Integrated maternity care: A concept analysis.

INTRODUCTION: Integrated maternity care is strongly promoted in the Netherlands. However, the term 'integrated' and its practical meaning is understood differently by professionals and policy makers. This lack of clarity is also visible in other countries and hinders implementation. In this study, we will examine how the concept of 'integrated maternity care' and its defining attributes are presented in the international literature. METHODS: This study aims to provide a definition and deeper understanding of the concept of integrated maternity care by conducting a concept analysis using Morse's method. We performed a systematic search using Embase and Ebscohost (CINAHL, PsychINFO, SocINDEX, MEDLINE) including records that described integrated maternity care from on organizational perspective. Through a qualitative analysis of the selected research and non-research records, we identified defining attributes, boundaries, antecedents, and consequences of the concept. Subsequently, we constructed a definition of the concept based on the findings. RESULTS: We included 36 records on integrated maternity care in the period from 1978 to 2022. Our search included 21 research and 15 non-research records (e.g. guidelines and policy records). Only half of these had a definition of integrated maternity care. Over time, the definition became more specific. Our concept analysis resulted in three defining attributes of integrated maternity care: collaboration, organizing collaboration and woman-centeredness. We identified role clarity, a culture of collaboration, and clear and timely communication as antecedents of integrated maternity care. A number of consequences were found: continuity of care, improved outcomes, and efficiency. All consequences were described as expected effects of integrated maternity care and not based on evidence. CONCLUSION: We propose the following definition: 'Integrated maternity care is woman-centred care provided by (maternity) care professionals collaborating together within and across different levels of healthcare with a specific focus on organizing seamless care.' Addressing the antecedents is important for the successful implementation of integrated maternity care.

The extent of implementation and perceptions of maternity and social care professionals about two interprofessional programs for care for pregnant women: a mixed methods study.

BACKGROUND: In 2018, the Dutch government initiated the Solid Start program to provide each child with the best start in life. Key program elements are a biopsychosocial perspective on pregnancy and children's development and stimulating local collaborations between social and health domains, with a specific focus on (future) families in vulnerable situations. Two programs for interprofessional collaboration between maternity and social care professionals to optimize care for pregnant women in vulnerable situations were developed and implemented, in Groningen in 2017 and in South Limburg in 2021. This paper describes the extent of implementation of these programs and the perceptions of involved professionals about determinants that influence program implementation. METHODS: We conducted a mixed-methods study in 2021 and 2022 in two Dutch regions, Groningen and South Limburg. Questionnaires were sent to primary care midwives, hospital-based midwives, obstetricians (i.e. maternity care professionals), (coordinating) youth health care nurses and social workers (i.e. social care professionals), involved in the execution of the programs. Semi-structured interviews were held with involved professionals to enrich the quantitative data. Quantitative and qualitative data were collected and analyzed using Fleuren's implementation model. RESULTS: The findings of the questionnaire (n = 60) and interviews (n = 28) indicate that professionals in both regions are generally positive about the implemented programs. However, there was limited knowledge and use of the program in Groningen. Promoting factors for implementation were mentioned on the determinants for the innovation and the user. Maternity care professionals prefer a general, conversational way to identify vulnerabilities that connects to midwives' daily practice. Low-threshold, personal contact with clear agreements for referral and consultation between professionals contributes to implementation. Professionals agree that properly identifying vulnerabilities and referring women to appropriate care is an important task and contributes to better care. On the determinants of the organization, professionals indicate some preconditions for successful implementation, such as clearly described roles and responsibilities, interprofessional training, time and financial resources. CONCLUSIONS: Areas for improvement for the implementation of interprofessional collaboration between maternity care and social care focus mainly on determinants of the organization, which should be addressed both regionally and nationally. In addition, sustainable implementation requires continuous awareness of influencing factors and a process of evaluation, adaptation and support of the target group.

Exploring psychosocial vulnerability among Dutch pregnant women: a register study.

