Performance of Maternity Care from the Client's Perspective: Development and Application of the ReproQuestionnaire

This thesis focuses on the development and validation, the determination of discriminative power, and the implementation and application for quality improvement of ReproQ, a questionnaire of client experiences in maternity care. The ReproQ evaluates the responsiveness of the Dutch maternity care system, in which responsiveness is defined as the way a client is treated by the professional and the environment in which the client is treated from the client’s perspective. This thesis shows that the ReproQ is a valid and efficient measure of client experiences in maternity care, that has the ability to discriminate well across perinatal units, and is suitable for benchmarking under routine conditions

Measuring client experiences in maternity care under change

Background Maternity care is an integrated care process, which consists of different services, involves different professionals and covers different time windows. To measure performance of maternity care based on clients' experiences, we developed and validated a questionnaire. Methods and Findings We used the 8-domain WHO Responsiveness model, and previous materials to develop a self-report questionnaire. A dual study design was used for development and validation. Content validity of the ReproQ-version-0 was determined through structured interviews with 11 pregnant women (≤28 weeks), 10 women who recently had given birth (≤12 weeks), and 19 maternity care professionals. Structured interviews established the domain relevance to the women; all items were separately commented on. All Responsiveness domains were judged relevant, with Dignity and Communication ranking highest. Main missing topic was the assigned expertise of the health professional. After first adaptation, construct validity of the ReproQ-version-1 was determined through a web-based survey. Respondents were approached by maternity care organizations with different levels of integration of services of midwives and obstetricians. We sent questionnaires to 605 third trimester pregnant women (response 65%), and 810 women 6 weeks after delivery (response 55%). Construct validity was based on: response patterns; exploratory factor analysis; association of the overall score with a Visual Analogue Scale (VAS), known group comparisons. Median overall ReproQ score was 3.70 (range 1-4) showing good responsiveness. The exploratory factor analysis supported the assumed domain structure and suggested several adaptations. Correlation of the VAS rating and overall ReproQ score (antepartum, postpartum) supported validity (r = 0.56; 0.59, p< 0.001 Spearman's correlation coefficient). Pre-stated group comparisons confirmed the expected difference following a good vs. adverse birth outcome. Fully integrated organizations performed slightly better (median = 3.78) than less integrated organizations (median = 3.63; p< 0.001). Participation rate of women with a low educational level and/or a non-western origin was low. Conclusions The ReproQ appears suitable for assessing quality of maternity care from the clients' perspective. Recruitment of disadvantaged groups requires additional non-digital approaches

The discriminative power of the ReproQ

Background. The aim of the ReproQuestionnaire (ReproQ) is to measure the client's experience with maternity care, following WHO's responsiveness model. To support quality improvement, ReproQ should be able to discriminate best from worst organisational units. Methods. We sent questionnaires to 27,487 third-trimester pregnant women (response 31%) and to 37,230 women 6 weeks after childbirth (response 39%). For analysis we first summarized the ReproQ domain scores into three summary scores: total score (all eight domains), personal score (four personal domains), and setting score (four setting domains). Second, we estimated the proportion of variance across perinatal units attributable to the `actual' difference across perinatal units using intraclass correlation coefficients (ICCs). Third, we assessed the ability of ReproQ to discriminate between perinatal units based on both a statistical approach using multilevel regression analyses, and a relevance approach based on the minimally important difference (MID). Finally, we compared the domain scores of the best and underperforming units. Results. ICCs ranged between 0.004 and 0.025 for the summary scores, and between 0.002 and 0.125 for the individual domains. ReproQ was able to identify the best and worst performing units with both the statistical and relevance approach. The statistical approach was able to identify four underperforming units during childbirth (total score), while the relevance approach identified 10 underperforming units. Conclusions. ReproQ, a valid and efficient measure of client experiences in maternity care, has the ability to discriminate well across perinatal units, and is suitable for benchmarking under routine conditions

