Factors that promote a positive childbearing experience : a qualitative study

Introduction: Experiences of pregnancy and birth are important and have long-term impacts on the well-being of women and their families. Perinatal services should aim for care that promotes a positive childbearing experience, as well as optimizing health outcomes for the woman and newborn. This study aimed to understand the health system factors that promote a positive childbearing experience. Methods: Women who had a positive experience and had given birth in Australia in the previous 12 months were recruited for individual semistructured interviews. The interview guide focused on health system factors that participants credited with contributing to their positive experience of perinatal care. Interviews were conducted until data saturation was reached. Qualitative data were transcribed verbatim and analyzed using inductive thematic analysis. Results: Data from 36 interviews were thematically analyzed, and 4 major themes were generated: health care provider attributes, health system attributes, communication and decision-making, and experience of care. The salient factors that promoted positive experiences included care that was respectful and individualized with effective communication, access to midwifery continuity of care models, and good integration between services. Competent and professional health care providers who facilitated shared decision-making were also essential. Discussion: Although women often sought out care that promoted physiologic birth, they emphasized that the way they were cared for was more important than fulfilling specific birth aspirations. Quality maternity care has the capacity to support a woman's confidence in her own abilities and promote a positive, and sometimes transformative, childbearing experience. © 2022 The Authors. Journal of Midwifery & Women's Health published by Wiley Periodicals LLC on behalf of American College of Nurse Midwives (ACNM)

Patient Safety in Maternity Care: Towards Better Outcomes

“A healthy start to life” is a health research priority of the National Health and Medical Research Council (NHMRC). Such a start to life is, in no small way, dependant upon both a healthy pregnant woman and high quality care during her pregnancy, labour and postpartum. In Australia, 99 of every 100 babies are born in hospital. While their mothers may receive care during their pregnancy in an array of settings, acute public health services are the major provider of care.<br> <br>    When Monash Health (formerly Southern Health), Victoria’s largest provider of maternity care, opened a new maternity service, encompassing outpatient antenatal, inpatient intrapartum and immediate postpartum, and domiciliary postpartum pregnancy care, in a new green-field site hospital a formal evaluation of the service was planned to provide both detailed information about the quality of the new service and insights into opportunities for care enhancement at its other two existing sites. The work detailed in this thesis is the result of that evaluation and of a broader view at the provision of safe maternity care. The underlying premise of the evaluation was that the highest priority for the service was safety. As such, I endeavoured to measure the <i>safety</i> of the service. The approach that I took to measure safety was influenced by the international momentum to improve patient safety and by the growing and increasingly informed debate about how to measure patient safety. The resultant mixed methods approach is intended to provide rich and detailed data about the pregnancy (antenatal) care provided by the service. Pregnancy care was considered a useful measure of the service on the assumption that quality pregnancy care reduces the risk of unexpected poor outcomes. Whilst an evaluation of intrapartum care, in addition to pregnancy care, would provide a more comprehensive evaluation of the service such an evaluation was beyond the scope of this PhD. At the outset, I had hoped that the data would usefully inform the service about opportunities for future patient safety initiatives in its maternity services and I am pleased to have been told that that has been so. Since I commenced my doctoral research Victorian public maternity services have been rocked by findings of a review of Djerriwarrh Health Service’s maternity service. While the detailed findings of that review have not been made public the summary findings echoed the need for all services to have a mature and embedded culture of safety. In that regard, I hope that my findings may also offer useful insights to others responsible for maternity services more broadly.<br> <br>    The research reported in the thesis is divided into quantitative and qualitative components. The quantitative research involved the development and validation of an audit tool <i>(Chapter Three)</i> that was then applied to measure actual health care delivery against those standards <i>(Chapter Four) </i>as recorded in the health records of women attending the new maternity service for their pregnancy care. At the research site, episodes of care were documented in hard copy and retained in a health record. A copy of the health record is scanned and stored electronically. While this facilitated access to records the inherent challenges of legibility and missing information in an unregulated hardcopy medical records system remained. In addition, the complex reporting required of clinicians likely confounded data completion and veracity as clinicians, at least apparently, struggled to ensure completion of duplicate information on various unconnected platforms. Of course, this observation in itself was inherent in an overall assessment of safety and I refer to the matter in the relevant Discussion in <i>Chapter Four,</i> providing recommendations for future service design and development. Despite these challenges, my review of pregnancy care, measured against a pre-defined template of <i>standards of care</i>, suggested that there was a <br>    high level of compliance with organisational expectations reflective of a high quality service <i>(Chapter Four).</i><br> <br>    Current concepts of patient safety internationally also influenced my use of qualitative research. Hospitals in the United State of America (USA) regularly conduct surveys of hospital staff as a component of assessing the hospital’s culture of patient safety. This survey was used to develop prompt questions for interviews with staff involved with maternity care at the research site about their perceptions of the safety and quality of the service in which they work. The semi-structured interviews yielded qualitative data for thematic analysis, described in <i>Chapter Five</i>, and indicated that staff perceived their service to be safe and of high quality. Nonetheless, staff, regardless of discipline or seniority referred to numerous systems at various organizational levels to optimise patient safety. Staff emphasised the influence of relationships and the importance of respect on team performance. These and other service improvement opportunities identified by the mixed method approach that I used are explored in depth across <i>Chapters Four, Five, and Six.</i><br> <br>    The results reported herein reassure that the service is safe, with lower error rates than those reported in the literature for acute medical and surgical settings. However, the usefulness of such comparisons is debatable, prompting the need for ongoing research measuring patient safety, particularly in pregnancy care. The qualitative results detailed in <i>Chapter Five</i> reaffirm the high standards of care, arguably attributable to the high levels of trust and mutual respect among senior staff