In the Netherlands adverse perinatal outcomes are also associated with non-medical factors which vary across geographical locations. This study analyses the presence of non-medical vulnerabilities in pregnant women in two regions with high numbers of psychosocial adversity using the same definition for vulnerability in both regions. A register study was performed in 2 regions. Files from women in midwife-led care were analyzed using a standardized case report form addressing non-medical vulnerability based on the Rotterdam definition for vulnerability: measurement A in Groningen (n = 500), measurement B in South-Limburg (n = 538). Only in South-Limburg a second measurement was done after implementing an identification tool for vulnerability (C (n = 375)). In both regions about 10% of pregnant women had one or more urgent vulnerabilities and almost all of these women had an accumulation of several urgent and non-urgent vulnerabilities. Another 10% of women had an accumulation of three or more non-urgent vulnerabilities. This study showed that by using the Rotterdam definition of vulnerability in both regions about 20% of pregnant women seem to live in such a vulnerable situation that they may need psychosocial support. The definition seems a good tool to determine vulnerability. However, without considering protective factors it is difficult to establish precisely women's vulnerability. Research should reveal whether relevant women receive support and whether this approach contributes to better perinatal and child outcomes.

Development of the Conversational Health Literacy Assessment Tool for maternity care (CHAT-maternity-care): participatory action research.

BACKGROUND: Limited health literacy in (expectant) parents is associated with adverse health outcomes. Maternity care providers often experience difficulties assessing (expectant) parents' level of health literacy. The aim was to develop, evaluate, and iteratively adapt a conversational tool that supports maternity care providers in estimating (expectant) parents' health literacy. METHODS: In this participatory action research study, we developed a conversational tool for estimating the health literacy of (expectant) parents based on the Conversational Health Literacy Assessment Tool for general care, which in turn was based on the Health Literacy Questionnaire. We used a thorough iterative process including different maternity care providers, (expectant) parents, and a panel of experts. This expert panel comprised representatives from knowledge institutions, professional associations, and care providers with whom midwives and maternity care assistants work closely. Testing, evaluation and adjustment took place in consecutive rounds and was conducted in the Netherlands between 2019 and 2022. RESULTS: The conversational tool 'CHAT-maternity-care' covers four key domains: (1) supportive relationship with care providers; (2) supportive relationship within parents' personal network; (3) health information access and comprehension; (4) current health behaviour and health promotion. Each domain contains multiple example questions and example observations. Participants contributed to make the example questions and example observations accessible and usable for daily practice. The CHAT-maternity-care supports maternity care providers in estimating (expectant) parents' health literacy during routine conversations with them, increased maternity care providers' awareness of health literacy and helped them to identify where attention is necessary regarding (expectant) parents' health literacy. CONCLUSIONS: The CHAT-maternity-care is a promising conversational tool to estimate (expectant) parents' health literacy. It covers the relevant constructs of health literacy from both the Conversational Health Literacy Assessment Tool and Health Literacy Questionnaire, applied to maternity care. A preliminary evaluation of the use revealed positive feedback. Further testing and evaluation of the CHAT-maternity-care is required with a larger and more diverse population, including more (expectant) parents, to determine the effectiveness, perceived barriers, and perceived facilitators for implementation.

Needs of parents and professionals to improve shared decision-making in interprofessional maternity care practice: A qualitative study.

BACKGROUND: Shared decision-making (SDM) is a critical but challenging component of high quality maternity care. In co-creation with parents and professionals, we are developing an intervention to improve SDM. As a first step we aimed to explore the experiences and needs of parents and professionals regarding shared decision-making in interprofessional antenatal, natal, and postnatal care. METHODS: We organized 11 focus groups in the Netherlands in November and December 2016. Parents, primary care midwives, hospital-based midwives, obstetricians, obstetric nurses, and maternity care assistants participated. RESULTS: Parents and professionals recognized the SDM steps of introducing a decision (choice talk) and discussing options (option talk), but most parents did not seem to discuss preferences and weigh options with professionals before making their final decision (decision talk). Barriers to SDM were often related to interprofessional collaboration, while good communication skills of parents and professionals facilitated SDM. An intervention to improve SDM would need to: (a) increase awareness and offer insight into the SDM process and roles and responsibilities of parents and professionals, (b) develop good communication skills, and (c) encourage interprofessional collaboration. The preferred design of the intervention was online, interactive, and practical. CONCLUSIONS: Parents and professionals will benefit from an intervention designed to improve SDM. A practical e-learning for all maternity care providers and e-health information for parents seems most appropriate. Key elements for the e-learning are raising awareness of the roles and responsibilities of parents and professionals, developing good communication skills and encouraging interprofessional collaboration. This requires a variety of educational strategies.

Birth place preferences and women's expectations and experiences regarding duration and pain of labor.

