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.     

Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature

BackgroundYoung pregnant women who continue a pregnancy are primarily from a socioeconomically deprived background. The risk factors associated with low socio-economic status may independently affect perinatal and neonatal morbidity to a greater extent than the young age of the woman. Young pregnant women are frequently sceptical about health care providers who they can perceive to be judgemental. This may lead to late booking for pregnancy care, attending few appointments, or not attending the health service for any antenatal care.QuestionDoes the way maternity care is provided affect maternal and neonatal outcomes for young women?MethodA systematic search of the major health databases.ResultsNine research articles met the eligibility criteria: one randomised controlled trial, three prospective cohort studies, two comparative studies with concurrent controls, two comparative studies with historical controls, and one case series.DiscussionProviding young women with a non-standard model of maternity care has some beneficial and no known detrimental effects on childbirth outcomes. While there is a dearth of evidence on the effectiveness of a Midwifery Group Practice model of care for young women, there is strong evidence to suggest that a Group Antenatal Care model increases antenatal visit attendance and breastfeeding initiation, and decreases the risk of preterm birth. There is research to indicate that a Young Women's Clinic model may also increase antenatal visit attendance and decrease the incidence of preterm birth.ConclusionMore well-designed and resourced midwifery models of care for young women should be implemented and rigorously researched.     

“You’re a ‘high-risk’ customer”: A qualitative study of women’s experiences of receiving information from health professionals regarding health problems or complications in pregnancy

BackgroundExperiencing complications in pregnancy is stressful for women and can impact on fetal and maternal outcomes. Supportive encounters with health professionals can reduce the worry women experience. Further research is needed to understand women’s perspectives on communicating with their healthcare providers about their concerns.AimThis study explored women’s experiences of receiving information about pregnancy complications from healthcare providers and their interactions with multiple professionals and services during pregnancy.MethodsThis was a qualitative interpretive study. Semi-structured interviews were conducted with 20 women experiencing pregnancy complications recruited from antenatal services at two hospitals in Sydney. Inductive thematic analysis was used to analyse the data.FindingsWomen had a range of reactions to their diagnoses, including concern for their baby, for themselves and for their labour. Most women reported that communication with healthcare providers was distressing, they were not listened to and staff used insensitive, abrupt language. Women were also distressed by delays in education, receiving contradictory information and having to repeatedly share their stories with different health professionals. In some cases, this damaged the therapeutic relationship and reduced trust towards healthcare providers. Midwives were generally preferred over doctors because they had a more woman-centred approach.ConclusionTo improve women’s experiences of care for pregnancy complications, it is critical to improve the communication skills of maternity service providers. Women’s need for information, resources and support can best be provided by continuity of care with a named health professional, for example, a midwife working within an integrated multidisciplinary antenatal service model.     

Paperbark and pinard: A historical account of maternity care in one remote Australian Aboriginal town

Background and aimMaternity care in remote areas of the Australian Northern Territory is restricted to antenatal and postnatal care only, with women routinely evacuated to give birth in hospital. Using one remote Aboriginal community as a case study, our aim with this research was to document and explore the major changes to the provision of remote maternity care over the period spanning pre-European colonisation to 1996.MethodsOur research methods included historical ethnographic fieldwork (2007–2013); interviews with Aboriginal women, Aboriginal health workers, religious and non-religious non-Aboriginal health workers and past residents; and archival review of historical documents.FindingsWe identified four distinct eras of maternity care. Maternity care staffed by nuns who were trained in nursing and midwifery serviced childbirth in the local community. Support for community childbirth was incrementally withdrawn over a period, until the government eventually assumed responsibility for all health care.ConclusionsThe introduction of Western maternity care colonised Aboriginal birth practices and midwifery practice. Historical population statistics suggest that access to local Western maternity care may have contributed to a significant population increase. Despite population growth and higher demand for maternity services, local maternity services declined significantly. The rationale for removing childbirth services from the community was never explicitly addressed in any known written policy directive. Declining maternity services led to the de-skilling of many Aboriginal health workers and the significant community loss of future career pathways for Aboriginal midwives. This has contributed to the current status quo, with very few female Aboriginal health workers actively providing remote maternity 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.     

Pregnancy after loss during the COVID19 pandemic

BackgroundRapid changes to how maternity health care is delivered has occurred in many countries across the globe in response to the COVID-19 pandemic. Maternity care provisions have been challenged attempting to balance the needs and safety of pregnant women and their care providers. Women experiencing a pregnancy after loss (PAL) during these times face particularly difficult circumstances.AimIn this paper we highlight the situation in three high income countries (Australia, Ireland and USA) and point to the need to remember the unique and challenging circumstances of these PAL families. We suggest new practices may be deviating from established evidence-based guidelines and outline the potential ramifications of these changes.FindingsRecommendations for health care providers are suggested to bridge the gap between the necessary safety requirements due to the pandemic, the role of the health care provider, and the needs of families experiencing a pregnancy after loss.DiscussionChanges to practices i.e. limiting the number of antenatal appointments and access to a support person may have detrimental effects on both mother, baby, and their family. However, new guidelines in maternity care practices developed to account for the pandemic have not necessarily considered women experiencing pregnancy after loss.ConclusionBereaved mothers and their families experiencing a pregnancy after loss should continue to be supported during the COVID-19 pandemic to limit unintended consequences.     

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.     

‘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.     

Trust,privacy, community,and culture: Important elements of maternity care for Aboriginal and Torres Strait Islander women giving birth in Victoria.

BackgroundThe Australian maternity system must enhance its capacity to meet the needs of Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however evidence regarding what is important to women is limited.AimsThe aim of this study was to explore what women having a First Nations baby rate as important for their maternity care as well as what life stressors they may be experiencing.MethodsWomen having a First Nations baby who booked for care at one of three urban Victorian maternity services were invited to complete a questionnaire.Results343 women from 76 different language groups across Australia. Almost one third of women reported high levels of psychological distress, mental illness and/or were dealing with serious illness or death of relatives or friends. Almost one quarter reported three or more coinciding life stressors. Factors rated as most important were privacy and confidentiality (98 %), feeling that staff were trustworthy (97 %), unrestricted access to support people during pregnancy appointments, (87 %) birth (66 %) and postnatally (75 %), midwife home visits (78 %), female carers (66 %), culturally appropriate artwork, brochures (68 %) and access to Elders (65 %).ConclusionsThis study provides important information about what matters to women who are having a First Nations baby in Victoria, Australia, bringing to the forefront social and cultural complexities experienced by many women that need to be considered in programme planning. It is paramount that maternity services partner with First Nations communities to implement culturally secure programmes that respond to the needs of local communities.     

It takes a virtual village: Childbearing women's experience of a closed Facebook support group for mothers

BackgroundChildbearing women engage in large public pregnancy and parenting forums, primarily for the purpose of seeking information and advice. There is an absence of research related to women's engagement in closed and private online mothers’ groups.AimThe aim of this study was to explore the experiences of participation and support for members within a closed online mothers’ group.MethodA qualitative study using in-depth interviews. Reflexive thematic analysis was used to analyse the data.FindingsThis study demonstrated that a closed online mothers’ group enabled a group of childbearing women to overcome isolation and form sustained, evolving and supportive friendships within a small, private and trusted group. The technology allowed women to engage and share at a level much deeper than what they would in “real life”. The depth of sharing was enhanced in a closed online mothers’ group due to a smaller, private audience of trusted friends. Virtual support felt safer than face-to-face support as information could not impact one's real world reputation, and communication was able to be controlled. This was particularly helpful to women experiencing social difficulties or isolation.ConclusionThis study has provided a unique and rare insight into the private world of closed online mothers’ groups. As a virtual village, this closed group enabled childbearing women to form a small community with members sharing responsibility and working for the wellbeing and benefit of all. By encouraging, locating and establishing similar groups, maternity health professionals may assist women to access their own ‘virtual village’.     