Measuring pregnancy care: towards better maternal and child health

BACKGROUND: Obstetrics remains the largest medico‐legal liability in healthcare. Neither an increasing awareness of patient safety nor a long tradition of reporting obstetric outcomes have reduced either rates of medical error or obstetric litigation. International debate continues about the best approaches to measuring and improving patient safety. In this study, we set out to assess the feasibility and utility of measuring the process of maternity care provision rather than care outcomes. AIMS: To report the development, application and results of a tool designed to measure the process of maternity care. MATERIALS AND METHODS: A dedicated audit tool was developed, informed by local, national and international standards guiding best practice and then applied to a convenience sample of individual healthcare records as proof of function. Omissions of care were rated in order of severity (low, medium or high) based on the likelihood of serious consequences on patient safety and outcome. RESULTS: The rate of high severity omissions of care was less that 2%. However, overall rates of all omissions varied from 0 to 99%, highlighting key areas for clinical practice improvement. CONCLUSIONS: Measuring process of care provision, rather than pregnancy outcomes, is feasible and insightful, effectively identifying gaps in care provision and affording opportunities for targeted care improvement. This approach to improving patient safety, and potentially reducing litigation burden, promises to be a useful adjunct to the measurement of outcomes

How effectively do midwives manage the care of obese pregnant women? A cross-sectional survey of Australian midwives

Background: Obesity and overweight are common issues for pregnant women and their healthcare providers. Obesity in pregnancy is associated with poorer maternal and perinatal outcomes and presents particular challenges in day-to-day clinical practice.Question: The aim of this study was to examine midwifery clinical practice for obese pregnant women.Methods: We conducted a cross-sectional survey of midwives using an on-line survey distributed to members of the Australian College of Midwives. Midwives were asked about: the extent to which they provided evidence-based care; their use of a clinical guideline; their education and training and confidence to counsel obese pregnant women. Data for the questions about knowledge, clinical practice and views of education and training were summarized using descriptive statistics. Unadjusted analyses were undertaken to examine the association between use of a guideline and provision of evidence-based care and ratings of education, training and counselling.Results: The survey highlighted considerable variations in practice in the care and management of obese pregnant women. Respondents' clinical knowledge and their views about education and training and counselling skills highlighted some deficits. Those using a clinical guideline were more likely to report that they 'always': tell the woman she is overweight or obese (OR 3.5; 95% CI: 1.9, 6.4); recommend a higher dose of folic acid (OR 4.6; 95% CI: 1.9, 6.4); refer to an obstetrician (OR 2.9; 95% CI: 1.2, 3.4); prepare a pregnancy plan (OR 2.0; 95% CI: 1.2, 3.3) and plan to obtain an anaesthetic referral (OR 2.6; 95% CI: 1.5, 4.3). They were also more likely to report adequate/comprehensive education and training and greater confidence to counsel obese pregnant women.Conclusions: Registered midwives need continuing professional development in communication and counselling to more effectively manage the care of obese pregnant women. The universal use of a clinical guideline may have a positive impact by helping midwives to base early care decisions on clinical evidence. (C) 2013 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved