Toward the development of a short multi‐country person‐centered maternity care scale

Person-centered maternity care during childbirth and associated factors at public hospitals in central Ethiopia

Objectives

Person-centered maternity care during childbirth is crucial for improving maternal and newborn health outcomes. Therefore, this study was aimed at assessing the determinants of person-centered maternity care in Central Ethiopia.

Methods

An institutional-based cross-sectional study was conducted in public hospitals in Central Ethiopia from 30 January to 1 March 2023. A systematic random sampling technique was employed to enroll the study participants. Data were collected through face-to-face interviews using a structured questionnaire. After data collection, it was checked for completeness and consistency, then coded and entered into Epi Data version 4.4.2 and exported to SPSS version 26 for analysis. Both bivariate and multivariable logistic regressions were used to identify associated factors.

Results

In this study, a total of 565 participants were involved, resulting in a response rate of 98.77%. The respondents mean score for person-centered maternity care was 60.2, with a 95% CI of (59.1, 62.3). No formal education (β = -2.00, 95% CI: -4.36, -0.69), fewer than four antenatal contacts (β = -4.3, 95% CI: -5.46, -2.37), being delivered at night (β = 2.20, 95% CI: 1.56, 6.45), and complications during delivery (β = -6.00, 95% CI: -9.2, -0.79) were factors significantly associated with lower person-centered maternity care.

Conclusion

This study revealed that person-centered maternity care is low compared with other studies. Consequently, it is imperative to prioritize initiatives aimed at enhancing awareness among healthcare providers regarding the benchmarks and classifications of person-centered maternity care. Moreover, efforts should be directed toward fostering improved communication between care providers and clients, along with the implementation of robust monitoring and accountability mechanisms for healthcare workers to prevent instances of mistreatment during labor and childbirth.

Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo

In sub-Saharan African settings like the Democratic Republic of the Congo, high-quality care during childbirth and the immediate postpartum period is lacking in public facilities, necessitating multipronged interventions to improve care. We used a pre-post design to examine the effectiveness of a low-dose, high-frequency capacity-building and quality improvement (QI) intervention to improve care for women and newborns around the day of birth in 16 health facilities in Kinshasa, Democratic Republic of the Congo. Effectiveness was assessed based on changes in provider skills, key health indicators, and beneficiary satisfaction. To assess changes in the competency of the 188 providers participating in the intervention, we conducted objective structured clinical examinations on care for mothers and newborns on the day of birth, immediate postpartum family planning (PPFP) counseling and method provision, and postabortion care before and after implementation of training and at 6 and 12 months after training. Interrupted time series (ITS) analysis techniques were used to analyze routine health service data for changes in select maternal, newborn, and postpartum outcomes before and after the intervention. To assess changes in clients' perceptions of care, 2 rounds of telephone surveys were administered. Before the intervention, less than 2% of participating providers demonstrated competency in skills. Immediately after training, more than 80% demonstrated competency, and 70% retained competency after 12 months. ITS analyses show the risk of early neonatal death declined significantly by 9% (95% confidence interval [CI]=4%, 13%, P<.001), and likelihood of immediate PPFP uptake increased significantly by 72% (95% CI=53%, 92%, P<.001). Client satisfaction improved by 58% over the life of the project. These findings build on previous studies documenting the effectiveness of clinical capacity-building and QI approaches. If implemented at scale, this approach has the potential to substantively contribute to improving maternal and perinatal health in similar settings.

Development and Validation of a Scale to Measure Person-Centered Care in Fetal Care Centers

INTRODUCTION

Fetal care centers (FCCs) in the U.S. lack a standardized instrument to measure person-centered care. This study aimed to develop and validate the Person-Centered Care in Fetal Care Centers (PCC-FCC) Scale.

METHODS

Initial items were developed based on literature and input from clinicians and former patients. A Delphi study involving 16 experts was conducted to validate the content and construct. Through three rounds of online questionnaires using open-ended questions and Likert scales, consensus on item clarity and relevancy was established. The resulting items were then piloted with former fetal care center patients via a web-based survey. The instrument's reliability and validity were validated using Cronbach's α and exploratory factor analysis, respectively. Concurrent validity was assessed by comparing scores with the Revised Patient Perception of Patient-Centeredness (PPPC-R) Questionnaire.

RESULTS

258 participants completed the 48-item pilot PCC-FCC survey, categorized into six domains. Factor analysis yielded a 2-factor, 28-item scale. Internal consistency of the final scale had good reliability (α=0.969). Data supported content, construct, and concurrent validity.