De psychometrische eigenschappen van de ReproQuestionnaire

__Abstract__ De organisatie van de geboortezorg is in beweging. Er zijn nieuwe samenwerkingsvormen, er zijn nieuwe risicobenaderingen, nieuwe verdelingen van taken en andere settings van bevallingszorg. Sommige disciplines zoals de huisarts hebben een steeds kleinere rol, andere zoals de klinisch-verloskundigen een steeds grotere. Er is geen masterplan van verandering, en er heerst op onderdelen verscheidenheid van opvatting over de wenselijke richting. Al deze veranderingen zijn - naar men stelt - gericht op het verbeteren van de kwaliteit van zorg. Hiermee wordt niet alleen het terugdringen van de perinatale sterfte (‘baby-sterfte’) beoogd, maar ook het verbeteren van de onderlinge samenwerking, met name, tussen eerstelijns verloskundigen en gynaecologen, en het realiseren van zorg die de zwangere als cliënt centraal stelt. Er is weinig informatie bekend over de huidige proceskwaliteit van de Nederlandse geboortezorg, mede door het ontbreken van daartoe geëigende lijnoverstijgende instrumenten. Kwaliteitsindicatoren zijn momenteel primair harde uitkomstindicatoren ontleend aan informatie uit zorgregistraties zoals de PRN. Deze geven wel een beeld van de medische uitkomsten, van sommige procedures, en van de belangrijkste bevallingsinterventies, maar niet van de cliëntervaringen met de zorgverlening, en ook niet van de subjectief ervaren uitkomst van c.q. bij moeder en kind. Proceskwaliteit kan men benaderen vanuit de professional bijvoorbeeld aan de hand van richtlijnen of het realiseren van procesdoelen zoals bij risicoselectie, maar dat is een ander perspectief dan de proceskwaliteit vanuit het cliëntperspectief. Ongeacht de vraag wie de zorg verleende, en los van de vraag of alle richtlijnen in acht werden genomen, is namelijk van belang of de cliënte in haar eigen ogen respect en bejegening ontving, of de communicatie in orde was, en of faciliteiten voldeden. Een en ander vraagt zorgvuldig ontwerp van vragenlijsten omdat alle betrokken professionals zeggen vanuit het cliëntperspectief te werken. Vaak, zo is ons gebleken, doelen professionals dan op het volgen van gedragsregels en richtlijnen zoals de beroepsorganisaties die aan hun leden voorschrijven. Het cliëntperspectief doet niets af aan dit professioneel perspectief, en een eindoordeel over de zorg kan ook niet zonder harde uitkomsten en procedure kwaliteit worden geveld, maar het cliëntperspectief vraagt niettemin een ander type vragen

Measuring clients’ experiences with antenatal care before or after childbirth: It matters

Background. When clients’ experiences with maternity care are measured for quality improvement, surveys are administered once, usually six weeks or more after childbirth. Most surveys conveniently cover pregnancy, childbirth and postnatal care all in one. However, the validity of measuring the experiences during pregnancy (antenatal experiences) after childbirth is unknown. We explored the relation between the measurement of antenatal experiences late in pregnancy but prior to childbirth (‘test’or gold standard) and its retrospective measurement after childbirth (retrospective test). Additionally, we explored the role of modifying determinants that explained the gap between these two measurements. Methods and Findings. Client’s experiences were measured by the ReproQuestionnaire that consists of an antenatal and postnatal version, and covers the eight WHO Responsiveness domains. 462 clients responded to the antenatal and postnatal questionnaire, and additionally filled out the repeated survey on antenatal experiences after childbirth. First, we determined the association between the test and retrospective test using three scoring models: mean score, equal or above the median score and having a negative experience. The association was moderate for having any negative experience (absolute agreement = 68%), for the median (absolute agreement = 69%) and for the mean score (ICC = 0.59). Multiple linear and logistic regression analysis for all three scoring models revealed systematic modifiers. The gap between antenatal and postnatal measurement was (partly) associated with clients’ experiences during childbirth and postnatal care and by professional discontinuity during childbirth but unrelated to the perceived health outcome. Conclusions. The antenatal experiences should be measured before and not after childbirth, as the association between the antenatal experiences measured before and after childbirth is moderate

