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.

The "Blessing" of Pregnancy? Barriers to accessing adequate maternal care in Poland: A mixed-method study among women, healthcare providers, and decision-makers.

OBJECTIVE: All women should have access to adequate and respectful maternal care to maximise health outcomes. In Poland, there is a mismatch between good maternal health indicators and poor care experiences. This study examined stakeholder views on access to adequate maternal care in Poland in terms of availability, appropriateness, affordability, approachability, and acceptability. DESIGN: A mixed-methods study. SETTING: Online survey and online semi-structured interviews conducted between March 2021 and May 2021. PARTICIPANTS: Five-hundred fifty-seven (557) women who recently gave birth in Poland, maternal care providers and decision-makers active in the field of maternal health. FINDINGS: The main barriers to adequate care were inappropriate communication of maternal care providers, insufficient compliance with standards of care, over-medicalisation of childbirth and suboptimal engagement of women in care provision, and high levels of out-of-pocket spending on maternal care services. Other barriers included limited availability of maternal care providers, particularly midwives, and low reproductive health literacy in women. KEY CONCLUSIONS: Provision of adequate and women-centred maternal care remains erratic, despite substantial care provision advancements in recent years. Addressing the barriers could substantially improve the experience of and access to adequate maternal care in Poland. IMPLICATIONS FOR PRACTICE: Barriers identified in the survey with women largely converged with those highlighted in the interviews. In addition, maternal care providers and decision-makers provided context-specific information and explanation of the current state of maternal care system. Consequently, this study provides direction-setting information for policy and practice in Poland and other Central and Eastern European countries, which share similar shortcomings related to adequate maternal care provision.

Barriers to access adequate maternal care in Romania, Bulgaria, and Moldova: A cross-country comparison.

BACKGROUND: Eastern European health system indicators (e.g., number of health workers and care coverage) suggest well-resourced maternity care systems, but maternal health outcomes compare poorly with those in Western Europe. Often, poor maternal health outcomes are linked to inequities in accessing adequate maternal care. This study investigates access-related barriers (availability, appropriateness, affordability, approachability, and acceptability) to maternity care in Romania, Bulgaria, and Moldova. METHODS: This cross-country study (n = 7345) is based on an online survey where women who received maternity care and gave birth in 2015-2018 in Bulgaria (n = 4951), Romania (n = 2018), and Moldova (n = 376) provided information on their experiences with the care received. We used regression analysis to identify factors associated with accessing maternity care across the three countries. RESULTS: Results show high rates of cesarean births (CB) and a low number of antenatal and postnatal care visits. Informal payments and use of personal connections are common practices. Formal and informal out-of-pocket payments create a financial burden for women with health complications. Women who had health complications, those who gave birth by cesarean, and women who gave birth in a public facility and had fewer antenatal check-ups, were more likely to describe facing access-related barriers. CONCLUSIONS: This study identifies several barriers to high-quality maternity care in Romania, Bulgaria and Moldova. More attention should be paid to the appropriateness of care provided to women with complicated pregnancies, to those who have CBs, to women who give birth in public facilities, and to those who receive fewer antenatal care visits.

Barriers to accessing adequate maternal care in Latvia: A mixed-method study among women, providers and decision-makers.

INTRODUCTION: Latvia has a high maternal mortality ratio compared to other European countries, as well as major inequities in accessing adequate maternal care. Adequacy refers to the extent to which services are safe, effective, timely, efficient, equitable and people-centred. This study aims to explore stakeholder views on access to adequate maternal care in Latvia and the extent to which there was consensus. METHODS: This mixed-method study is based on an online survey among women who recently gave birth, as well as interviews with healthcare providers and decision-makers. The data were analysed using the method of directed qualitative content analysis. The extent of stakeholder consensus was determined by studying five access-related aspects of maternal care: availability, adequacy, affordability, approachability and acceptability. FINDINGS: Our study identified barriers to accessing adequate maternal care related to availability (i.e. shortage of human resources, geographical distance) and appropriateness (i.e. inequalities in provider knowledge, care provision and use of clinical guidelines). Other challenges were related to providers' approaches towards women (i.e. communication) and, to a lesser extent, maternal care acceptance by women (i.e. health literacy). CONCLUSIONS: The barriers identified in our study highlight areas that should be addressed in future reforms of maternal care. These barriers also indicate the need for micro-level indicators that can facilitate a comprehensive evaluation of maternal care in Latvia and elsewhere.

Barriers to accessing adequate maternal care in Georgia: a qualitative study.

BACKGROUND: The maternal health outcomes in Georgia are linked to shortcomings in healthcare such as inequities in access to adequate maternal care. Due to the macro-level, quantitative approach applied in most previous studies, little is known about the underlying reasons that influence maternal care and care-seeking behaviour of pregnant women. METHODS: This qualitative study explores the stakeholders' perspectives on access to adequate maternal care in Georgia. Focus-group discussions are conducted with mothers who gave birth within in the past four years and in-depth interviews are conducted with decision-makers and health professionals in the field. Five access-related aspects are studied: availability, appropriateness, affordability, approachability and acceptability of maternal care. The method of direct content analysis is applied. RESULTS: Results indicate problems with maternal care standards, inequalities across population groups and drawbacks in maternal care financing. This includes gaps in clinical quality and staff skills, as well as poor communication between women and health professionals. Geographical barriers to adequate maternal care exist in rural and mountainous areas due to the weak infrastructure (poor roads and weak transportation), in addition to financial hardships. Despite improvements in the coverage of maternal care, affordability remains an access barrier. Poorer population groups are financially unprotected from the high out-of-pocket payments for maternal care services. CONCLUSION: These findings imply that micro-level indicators, such as disrespectful behaviour of health professionals and affordability of care, should be taken into account when assessing maternal care provision in Georgia. It should complement the existing macro-level indicators for a comprehensive evaluation of maternal care.

Barriers to accessing adequate maternal care in Central and Eastern European countries: A systematic literature review.

Maternal health outcomes in Central and Eastern Europe (CEE) compare unfavorable with those in Western Europe, despite macro-indicators that suggest well-designed maternal care systems. However, macro-indicators at the system level only capture capacity, funding and utilization of care and not the actual allocation of financial and human resources, the quality of care and access to it. It is these latter which are problematic in the CEE region. In this study service-related indicators of access to maternal care in CEE are examined. These include availability, appropriateness, affordability, approachability and acceptability of maternal care. This study uses a qualitative systematic literature review, analyzing information of peer-reviewed articles published since 2004. Other inclusion criteria included language, setting and publication purpose. The included articles were analyzed using a framework analysis technique and quality was assessed using standardized evaluation checklists. Results indicate improvements in maternal care. However, availability of care is limited by outdated equipment and training curricula, and the lack of professionals and pharmaceuticals. Geographical distance to healthcare institutions, inappropriate communication of providers and waiting times are the main approachability barriers. Some mothers are unaware of the importance of care or are discouraged to utilize healthcare services because of cultural aspects. Finally, a major barrier in accessing maternal care in the CEE is the inability to pay for it. Our findings indicate that major gaps in evidence exist and that more representative and better quality data should be collected. Governments in CEE countries need to establish a reliable system for measuring and monitoring a suitable set of indicators, as well as deal with the general social and economic problem of informality. Medical curricula in the CEE region need to be overhauled and there should be a focus on improving the allocation of medical staff and institutions as well as protecting vulnerable population groups to ensure universal access to care.