CONCLUSION

The PCC-FCC Scale is a reliable and valid measure of person-centered care in U.S. FCCs. It can be used to enhance services and begin connecting person-centered care to maternal-child health outcomes.

Respectful Maternity Care : A Systematic Review

BACKGROUND

Severe maternal morbidity and mortality are worse in the United States than in all similar countries, with the greatest effect on Black women. Emerging research suggests that disrespectful care during childbirth contributes to this problem.

PURPOSE

To conduct a systematic review on definitions and valid measurements of respectful maternity care (RMC), its effectiveness for improving maternal and infant health outcomes for those who are pregnant and postpartum, and strategies for implementation.

DATA SOURCES

Systematic searches of Ovid Medline, CINAHL, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, and SocINDEX for English-language studies (inception to July 2023).

STUDY SELECTION

Randomized controlled trials and nonrandomized studies of interventions of RMC versus usual care for effectiveness studies; additional qualitative and noncomparative validation studies for definitions and measurement studies.

DATA EXTRACTION

Dual data abstraction and quality assessment using established methods, with resolution of disagreements through consensus.

DATA SYNTHESIS

Thirty-seven studies were included across all questions, of which 1 provided insufficient evidence on the effectiveness of RMC to improve maternal outcomes and none studied RMC to improve infant outcomes. To define RMC, authors identified 12 RMC frameworks, from which 2 main concepts were identified: disrespect and abuse and rights-based frameworks. Disrespect and abuse components focused on recognizing birth mistreatment; rights-based frameworks incorporated aspects of reproductive justice, human rights, and antiracism. Five overlapping framework themes include freedom from abuse, consent, privacy, dignity, communication, safety, and justice. Twelve tools to measure RMC were validated in 24 studies on content validity, construct validity, and internal consistency, but lack of a gold standard limited evaluation of criterion validity. Three tools specific for RMC had at least 1 study demonstrating consistency internally and with an intended construct relevant to U.S. settings, but no single tool stands out as the best measure of RMC.

LIMITATIONS

No studies evaluated other health outcomes or RMC implementation strategies. The lack of definition and gold standard limit evaluation of RMC tools.

CONCLUSION

Frameworks for RMC are well described but vary in their definitions. Tools to measure RMC demonstrate consistency but lack a gold standard, requiring further evaluation before implementation in U.S. settings. Evidence is lacking on the effectiveness of implementing RMC to improve any maternal or infant health outcome.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42023394769).

Modeling Pathways to Describe How Maternal Health Care Providers' Mental Health Influences the Provision of Respectful Maternity Care in Malawi

INTRODUCTION

Maternal health (MH) providers may experience traumatic events, such as maternal or fetal death, that can contribute to stress and burnout. Past trauma, poor working relationships, and under-resourced environments not only affect providers' own emotional well-being but also reduce their ability to provide respectful maternity care (RMC).

METHODS

Data were collected in mid-2021 as a cross-sectional survey with 302 MH providers working in 25 maternities in 3 districts in Malawi to measure burnout, depression, and post-traumatic stress disorder (PTSD). We present a pathway model describing how these factors interact and influence RMC. We used the provider-reported person-centered maternity care scale to measure RMC; the Maslach Burnout Inventory, which examines emotional exhaustion, depersonalization, and professional accomplishment; and standard validated screening tools to measure the prevalence of depression and PTSD.

RESULTS

Although levels of burnout varied, 30% of MH providers reported high levels of exhaustion, feelings of cynicism manifesting as depersonalization toward their clients (17%), and low levels of professional accomplishment (42%). Moderate to severe depression (9%) and suicidal ideation within the past 2 weeks (10%) were also recorded. Many (70%) reported experiencing an event that could trigger PTSD, and 12% reported at least 4 of 5 symptoms in the PTSD scale. Path analysis suggests that depression and emotional exhaustion negatively influence RMC, and depersonalization is mediated through depression. PTSD has no direct effect on RMC, but increased PTSD scores were associated with increased burnout and depression scores. Positive relationships with facility managers were significantly associated with increased RMC and decreased emotional exhaustion and depersonalization.

CONCLUSION

Burnout will continue to be a challenge among MH providers. However, pragmatic approaches for improving teamwork, psychosocial, and managerial support for MH providers working in challenging environments may help mitigate burnout, improve MH provider well-being, and, in turn, RMC for women seeking MH services.