Elements of cultural competence in an Australian Aboriginal maternity program

Background

Pregnancy, labour and neonatal health outcomes for Australian Aboriginal women and their infants are frequently worse than those of the general population. Provision of culturally competent services may reduce these differences by improving access to timely and regular antenatal care. In an effort to address these issues, the Aboriginal Maternity Group Practice Program commenced in south metropolitan Perth, Western Australia, in 2011. The program employed Aboriginal Grandmothers, Aboriginal Health Officers and midwives working in a partnership model with pre-existing maternity services in the area.

Cross-sectional survey of antenatal education attendance among nulliparous pregnant women in Sydney,Australia

BackgroundAntenatal education aims to provide expectant parents with strategies for dealing with pregnancy, childbirth and parenthood and may have the potential to reduce obstetric intervention and fear of childbirth. We aimed to investigate antenatal education attendance, reasons for and barriers to attending, and techniques taught and used to manage labour.MethodsAntenatal and postnatal surveys were conducted among nulliparous women with a singleton pregnancy at two maternity hospitals in Sydney, Australia in 2018. Classes were classified into psychoprophylaxis, birth and parenting, other, or no classes. Reasons for and barriers to attendance, demographic characteristics, and techniques taught and used in labour were compared by class type, using Pearson’s Chi Squared tests of independence.Findings724 women were surveyed antenatally. The main reasons for attending classes were to better manage the birth (86 %), feel more secure in baby care (71 %) and as a parent (60 %); although this differed by class type. Reasons for not attending classes included being too busy (33 %) and cost (27 %). Epidural, breathing techniques, massage and nitrous oxide were the most common techniques taught. Women who attended psychoprophylaxis classes used a wider range of pain relief techniques in labour. Women found antenatal classes useful preparation for birth (94 %) and parenting (74 %). Women surveyed postnatally wanted more information on baby care/sleeping and breastfeeding.ConclusionThe majority of women found antenatal education useful and utilised techniques taught. Education providers should ensure breastfeeding and infant care information is provided, and barriers to attendance such as times and cost should be addressed.     

An emerging model of maternity care: Smartphone,midwife, doctor?

BackgroundMobile technology in the form of the smartphone is widely used, particularly in pregnancy and they are an increasing and influential source of information.AimTo describe the diverse nature of pregnancy related applications (apps) for the smartphone and to flag that these apps can potentially affect maternity care and should be considered in future planning of care provision.MethodsThe 2 smartphone platforms, Apple and Android, were searched for pregnancy related apps and reviewed for their purpose and popularity.FindingsiTunes and Google Play returned 1059 and 497 pregnancy related apps respectively. Forty percent of the apps were informative, 13% interactive, 19% had features of a medical tool and 11% were social media apps. By far the most popular apps, calculated as the number of reviews multiplied by average reviewer rating, were those with interactive features.DiscussionThe popularity of pregnancy-related apps could indicate a shift towards patient empowerment within maternity care provision. The traditional model of ‘shared maternity care’ needs to accommodate electronic devices into its functioning. Reliance on healthcare professionals may be reduced by the availability of interactive and personalised information delivered via a smartphone. This combined with the fact that smartphones are widely used by many women of childbearing age, has the potential to modify maternity care and experiences of pregnancy. Therefore it is important that healthcare professionals and policy-makers are more aware of these new developments, which are likely to influence healthcare and alter health-seeking behaviour. In addition healthcare professionals need to consider whether to discuss the use of apps in pregnancy with the women in their 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.     

Pregnancy care and birth outcomes for women with moderate to super-extreme obesity

PurposeTo describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity.BackgroundMaternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40.MethodWomen with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women.Results153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1–16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n = 150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n = 74, 48.4%).ConclusionClinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.     

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.