of the purpose of the monitoring. Ineffective communication and logistical barriers were highlighted to negatively impact women's ability to engage in shared decision making and their overall experience of the earlier monitoring.ConclusionsThe additional monitoring is reported by these women to have an overall positive impact on their maternity care. Future work should explore the experiences of non-English speaking South-Asian women and those who declined monitoring.     

Developing an instrument to measure satisfaction with continuity of midwifery care drawing on the Delphi technique

BackgroundMaternal satisfaction with maternity care is an important indicator of quality maternity services. Continuity of midwifery models of care are increasing in Australia and while several instruments have been developed to measure satisfaction with maternity care most of these have not been validated and there are none that are appropriate to continuity of midwifery maternity care models.AimTo develop a questionnaire to measure women’s satisfaction with maternity services provided in a continuity of midwifery care service model.MethodsA modified Delphi technique was used. A heterogenous panel of eight experts provided feedback over four rounds. The starting point for the questionnaire was informed by two systematic literature reviews focusing on available instruments for measuring maternal satisfaction with maternity care and what women value continuity of midwifery models of care.FindingsThe Continuity of Midwifery Care Satisfaction Survey (COMcareSS) was developed after four rounds of feedback with the expert panel. The survey comprises nine domains and fifty-nine questions. The domains include demographics, maternity care outcomes, facilities, the midwife/woman relationship, building capacity-empowerment, decision making and involvement, personalised care, advice care and support and general.ConclusionsConsumer satisfaction is an important indicator of quality care. This is the first instrument to be developed that is appropriate to continuity of midwifery models of care. The important next step is to pilot test the instrument to establish its validity and reliability.     

Women’s experiences of their maternity care: A principle- based concept analysis

BackgroundDespite many countries employing the use of national and large scale regional surveys to explore women’s experiences of their maternity care, with the results informing national maternity policy and practice, the concept itself is ambiguous and ill-defined having not been subject of a structured concept development endeavour.AimThe aim of this review is to report on an in-depth analysis conducted on the concept of ‘women’s experiences of their maternity care’.MethodsUsing the principle-based method of concept analysis by Penrod and Hupcey (2005), the concept of ‘women’s experiences of their maternity care’ was analysed under the epistemological, pragmatic, linguistic and logical principles. The final dataset included 87 items of literature published between 1990 and 2017 retrieved from a systematic search of the MEDLINE, CINAHL, EMBASE and PSYCinfo databases.FindingsThe epistemological principle identified that a theoretical definition of the concept is elusive with a variety of implicit meanings. The pragmatic principle supports the utility of the concept in scientific literature, however the lack of a theoretical definition has led to inconsistent use of the concept, as highlighted by the linguistic principle. Furthermore, the logical principle highlighted that as the concept lacks definition blurring is identifiable when theoretically positioned with related concepts.ConclusionThe outcome of this concept analysis is a theoretical definition of a previously undefined concept. This definition highlights the subjective nature of the concept, its dependency upon a woman’s individual needs, expectations and circumstances and the influence of the organisation and delivery of maternity care.     

‘I really needed help’: What mothers say about their post-birth care in Queensland,Australia

BackgroundAustralian mothers consistently rate postnatal care as the poorest aspect of their maternity care, and researchers and policymakers have widely acknowledged the need for improvement in how postnatal care is provided.AimTo identify and analyse mothers’ comments about postnatal care in their free text responses to an open ended question in the Having a Baby in Queensland Survey, 2010, and reflect on their implications for midwifery practice and maternity service policies.MethodsThe survey assessed mothers’ experiences of maternity care four months after birth. We analysed free-text data from an open-ended question inviting respondents to write ‘anything else you would like to tell us’. Of the final survey sample (N = 7193), 60% (N = 4310) provided comments, 26% (N = 1100) of which pertained to postnatal care. Analysis included the coding and enumeration of issues to identify the most common problems commented on by mothers. Comments were categorised according to whether they related to in-hospital or post-discharge care, and whether they were reported by women birthing in public or private birthing facilities.ResultsThe analysis revealed important differences in maternal experiences according to birthing sector: mothers birthing in public facilities were more likely to raise concerns about the quality and/or duration of their in-hospital stay than those in private facilities. Conversely, mothers who gave birth in private facilities were more likely to raise concerns about inadequate post-discharge care. Regardless of birthing sector, however, a substantial proportion of all mothers spontaneously raised concerns about their experiences of inadequate and/or inconsistent breastfeeding support.ConclusionWomen who birth in private facilities were more likely to spontaneously report concerns about their level of post-discharge care than women from public facilities in Queensland, and publically provided community based care is not sufficient to meet women's needs. Inadequate or inconsistent professional breastfeeding support remains a major issue for early parenting women regardless of birthing sector.     