Development and psychometric properties of the Respectful Maternity Care Scale (RMCS)

AIMS/BACKGROUND

The Respectful Maternity Care Scale (RMCS) was developed specifically to assess the health care that women receive during pregnancy, labour and the postnatal period. The aim of this study was to investigate the validity and reliability of the RMCS.

DESIGN/METHODS

This study used a methodological design. The RMCS, a self-report instrument, was developed in consultation with professionals and women who had given birth, based on the literature. It was tested for content and construct validity. Reliability was assessed using Cronbach's alpha, test-retest method, and adjusted item-total correlation. The study sample consisted of 405 women between 6 weeks and 12 months postpartum who were admitted to a family health centre in Istanbul between April and June 2023.

RESULTS

The scale's content validity index is 0.92. The scale consists of 29 items and 3 sub-dimensions, which explain 61% of the total variance. χ2/df was less than 5 and RMSEA was less than 0.08, which confirms the validity of this model. The corrected item-total correlations were acceptable, and the Cronbach's alpha coefficient was 0.96.

CONCLUSION

The RMCS has been shown to be valid and reliable and can be used to assess respectful maternity care among Turkish women.

A scoping review, mapping, and prioritisation process for emergency obstetric and neonatal quality of care indicators: Focus on provision and experience of care

Background

Globally, approximately 800 women and 6400 newborns die around the time of childbirth each day. Many of these deaths could be prevented with high-quality emergency obstetric and newborn care (EmONC). The Monitoring Emergency Obstetric Care: A handbook guides strengthening EmONC services. However, the handbook contains limited quality of care measures. Our study identified and prioritised quality of care indicators for potential inclusion in the handbook, which is undergoing revision.

Methods

We conducted a consultative scoping review, mapping, and prioritisation exercise to select a short list of indicators on facility-based maternal and newborn quality of care. Indicators were identified from literature searches and expert suggestions and organised by the categories of structure, process, and outcomes as defined in the World Health Organization's Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. We focused on process indicators, encompassing the provision of care and experience of care during the intrapartum period, and developed a priority list of indicators using the selection criteria of relevance and feasibility. Experience of care indicators were also mapped against the Person-Centered Maternity Care (PCMC) scale.

Results

We extracted a total of 3023 quality of care indicators. After removing out-of-scope and duplicate indicators and applying our selection criteria, we identified 20 provision of care indicators for possible inclusion in the revised EmONC handbook. We recommend including a score for experience of care that could be measured with the 30-item or the 13-item PCMC scale. We also identified 29 experience of care items not covered by the PCMC scale that could be used. Provider experience, patient safety, and quality of abortion care were identified as areas for which no or few indicators were found through our scoping review.

Conclusions

Through a rigorous, consultative, and multi-step process, we selected a short list of process-related, facility-based quality of care indicators for emergency obstetric and newborn care. This list could be included in the EmONC handbook or used for other monitoring purposes. Country consultations to assess the utility and feasibility of the proposed indicators and their adaptation to local contexts will support their refinement and uptake.

Registration

https://osf.io/msxbd (Open Science Framework).

A critical review: developing a birth integrity framework for epidemiological studies through meta-ethnography

Over the past decade, there has been growing evidence that women worldwide experience sub-standard care during facility-based childbirth. With this critical review, we synthesize concepts and measurement approaches used to assess maternity care conditions and provision, birth experiences and perceptions in epidemiological, quantitative research studies (e.g., obstetric violence, maternal satisfaction, disrespect or mistreatment during childbirth, person-centered care), aiming to propose an umbrella concept and framework under which the existing and future research strands can be situated. On the 82 studies included, we conduct a meta-ethnography (ME) using reciprocal translation, in-line argumentation, and higher-level synthesis to propose the birth integrity multilevel framework. We perform ME steps for the conceptual level and the measurement level. At the conceptual level, we organize the studies according to the similarity of approaches into clusters and derive key concepts (definitions). Then, we 'translate' the clusters into one another by elaborating each approach's specific angle and pointing out the affinities and differences between the clusters. Finally, we present an in-line argumentation that prepares ground for the synthesis. At the measurement level, we identify themes from items through content analysis, then organize themes into 14 categories and subthemes. Finally, we synthesize our result to the six-field, macro-to-micro level birth integrity framework that helps to analytically distinguish between the interwoven contributing factors that influence the birth situation as such and the integrity of those giving birth. The framework can guide survey development, interviews, or interventional studies.