INTRODUCTION: We know a great deal about how childbirth is affected by setting; we know less about how the experience of birth is shaped by the attitudes women bring with them to the birthing room. In order to better understand how women frame childbirth, we examined the relationship between birth place preference and expectations and experiences regarding duration of labor and labor pain in healthy nulliparous women. METHODS: A prospective cohort study (2007-2011) of 454 women who preferred a home birth (n = 179), a midwife-led hospital birth (n = 133) or an obstetrician-led hospital birth (n = 142) in the Netherlands. Data were collected using three questionnaires (before 20 weeks gestation, 32 weeks gestation and 6 weeks postpartum) and medical records. Analyses were performed according to the initial preferred place of birth. RESULTS: Women who preferred a home birth were significantly less likely to be worried about the duration of labor (OR 0.5, 95%CI 0.2-0.9) and were less likely to expect difficulties with coping with pain (OR 0.4, 95%CI 0.2-0.8) compared with women who preferred an obstetrician-led birth. We found no significant differences in postpartum accounts of duration of labor. When compared to women who preferred an obstetrician-led birth, women who preferred a home birth were significantly less likely to experience labor pain as unpleasant (OR 0.3, 95%CI 0.1-0.7). Women who preferred a midwife-led birth - either home or hospital - were more likely to report that it was not possible to make their own choices regarding pain relief compared to women who preferred obstetrician-led care (OR 4.3, 95%CI 1.9-9.8 resp. 3.4, 95%CI 1.5-7.7). Compared to women who preferred a midwife-led hospital birth, women who preferred a home birth had an increased likelihood of being dissatisfied about the management of pain relief (OR 2.5, 95%CI 1.1-6.0). DISCUSSION: Our findings suggest a more natural orientation toward birth with the acceptance of labor pain as part of giving birth in women with a preference for a home birth. Knowledge about women's expectations and experiences will help caregivers to prepare women for childbirth and will equip them to advise women on birth settings that fit their cognitive frame.

The influence of preferred place of birth on the course of pregnancy and labor among healthy nulliparous women: a prospective cohort study.

BACKGROUND: Most studies on birth settings investigate the association between planned place of birth at the start of labor and birth outcomes and intervention rates. To optimize maternity care it also is important to pay attention to the entire process of pregnancy and childbirth. This study explores the association between the initial preferred place of birth and model of care, and the course of pregnancy and labor in low-risk nulliparous women in the Netherlands. METHODS: As part of a Dutch prospective cohort study (2007-2011), we compared medical indications during pregnancy and birth outcomes of 576 women who initially preferred a home birth (n = 226), a midwife-led hospital birth (n = 168) or an obstetrician-led hospital birth (n = 182). Data were obtained by a questionnaire before 20 weeks of gestation and by medical records. Analyses were performed according to the initial preferred place of birth. RESULTS: Low-risk nulliparous women who preferred a home birth with midwife-led care were less likely to be diagnosed with a medical indication during pregnancy compared to women who preferred a birth with obstetrician-led care (OR 0.41 95% CI 0.25-0.66). Preferring a birth with midwife-led care - both at home and in hospital - was associated with lower odds of induced labor (OR 0.51 95% CI 0.28-0.95 respectively OR 0.42 95% CI 0.21-0.85) and epidural analgesia (OR 0.32 95% CI 0.18-0.56 respectively OR 0.34 95% CI 0.19-0.62) compared to preferring a birth with obstetrician-led care. In addition, women who preferred a home birth were less likely to experience augmentation of labor (OR 0.54 95% CI 0.32-0.93) and narcotic analgesia (OR 0.41 95% CI 0.21-0.79) compared to women who preferred a birth with obstetrician-led care. We observed no significant association between preferred place of birth and mode of birth. CONCLUSIONS: Nulliparous women who initially preferred a home birth were less likely to be diagnosed with a medical indication during pregnancy. Women who initially preferred a birth with midwife-led care - both at home and in hospital - experienced lower rates of interventions during labor. Although some differences can be attributed to the model of care, we suggest that characteristics and attitudes of women themselves also play an important role.

Eliciting preferences for key attributes of intrapartum care in the Netherlands.