Women's access needs in maternity care in rural Tasmania,Australia: A mixed methods study

ObjectivesThis study investigates (i) maternity care access issues in rural Tasmania, (ii) rural women's challenges in accessing maternity services and (iii) rural women's access needs in maternity services.MethodsA mixed-method approach using a survey and semi-structured interviews was conducted. The survey explored women's views of rural maternity services from antenatal to postnatal care, while interviews reinforced the survey results and provided insights into the access issues and needs of women in maternity care.FindingsThe survey was completed by n = 210 women, with a response rate of 35%, with n = 22 follow-up interviews being conducted. The survey indicated the majority of rural women believed antenatal education and check-ups and postnatal check-ups should be provided locally. The majority of women surveyed also believed in the importance of having a maternity unit in the local hospital, which was further iterated and clarified within the interviews. Three main themes emerged from the interview data, namely (i) lack of access to maternity services, (ii) difficulties in accessing maternity services, and (iii) rural women's access needs.ConclusionThe study suggested that women's access needs are not fully met in some rural areas of Tasmania. Rural women face many challenges when accessing maternity services, including financial burden and risk of labouring en route. The study supports the claim that the closure of rural maternity units shifts cost and risk from the health care system to rural women and their families.     

Reasons for women's non-participation in follow-up screening after gestational diabetes

BackgroundDue to the increased risk of type 2 diabetes, follow-up screening after birth is recommended to women with previous gestational diabetes. Low participation in such screening has been shown to delay detection of diabetes with potentially serious consequences for the women's future health. The women's experiences of treatment and care during their pregnancies may affect participation.AimThis study aimed at understanding the women's experiences with treatment and care during pregnancy and to understand how these experiences influence participation in follow-up screening.MethodsA qualitative study was undertaken drawing on a phenomenological methodology. Seven women treated for gestational diabetes at a university hospital in the North Denmark Region participated in interviews.FindingsThe women experienced lack of continuity in care between hospital departments and health sectors. We identified the following causes for low participation in follow-up screening: poor coordination, little elaboration of information, a lack of clear coordination of responsibility for follow-up screening among health care professionals and absence of focus and inclusion of their individual needs and preferences.ConclusionThe women wished to be reminded of screening to increase their sense of safety. The women's experiences seem to reflect a lack of patient-centeredness during the pregnancy, which may be remedied by increasing the focus on the women's need for improved continuity in treatment and care. Participation in follow-up screening after gestational diabetes may be increased by sending reminders to the women. Raised awareness of the women's individual needs and preferences for treatment and care offers potential for improvement.     

Midwifery continuity of care for women with complex pregnancies in Australia: An integrative review

BackgroundAll women require access to quality maternity care. Continuity of midwifery care can enhance women’s experiences of childbearing and is associated with positive outcomes for women and infants. Much research on these models has been conducted with women with uncomplicated pregnancies; less is known about outcomes for women with complexities.AimTo explore the outcomes and experiences for women with complex pregnancies receiving midwifery continuity of care in Australia.MethodsThis integrative review used Whittemore and Knafl’s approach. Authors searched five electronic databases (PubMed/MEDLINE, EMBASE, CINAHL, Scopus, and MAG Online) and assessed the quality of relevant studies using the Critical Appraisal Skills Programme (CASP) appraisal tools.FindingsFourteen studies including women with different levels of obstetric risk were identified. However, only three reported outcomes separately for women categorised as either moderate or high risk. Perinatal outcomes reported included mode of birth, intervention rates, blood loss, perineal trauma, preterm birth, admission to special care and breastfeeding rates. Findings were synthesised into three themes: ‘Contributing to safe processes and outcomes’, ‘Building relational trust’, and ‘Collaborating and communicating’. This review demonstrated that women with complexities in midwifery continuity of care models had positive experiences and outcomes, consistent with findings about low risk women.DiscussionThe nascency of the research on midwifery continuity of care for women with complex pregnancies in Australia is limited, reflecting the relative dearth of these models in practice.ConclusionDespite favourable findings, further research on outcomes for women of all risk is needed to support the expansion of midwifery continuity of care.     

Clinical practice guidelines for perinatal bereavement care — An overview

BackgroundHigh quality perinatal bereavement care is critical for women and families following stillbirth or newborn death. It is a challenging area of practice and a difficult area for guideline development due to a sparse and disparate evidence base.AimWe present an overview of the newly updated Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Excellence guideline for perinatal bereavement care. The guideline aims to provide clear guidance for maternity health care providers and their services to support the provision of care that meets the needs of bereaved parents.DiscussionThe Guideline for Respectful and Supportive Perinatal Bereavement Care is underpinned by a review of current research combined with extensive stakeholder consultation that included parents and their organisations and clinicians from a variety of disciplines. The Guideline contains 49 recommendations that reflect five fundamental goals of care: good communication; shared decision-making; recognition of parenthood; effective support; and organisational response.ConclusionBest available research, parents’ lived experiences and maternity care providers’ insights have contributed to a set of implementable recommendations that address the needs of bereaved parents.