Development, woman-centricity and psychometric properties of maternity patient-reported experience measures: a systematic review

OBJECTIVE

Valid and reliable maternity patient-reported experience measures are critical to understanding women's experiences of care. They can support clinical practice, health service and system performance measurement, and research. The aim of this review is to identify and critically appraise the risk of bias, woman-centricity (content validity), and psychometric properties of maternity patient-reported experience measures published in the scientific literature.

DATA SOURCES

MEDLINE, CINAHL Plus, PsycINFO, and Embase were systematically searched for relevant records between January 1, 2010 and July 10, 2021.

STUDY ELIGIBILITY CRITERIA

We searched for articles describing the instrument development of maternity patient-reported experience measures and measurement properties associated with instrument validity and reliability testing. Articles that described patient-reported experience measures developed outside of the maternity context and articles that did not contribute to the instruments' development, content validation, and/or psychometric evaluation were excluded.

METHODS

Included articles underwent risk of bias, content validity, and psychometric properties assessments in line with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidance. Patient-reported experience measure results were summarized according to language subgroups. An overall recommendation for use was determined for each patient-reported experience measure language subgroup.

RESULTS

A total of 54 studies reported on the development and psychometric evaluation of 25 maternity patient-reported experience measures, grouped into 45 language subgroups. The quality of evidence underpinning the instruments' development was generally poor. Only 2 (4.4%) patient-reported experience measures reported sufficient content validity, and only 1 (2.2%) received a level "A" recommendation, required for real-world use.

CONCLUSION

Maternity patient-reported experience measures demonstrated poor-quality evidence for their measurement properties and insufficient detail about content validity. Future maternity patient-reported experience measure development needs to prioritize women's involvement in deciding what is relevant, comprehensive, and comprehensible to measure. Improving the content validity of maternity patient-reported experience measures will improve overall validity and reliability and facilitate real-world practice improvements. Standardized patient-reported experience measure implementation also needs to be prioritized to support advancements in clinical practice for women.

Person-centred sexual and reproductive health: A call for standardized measurement

Person-centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person-centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person-centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person-centred care across the SRH continuum. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.

Quality of maternal and newborn health care at private hospitals in Iraq: a cross-sectional study

BACKGROUND

Approximately 25% of facility births take place in private health facilities. Recent national studies of maternal and newborn health (MNH) service availability and quality have focused solely on the status of public sector facilities, leaving a striking gap in information on the quality of maternal and newborn care services.

METHODS

A rapid cross-sectional assessment was conducted in November 2022 to assess the quality of MNH services at private hospitals in Iraq. Multi-stage sampling was used to select 15% of the country's 164 private hospitals. Assessment tools included a facility assessment checklist, a structured health worker interview tool, and a structured client exit interview tool. Data collection was conducted using KoboToolbox software on Android tablets, and analysis conducted using SPSS v28.

RESULTS

All hospitals visited provided MNH services and had skilled personnel present or on-call 24 h/day, 7 days/week. Most births (88%) documented between January and June 2022 were cesarean births. Findings indicate that nearly all hospitals have the human resources, equipment, medicines and supplies necessary for quality antenatal, intrapartum and early essential newborn care, and many are also equipped with special units and resources needed to care for small and sick babies. However, while resources are in place for basic and advanced care, there are gaps in knowledge and practice of high-impact interventions that require few or no resources to perform, including skin-to-skin thermal care and support for early initiation of breastfeeding. Person-centered maternity care scores suggest that private hospitals offer a positive experience of care for all clients, however there is room for improvement in provider-client communication.

CONCLUSIONS

This assessment highlights the need for deeper dives into factors that underly decisions about how and where to give birth, and both understanding and practice of early essential newborn care and pre-discharge examinations and counseling at private healthcare facilities in Iraq. Engaging private health facility staff in efforts to monitor and improve the quality of maternal and newborn care, with a focus on early essential newborn care and provider-client communication for all clients, will ensure that women and newborns benefit from the best care possible with available resources.

Postnatal women's perception on person-centered maternity care in twin cities of Rawalpindi and Islamabad: a descriptive study

BACKGROUND

Person-Centered Maternity Care (PCMC) is known as one of the most important components of maternal care. Every woman has the ultimate right of respectful health care. Previous research documents that lack of supportive care and respectful behavior experienced by pregnant women can act as a barrier to the utilization of health care services. Few studies have used PCMC tool to document this phenomenon. The objective of this descriptive study was to assess the women's perception of PCMC in Pakistan.