BACKGROUND: As part of the move toward "patient-centered care," women's preferences with regard to maternity services have become increasingly important to policy makers. To realize optimal patient-centered care, knowledge of patients' preferences is essential. The aim of our study was to assess the strength and relative importance of women's preferences for different aspects of intrapartum care in The Netherlands, where women have easy access to both home and hospital birth. METHODS: A discrete choice experiment was conducted at 16 weeks of gestation as part of a Dutch multicenter, prospective cohort study from 2007 to 2011 of low-risk, nulliparous women. Responses were analyzed per intended place of birth group: midwifery-led home (n = 191) and hospital birth (n = 152) and obstetric-led hospital birth (n = 188). RESULTS: We analyzed 562 questionnaires. Women in all groups preferred the possibility of influencing decision making and pain-relief treatment during birth and no co-payment for childbirth. Women with an intended home birth preferred a home-like birth setting with the assistance of a midwife and transport during birth in case of complications. Type of birth setting and transport during birth were not considered important to women with an intended midwifery- or obstetric-led hospital birth. CONCLUSION: Policies aimed at the improvement of maternity care must take into account women's preferences for the possibility of pain-relief treatment and the fact that all women desire a high level of involvement in decision making. Furthermore, efforts to change maternity care systems must consider how to counter the culturally embedded nature of women's preferences.

Preferred place of birth: characteristics and motives of low-risk nulliparous women in the Netherlands.

OBJECTIVE: to explores preferences, characteristics and motives regarding place of birth of low-risk nulliparous women in the Netherlands. DESIGN: a prospective cohort study of low-risk nulliparous women and their partners starting their pregnancy in midwifery-led care or in obstetric-led care. Data were collected using a self-administered questionnaire, including questions on demographic, psychosocial and pregnancy factors and statements about motives with regard to place of birth. Depression, worry and self-esteem were explored using the Edinburgh Depression Scale (EDS), the Cambridge Worry Scale (CWS) and the Rosenberg Self Esteem Scale (RSE). SETTING: participants were recruited in 100 independent midwifery practices and 14 hospitals from 2007 to 2011. PARTICIPANTS: 550 low-risk nulliparous women; 231 women preferred a home birth, 170 women a hospital birth in midwifery-led care and 149 women a birth in obstetric-led care. FINDINGS: Significant differences in characteristics were found in the group who preferred a birth in obstetric-led care compared to the two groups who preferred midwifery-led care. Those women were older (F (2,551)=16.14, p<0.001), had a higher family income (χ(2) (6)=18.87, p=0.004), were more frequently pregnant after assisted reproduction (χ(2)(2)=35.90, p<0.001) and had a higher rate of previous miscarriage (χ(2)(2)=25.96, p<0.001). They also differed significantly on a few emotional aspects: more women in obstetric-led care had symptoms of a major depressive disorder (χ(2)(2)=6.54, p=0.038) and were worried about health issues (F (2,410)=8.90, p<0.001). Women's choice for a home birth is driven by a desire for greater personal autonomy, whereas women's choice for a hospital birth is driven by a desire to feel safe and control risks. KEY CONCLUSIONS: the characteristics of women who prefer a hospital birth are different than the characteristics of women who prefer a home birth. It appears that for women preferring a hospital birth, the assumed safety of the hospital is more important than type of care provider. This brings up the question whether women are fully aware of the possibilities of maternity care services. Women might need concrete information about the availability and the characteristics of the services within the maternity care system and the risks and benefits associated with either setting, in order to make an informed choice where to give birth.

Differences in preferences for obstetric care between nulliparae and their partners in the Netherlands: a discrete-choice experiment.

BACKGROUND: In the Netherlands, in low-risk pregnancies, the views of pregnant women and their partners on characteristics of obstetric care services are leading for the selection of place of birth. The aim of this study was to investigate whether there are differences between the decision-making process of pregnant women and their partners with regard to these attributes of obstetric care. METHODS: This study was a prospective cohort study with low-risk nulliparae and their partners. A questionnaire, based on the method of discrete-choice experiment, was used to gather the data. RESULTS: Possibility of influencing decision-making was, both for pregnant women (n = 321) and their partners (n = 212), the most important characteristic of the obstetric care. For women, a home-like birth setting was an important characteristic, while the partners found the possibility on pain-relief treatment during birth important. CONCLUSIONS: The results of this study suggest that women and their partners have clearly defined preferences for obstetric care. There are also some essential differences between the preferences of these two groups. The findings are important where policy issues related to aspects of maternity care service delivery are being considered.

Cost analysis of the Dutch obstetric system: low-risk nulliparous women preferring home or short-stay hospital birth--a prospective non-randomised controlled study.