Shared agenda making for quality improvement; towards more synergy in maternity care

OBJECTIVES: Professionals in maternity care have started working in a network approach. To further enhance the efficacy of this multidisciplinary maternity network, the identification of priorities for improvement is warranted. The aim of this study was to create key recommendations for the improvement agenda, in co-production with patients and professionals. STUDY DESIGN: We conducted a Delphi study to inventory (round 1), prioritize (round 2) and eventually approve (round 3) the improvement agenda for the maternity network. Both patients and professionals joined this study. Initial input for the study consisted of experiences from 397 patients, collected using the ReproQ questionnaire. In round 1, the expert panel, gave improvement recommendations, based on the ReproQ results. This resulted in 11 recommendations. In the second round, the expert panel prioritised these recommendations. In the consensus meeting then finally the concrete improvement agenda was composed. RESULTS: Priority scores differed considerably between patients and professionals in seven items, while four items received similar priority scores from both groups. The four most important improvement activities were: Realise more single bedrooms in hospitals; Create more opportunities for the continued presence of the community midwife during labour; Initiate a digital patient record view system for the network with a view function for patients; and Introduce a case manager for pregnant woman. CONCLUSION: Based on patient experience and the active involvement of patients and professionals, we were able to compose the shared agenda for quality improvement in maternity care

Experiences of women who planned birth in a birth centre compared to alternative planned places of birth. Results of the Dutch Birth Centre Study

Objective to assess the experiences with maternity care of women who planned birth in a birth centre and to compare them to alternative planned places of birth, by using the responsiveness concept of the World Health Organization. Design this study is a cross-sectional study using the ReproQ questionnaire filled out eight to ten weeks after birth. The primary outcome was responsiveness of birth care. Secondary outcomes included overall grades for birth care and experiences with the birth centre services. Regression analyses were performed to compare experiences among the planned places of birth. The study is part of the Dutch Birth Centre Study. Setting the women were recruited by 82 midwifery practices in the Netherlands, within the study period 1 August 2013 and 31 December 2013. Participants a total of 2162 women gave written consent to receive the questionnaire and 1181 (54.6%) women completed the questionnaire. Measurements and findings women who planned to give birth at a birth centre: (1) had similar experiences as the women who planned to give birth in a hospital receiving care of a community midwife. (2) had significantly less favourable experiences than the women who planned to give birth at home. Differences during birth were seen on the domains dignity (OR=1.58, 95% CI=1.09–2.27) and autonomy (OR=1.77, 95% CI=1.25–2.51), during the postpartum period on the domains social considerations (OR=1.54, 95% CI=1.06–2.25) and choice and continuity (OR=1.43, 95% CI=1.00–2.03). (3) had significantly better experiences than the women who planned to give birth in a hospital under supervision of an obstetrician. Differences during birth were seen on the domains dignity (OR=0.51, 95% CI=0.31–0.81), autonomy (OR=0.59, 95% CI=0.35–1.00), confidentiality (OR=0.57, 95% CI=0.36–0.92) and social considerations (OR=0.47, 95% CI=0.28–0.79). During the postpartum period differences were seen on the domains dignity (OR=0.61, 95% CI=0.38–0.98), autonomy (OR=0.52, 95% CI=0.31–0.85) and basic amenities (OR=0.52, 95% CI=0.30–0.88). More than 80% of the women who received care in a birth centre rated the facilities, the moment of arrival/departure and the continuity in the birth centre as good. Key conclusions and implications for practice in the last decades, many birth centres have been established in different countries, including the United Kingdom, Australia, Sweden and the Netherlands. For women who do not want to give birth at home a birth centre is a good choice: it leads to similar experiences as a planned hospital birth. Emphasis should be placed on ways to improve autonomy and prompt attention for women who plan to give birth in a birth centre as well as on the improvement of care in case of a referral