METHODS

Three hundred and seventy-seven (377) postnatal women of ages 18-49 years participated in the research. The study sites were secondary and tertiary care hospitals located in the twin cities of Rawalpindi and Islamabad. The PCMC tool used in this study is a validated scale with three sub-domains of i) communication and autonomy, ii) supportive care, and iii) dignity and respect. Data was analyzed using SPSS version 16, and descriptive and bivariate analysis was undertaken.

RESULTS

The PCMC mean score was 54 ± [10.7] out of 90. About half (55%) of women had good perception of PCMC. Sub-domain of supportive care scored the lowest as compared to the other two domains. Overall, 36% women reported physical abuse while 22% reported verbal abuse at the hands of the healthcare providers. Most of the women (88%) said that health providers did not introduce themselves. About 30% women claimed that health care providers never asked for permission before doing any medical procedures and 20% of women claimed that doctors did not describe the purpose of examination while 178 (47%) of women said that health provider explained the purpose of medications all the time, additionally, about 14% were never given the choice to ask questions.

CONCLUSION

The study concluded that the majority of postnatal women perceived that they were not getting optimum Person-Centered Maternity Care. Some core aspects in supportive care domain were missing. In order to improve the quality of hospital-based childbirths, efforts are needed to improve the quality of care.

Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia

BACKGROUND

Effective communication, respect and dignity, and emotional support are critical for a positive childbirth experience that is responsive to the needs and preferences of women.

OBJECTIVE

This study evaluated the performance of a person-centered maternity care scale in a large, representative household sample of postpartum women, and it describes differences in person-centered maternity care across individuals and communities in Ethiopia.

STUDY DESIGN

The study used data from 2019 and 2020 from a representative sample of postpartum women in 6 regions of Ethiopia. It measured person-centered maternity care using a scale previously validated in other settings. To assess the scale validity in Ethiopia, we conducted cognitive interviews, measured internal consistency, and evaluated construct validity. Then, we fit univariable and multivariable linear regression models to test for differences in mean person-centered maternity care scores by individual and community characteristics. Lastly, multilevel modeling separated variance in person-centered maternity care scores within and between communities.

RESULTS

Effective communication and support of women's autonomy scored lowest among person-centered maternity care domains. Of 1575 respondents, 704 (44.7%) were never asked their permission before examinations and most said that providers rarely (n=369; 23.4%) or never (n=633; 40.2%) explained why procedures were done. Person-centered maternity care was significantly higher for women with greater wealth, more formal education, and those aged >20 years. Variation in person-centered maternity care scores between individuals within the same community (τ²=58.3) was nearly 3 times greater than variation between communities (σ²=21.2).

CONCLUSION

Ethiopian women reported widely varying maternity care experiences, with individuals residing within the same community reporting large differences in how they were treated by providers. Poor patient-provider communication and inadequate support of women's autonomy contributed most to poor person-centered maternity care.

Person-centered care during childbirth and associated factors among mothers who gave birth at health facilities in Hawassa city administration Sidama Region, Southern Ethiopia

Introduction

Person-centered care is a pivotal component of strategies to improve the utilization of maternity care during childbirth. However, there is limited information on the level of person-centered care during childbirth in Ethiopia. Therefore, this study aimed to assess the level of person-centered care during childbirth and associated factors in Hawassa city administration health facilities Sidama region, Ethiopia.

Method

Institutional based cross-sectional study was conducted among randomly selected health facilities in Hawassa city administration from September 5 to October 30, 2021. A multistage sampling technique was employed to enroll the study participants. Data were collected through face-to-face interviews using a structured questionnaire. After data collection, it was checked for completeness and consistencies then coded and entered into Epi data version 4.4.2 and exported to SPSS version 25 for analysis. Descriptive statistics were generated to describe the study findings. Then simple and multivariable linear regressions were computed. All predictor variables with P-value ≤ 0.25 in the simple linear regression were fitted into the multivariable linear regression model and a P < 0.05 was considered statistically significant. Finally, the result of the study was presented in texts, tables, and figures.