BACKGROUND: In the Netherlands, pregnant women without medical complications can decide where they want to give birth, at home or in a short-stay hospital setting with a midwife. However, a decrease in the home birth rate during the last decennium may have raised the societal costs of giving birth. The objective of this study is to compare the societal costs of home births with those of births in a short-stay hospital setting. METHODS: This study is a cost analysis based on the findings of a multicenter prospective non-randomised study comparing two groups of nulliparous women with different preferences for where to give birth, at home or in a short-stay hospital setting. Data were collected using cost diaries, questionnaires and birth registration forms. Analysis of the data is divided into a base case analysis and a sensitivity analysis. RESULTS: In the group of home births, the total societal costs associated with giving birth at home were euro3,695 (per birth), compared with euro3,950 per birth in the group for short-stay hospital births. Statistically significant differences between both groups were found regarding the following cost categories 'Cost of contacts with health care professionals during delivery' (euro138.38 vs. euro87.94, -50 (2.5-97.5 percentile range (PR)-76;-25), p < 0.05), 'cost of maternity care at home' (euro1,551.69 vs. euro1,240.69, -311 (PR -485; -150), p < 0.05) and 'cost of hospitalisation mother' (euro707.77 vs. 959.06, 251 (PR 69;433), p < 0.05). The highest costs are for hospitalisation (41% of all costs). Because there is a relatively high amount of (partly) missing data, a sensitivity analysis was performed, in which all missing data were included in the analysis by means of general mean substitution. In the sensitivity analysis, the total costs associated with home birth are euro4,364 per birth, and euro4,541 per birth for short-stay hospital births. CONCLUSION: The total costs associated with pregnancy, delivery, and postpartum care are comparable for home birth and short-stay hospital birth. The most important differences in costs between the home birth group and the short-stay hospital birth group are associated with maternity care assistance, hospitalisation, and travelling costs.

The choice of obstetric care by low-risk pregnant women in the Netherlands: implications for policy and management.

In the Netherlands, pregnant women at low risk of complications during pregnancy, have the opportunity to choose freely between giving birth at home or in a hospital maternity unit. This study analyses how various attributes of obstetric care, socio-economic characteristics and attitudes influence the decisions that these women make with regard to obstetric care. The method of discrete-choice experiment was applied in the process of data collection and analysis. The data were collected among low-risk nulliparous pregnant women. The analysis suggests that there are strong preferences among some Dutch women for a home birth. Nevertheless, the absence of a medical pain-relief treatment during home birth, might provide incentives for some women to opt for a birth in a hospital, especially at the end of their pregnancy. If the attractiveness of home birth should be preserved in the Netherlands, specific attention should be paid on the approach to pain during a home birth. Efforts could also be made in offering a domestic atmosphere during hospital births to improve hospital-based obstetric care in view of women's preferences.

Operative deliveries in low-risk pregnancies in The Netherlands: primary versus secondary care.

BACKGROUND: In The Netherlands, 35 percent of births take place in "primary care" to women considered at low risk and during labor, approximately 30 percent are referred to "secondary care." High-risk women and some low-risk women deliver in secondary care. This study sought to compare planned place of birth and incidence of operative delivery among women at low risk of complications at the time of onset of labor. METHODS: A retrospective analysis was conducted of data about births in The Netherlands during 2003 that were recorded routinely in the Netherlands Perinatal Registry. Mode of delivery was analyzed for women classified as low risk at labor onset according to their planned place of birth (intention-to-treat analysis). The primary outcome was the rate of operative deliveries (vacuum or forceps extraction or cesarean section). RESULTS: Women at low risk who planned to give birth, and therefore labored and delivered in secondary care, had a significantly higher rate of operative deliveries than women who began labor in primary care where they intended to give birth (18% [3,558/19,850] vs 9% [7,803/87,187]) (OR 2.25, 95% CI 2.00-2.52). For cesarean section, the rates were 12 percent (2,419/19,850) versus 3 percent (2,990/87,817) (OR 3.97, 95% CI 3.15-5.01), irrespective of parity. CONCLUSIONS: The rate of operative deliveries was significantly lower for low-risk pregnant women who gave birth in a primary care setting compared with similar women who planned birth in secondary care. As with any retrospective analysis, it was not possible to eliminate bias, such as possible differences between primary and secondary care in assignment of risk status. In addition, known risk factors for interventions, technologies such as induction of labor and fetal monitoring, are only available in secondary care. These findings clearly demonstrate the need for a prospective study to examine the relationship between planned place of birth and mode of delivery and neonatal and maternal outcomes.