Result

The mean score of person-centered care during childbirth in Hawassa city was 56 with 95% of CI: [55.1, 57] and with SD ± 11.2. Giving birth at private health institutions (β = 4.3, 95% CI: (2.37, 6.22) and childbirth which was attended by a care provider who had provided ANC for mothers initially (β = 5.48, 95% CI: 3.15, 7.81) had significantly higher positive betas on person-centered care during childbirth. However, mothers who didn’t get a formal education (β = -3.00, 95% CI: (-5.27, -.73) and mothers with a dead pregnancy outcome (β = -7.04, 95% CI: -10.4, -3.66) decreases the person-centered care during childbirth.

Conclusion

This paper showed that person-centered care during childbirth was low compared with other studies. It shall be beneficial if the city administration health facilities implement midwife-led care to improve person-centered care during childbirth.

A landscaping review of interventions to promote respectful maternal care in Africa: Opportunities to advance innovation and accountability

OBJECTIVE

In the past decade, global recognition of the need to address disrespect and abuse (also described as mistreatment of women) and promote respectful maternal care in facility-based childbirth has increased. While many studies have documented gaps in respectful maternal care, little is known about the design and implementation of these interventions. Our aim was to summarize and describe respectful maternal care -promoting interventions during childbirth implemented in Africa.

DESIGN

We identified respectful maternal care -promoting interventions in Africa through a rapid scoping of peer-reviewed articles and gray literature, and a crowdsourcing survey distributed through stakeholder networks.

SETTING

Africa PARTICIPANTS: NA MEASUREMENTS AND FINDINGS: We identified 43 unique interventions implemented in 16 African countries, gathered from a crowdsourcing survey, gray and published literature between 2010 and 2020. Most interventions were implemented in East Africa (N = 13). The interventions had various targets and were categorized into nine approaches, 60% of interventions focused on training providers about respectful maternal care and practice. About two thirds included multiple intervention approaches, and about two thirds addressed respectful maternal care beyond the period of childbirth. Few publications presented data on the effectiveness of the intervention, and those that did used a wide variety of indicators.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a reliance on provider training approaches to promote respectful maternal care and there are few examples of either engaging women in the community or adopting social accountability approaches. We encourage implementors to develop interventions targeting multiple approaches beyond provider training and consider delivery across pre-pregnancy, pregnancy, birth, and the postnatal periods. Finally, in order to effectively move from documenting respectful maternal care gaps to action and scale, we need global consensus on common indicators and measures of effectiveness for interventions promoting respectful care across the life course.

Psychometric validation of a patient-reported experience measure of obstetric racism© (The PREM-OB Scale™ suite)

BACKGROUND

Perinatal quality improvement lacks valid tools to measure adverse hospital experiences disproportionately impacting Black mothers and birthing people. Measuring and mitigating harm requires using a framework that centers the lived experiences of Black birthing people in evaluating inequitable care, namely, obstetric racism. We sought to develop a valid patient-reported experience measure (PREM) of Obstetric Racism^© in hospital-based intrapartum care designed for, by, and with Black women as patient, community, and content experts.

METHODS

PROMIS© instrument development standards adapted with cultural rigor methodology. Phase 1 included item pool generation, modified Delphi method, and cognitive interviews. Phase 2 evaluated the item pool using factor analysis and item response theory.

RESULTS

Items were identified or written to cover 7 previously identified theoretical domains. 806 Black mothers and birthing people completed the pilot test. Factor analysis concluded a 3 factor structure with good fit indices (CFI = 0.931-0.977, RMSEA = 0.087-0.10, R²  > .3, residual correlation < 0.15). All items in each factor fit the IRT model and were able to be calibrated. Factor 1, "Humanity," had 31 items measuring experiences of safety and accountability, autonomy, communication, and empathy. A 12-item short form was created to ease respondent burden. Factor 2, "Racism," had 12 items measuring experiences of neglect and mistreatment. Factor 3, "Kinship," had 7 items measuring hospital denial and disruption of relationships between Black mothers and their child or support system.

CONCLUSIONS

The PREM-OB Scale™ suite is a valid tool to characterize and quantify obstetric racism for use in perinatal improvement initiatives.

To call or not to call: exploring the validity of telephone interviews to derive maternal self-reports of experiences with facility childbirth care in northern Nigeria

Background

To institutionalise respectful maternity care, frequent data on the experience of childbirth care is needed by health facility staff and managers. Telephone interviews have been proposed as a low-cost alternative to derive timely and actionable maternal self-reports of experience of care. However, evidence on the validity of telephone interviews for this purpose is limited.

Methods

Eight indicators of positive maternity care experience and 18 indicators of negative maternity care experience were investigated. We compared the responses from exit interviews with women about their childbirth care experience (reference standard) to follow-up telephone interviews with the same women 14 months after childbirth. We calculated individual-level validity metrics including, agreement, sensitivity, specificity, area under the receiver operating characteristic curve (AUC). We compared the characteristics of women included in the telephone follow-up interviews to those from the exit interviews.

Results

Demographic characteristics were similar between the original exit interview group (n=388) and those subsequently reached for telephone interview (n=294). Seven of the eight positive maternity care experience indicators had reported prevalence higher than 50% at both exit and telephone interviews. For these indicators, agreement between the exit and the telephone interviews ranged between 50% and 92%; seven positive indicators met the criteria for validation analysis, but all had an AUC below 0.6. Reported prevalence for 15 of the 18 negative maternity care experience indicators was lower than 5% at exit and telephone interviews. For these 15 indicators, agreement between exit and telephone interview was high at over 80%. Just three negative indicators met the criteria for validation analysis, and all had an AUC below 0.6.

Conclusions

The telephone interviews conducted 14 months after childbirth did not yield results that were consistent with exit interviews conducted at the time of facility discharge. Women’s reports of experience of childbirth care may be influenced by the location of reporting or changes in the recall of experiences of care over time.

Adaptation of the Person-Centered Maternity Care Scale in the United States: Prioritizing the Experiences of Black Women and Birthing People

INTRODUCTION

Mistreatment by health care providers disproportionately affects Black, Indigenous, and other people of color in the United States. The goal of this study is to adapt the global Person-Centered Maternity Care (PCMC) scale for use in the United States, with particular attention to the experiences of Black women and birthing people.

METHODS

We used a community-engaged approach including expert reviews and cognitive interviews to assess content validity, relevance, comprehension, and comprehensiveness of the PCMC items. Surveys of 297 postpartum people, 82% of whom identified as Black, were used for psychometric analysis in which we assessed construct and criterion validity and reliability. The University of California, San Francisco, California Preterm Birth Initiative's Community Advisory Board, which consists of community members, community-based health workers, and social service providers in Northern California, provided input during all stages of the project.

RESULTS

Through an iterative process of factor analysis, discussions with the Community Advisory Board, and a prioritization survey, we eliminated items that performed poorly in psychometric analysis, yielding a 35-item PCMC-U.S. scale with subscales for dignity and respect, communication and autonomy, and responsive and supportive care. The Cronbach's alpha for the full scale is 0.95 and for the subscales is 0.87. Standardized summative scores range from 0 to 100, with higher scores indicating more PCMC. Correlations with related measures indicated high criterion validity.

CONCLUSIONS

The 35-item PCMC-U.S. scale and its subscales have high validity and reliability in a sample of predominantly Black women. This scale provides a tool to support efforts to reduce the inequities in birth outcomes experienced by Black, Indigenous, and other people of color.

Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic

We explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women's characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one's infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special "catch-up" strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.

Midwives' perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study

Background

Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers’ perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria.

Materials and methods

This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically.

Results

The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives’ perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives’ weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care.

Conclusion

PCMC is inadequate in public hospitals as seen from midwives’ perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives’ delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.

Potential of Standard Perinatal Data for Measuring Violation of Birth Integrity

Background: Measuring the phenomenon of violation of birth integrity (vBI) (e.g., obstetric violence) relies in part on the availability and content of maternity care providers' data. The population coverage and linkage possibilities that these data provide make for a yet untapped potential. Although vBI is a complex phenomenon best measured with dedicated instruments, we argue that maternity care providers' data could contribute to enhance our knowledge of the manifestations and frequency of vBI, and allow for analyses across different sub-groups of the population. Looking into the German standardized perinatal data, we investigate which variables are relevant to vBI-related research, and how complete their reporting is.

Methods: First, we analyse state-of-the-art frameworks and recommendations, and, for each vBI-related domain, we search for and list corresponding variables in the perinatal data which could contribute to a better understanding of vBI issues. Second, we use an example and analyse the content of perinatal data obtained between 2013 and 2016 in the context of the BaBi birth cohort study set in Bielefeld, Germany. We use descriptive statistics to assess the completeness of the data.

Results: The vBI-related variables can be classified in three main categories: discrimination based on specific patient socio-demographic attributes (e.g., height and weight to calculate BMI before pregnancy, foreign origin), indication for medical interventions (i.e., medicalization-related variables: indication for cesarean sections and induction), and supportive care, in particular the mobilization dimension (e.g., continuous fetal heartbeat monitoring). The data analyses included 876 births, of which 601 were vaginal birth. We found poor reporting on demographic variables in terms of completeness. Medicalization and mobilization variables are better documented, although limited in scope.

Conclusions: Putting more emphasis on the completeness of standardized data could increase their potential for vBI-related research. Perinatal data alone are insufficient to assess vBI, but a broader, theory-informed discussion of indicators to be included in standardized datasets would contribute to capturing the different aspects of integrity violation in a more systematic way and expand the evidence-base on different types of vBI.

Continuous Labor Support and Person-Centered Maternity Care: A Cross-Sectional Study with Women in Rural Kenya

Objective

This study assessed whether having continuous support during labor is associated with better person-centered maternity care (PCMC) among women in rural Kenya.

Methods

Data are from a cross-sectional survey with women aged 15–49 years who delivered in the 9 weeks preceding survey completion (N = 865). PCMC was operationalized using a validated 13-item scale, with a summative score developed from responses that capture dignity and respect, communication and autonomy, and supportive care from providers (excluding support from a lay companion). Continuous support was operationalized as the continuous presence of a lay companion (friend or family) during labor. We carried out bivariate analyses using chi-squared and t-tests and ran multivariable linear regression models to examine the association between continuous labor support and PCMC.

Results

The average PCMC score was 24.2 (SD = 8.4) out of a total score of 39. About two-thirds (68%) of women had continuous support during labor. The average PCMC scores among women who had continuous support was 25.7 (SD = 8.4) compared to 21.0 (SD = 7.6) among those who did not have continuous support (p-value ≤ 0.001). After controlling for various confounders this association was still significant (coefficient = 4.0; 95% CI 2.9, 5.2; p-value ≤ 0.001).

Conclusions

Women who have continuous labor support during childbirth are more likely to have improved PCMC. Efforts to promote PCMC should thus include continuous labor support.

Community Perceptions of Person-Centered Maternity Care in Migori County, Kenya

Background: Community perceptions of quality of maternal healthcare services-including Person-centered maternity care (PCMC)-influences the health-seeking behavior of women. Yet few studies have examined this quantitatively. This study aims to examine community perceptions of PCMC and its associated factors. Materials and Methods: We used data from a survey on community perceptions of PCMC in Migori County, Kenya conducted in August 2016. Community members were relatives or friends of women aged 15 to 49 years who gave birth in the 9 wk preceding the survey (N = 198). PCMC was measured using a 30-item scale with three sub-scales for dignity and respect, communication and autonomy, and supportive care. PCMC scores were standardized to range from 0 to 100, with higher scores indicative of higher PCMC. Descriptive, bivariate, and multivariate analyses were performed in STATA (version 14). Results: The average total PCMC score was 62 (SD = 15.7), with scores of 74, 63, and 53 for dignity and respect, supportive care, and communication and autonomy, respectively. Controlling for other factors, respondents who were employed and literate had higher PCMC perception scores than those who were less literate and unemployed. Respondents who rated their health as very good had higher PCMC perception scores than those who rated their health as poor. Female respondents who previously gave birth at a health facility had lower perceptions of dignity and respect than those with no prior facility birth. Conclusion: The findings imply that community perceptions of PCMC, particularly related to communication and autonomy, are poor. Given the effects of these perceptions on use of maternal health services, there is a need to improve PCMC.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review

BACKGROUND

Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.

METHODS

Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.

RESULTS

Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.

CONCLUSIONS

Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

Development of measures for assessing mistreatment of women during facility-based childbirth based on labour observations

INTRODUCTION

Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings.

METHODS

Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO's multicountry study 'How women are treated during facility-based childbirth' (2016-2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability.

RESULTS

Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index and a 12-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries based on factor loadings and interitem correlations, indicating good structural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.60 in Ghana and Guinea. Low correlations (Spearman correlation range: -0.06-0.19; p≥0.05) between mistreatment measures supported our decision to develop three separate measures. Predictive criterion validation yielded mixed results across countries. Both items within measures and measure scores were internally consistent across countries; each item co-occurred with other items in a measure, and scores consistently distinguished between 'high' and 'low' mistreatment levels.

CONCLUSION

The set of concise, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify burden, identify risk factors and determine its impact on health and well-being outcomes. Further validation and reliability testing of the measures in other contexts is needed.