Antenatal care for first time mothers: a discrete choice experiment of women's views on alternative packages of care

Women's preferences for antenatal care in Tanzania: a discrete choice experiment

Background

The stillbirth rate in Tanzania remains high. Greater engagement with antenatal care may help to reduce stillbirths. We investigated which characteristics of antenatal care clinics are preferred by pregnant women in Tanzania.

Methods

We conducted an unlabelled discrete choice experiment (DCE) with think-aloud interviews. Participants were pregnant women, regardless of parity/gestation, from the Mwanza and Manyara regions of Tanzania. We asked participants to choose which of two hypothetical antenatal clinics they would rather attend. Clinics were described in terms of transport mode, cleanliness, comfort, visit content, and staff attitude. Each participant made 12 choices during the experiment, and a purposively selected sub-set simultaneously verbalised the rationale for their choices. We analysed DCE responses using a multinomial logit model adjusted for study region, and think-aloud data using the Framework approach.

Results

We recruited 251 participants split evenly between the 2 geographical regions. Staff attitude was the most important attribute in clinic choice and dominated the think-aloud narratives. Other significant attributes were mode of transport (walking was preferred) and content of clinic visit (preference was stronger with each additional element of care provided). Cleanliness of the clinic was not a significant attribute overall and the think-aloud exercise identified a willingness to trade-off cleanliness and comfort for respectful care.

Conclusion

Women would prefer to attend a clinic with kind staff which they can access easily. This study suggests that exploration of barriers to providing respectful care, and enabling staff to deliver it, are important areas for future investment. The DCE shows us what average preferences are; antenatal care that is aligned with identified preferences should increase uptake and engagement versus care which does not acknowledge them.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04634-x.

Overuse of antenatal visits and ultrasounds in low-risk women: A national population-based study

BACKGROUND

A better understanding of the overuse of antenatal care is needed to improve its organisation to deal with limited medical resources and doctor shortages.

OBJECTIVES

To assess the proportion of women who overuse antenatal care and the associations of overuse with maternal characteristics and the qualifications of healthcare providers.

METHODS

We used the 2016 National Perinatal Survey, a cross-sectional population-based survey, performed in all maternity units in France, including 13,132 women. Based on the French national guidelines, 6-8 antenatal visits were defined as adequate, 9-11 as high use, and ≥12 as overuse, while 3 ultrasounds were considered adequate, 4-5 as high use, and ≥6 as overuse. We performed binary modified Poisson regressions-with adequate care as the reference-including maternal social and medical characteristics and the healthcare professionals' qualifications.

RESULTS

After women with inadequate care were excluded, 19.2% of low-risk women had at least 12 visits and 30.5% at least 6 ultrasounds. Overuse of visits was associated with primiparity, average to high income, less than good psychological well-being, and care by an obstetrician. The risks of overuse of ultrasounds were higher among primiparous, women with average to high income and those receiving care from a public-sector obstetrician (adjusted relative risk 1.17, 95% CI, 1.13, 1.21) or private obstetrician (adjusted relative risk 1.12, 95% CI, 1.07, 1.16), compared with a public-sector midwife.

CONCLUSIONS

Antenatal care overuse is very common in France and associated with some maternal characteristics and also the qualification of care provider. Antenatal care should be customised according to women's needs, in particular for primiparae and those with poor well-being, and available medical resources.

Call (and pay) the midwife: A discrete choice experiment on mothers' preferences and their willingness to pay for midwifery care

BACKGROUND

Mothers in Germany are entitled to midwifery care; however, they face a lack of skilled professionals. While the reliability of the access to midwifery is of great public interest, we know little about clients' preferences.

OBJECTIVES

We conduct a discrete choice experiment to study preferences and willingness to accept copayment for the entire scope of midwifery care (pregnancy, delivery, and postnatal). Thereby, we aim to provide policy recommendations for priority settings in times of scarcity. Furthermore, we evaluate to what extent midwives' education matters to parents and assess the degree of support for the latest Midwifery Reform Act that transfers education from vocational schools to universities.

DESIGN

Discrete choice experiment with separated adaptive dual response.

SETTINGS

Online Survey promoted through Facebook to parents in Germany.

RESPONDENTS

2080 respondents completed the experiment. They all have or are expecting at least one natural child, mainly born between 2018 and 2020 (87%). The average respondent is female (99%), 33 years old, with a university degree (50%).

METHODS

We use a d-optimal fractional factorial design and obtain individual parameter estimates through a Multinomial Logit analysis with Hierarchical Bayes estimation techniques. We calculate willingness to pay and importance weights and simulate uptake probabilities for different packages of care. To avoid extreme choice behavior, we apply separated adaptive dual response.

RESULTS

Home visits during the postnatal phase are most important (importance weight 50%); online support is demanded when no personal support is available. We find that 1:1 care during delivery is highly preferred, but one midwife supporting two women intrapartum is still acceptable. The midwife´s education plays a minor role with an importance weight of 3%; however, we find a preference for midwives trained at vocational schools rather than at universities.

CONCLUSIONS

In times of scarcity, postnatal care in the form of home visits should be prioritized over pregnancy counseling, and online services should be promoted as an add-on but not as a substitute for personal support. There is a high level of willingness to accept co-financing to ensure the availability of services usually covered by health insurance.

Trading patients' choice in providers for quality of maternity care? A discrete choice experiment amongst pregnant women

BACKGROUND

The introduction of bundled payment for maternity care, aimed at improving the quality of maternity care, may affect pregnant women's choice in providers of maternity care. This paper describes a Dutch study which examined pregnant women's preferences when choosing a maternity care provider. The study focused on factors that enhance the quality of maternity care versus (restricted) provider choice.

METHODS

A discrete choice experiment was conducted amongst 611 pregnant women living in the Netherlands using an online questionnaire. The data were analysed with Latent Class Analyses. The outcome measure consisted of stated preferences in the discrete choice experiment. Included factors were: information exchange by care providers through electronic medical records, information provided by midwife, information provided by friends, freedom to choose maternity care provider and travel distance.

RESULTS

Four different preference structures were found. In two of those structures, respondents found aspects of the maternity care related to quality of care more important than being able to choose a provider (provider choice). In the two other preference structures, respondents found provider choice more important than aspects related to quality of maternity care.

CONCLUSIONS

In a country with presumed high-quality maternity care like the Netherlands, about half of pregnant women prefer being able to choose their maternity care provider over organisational factors that might imply better quality of care. A comparable amount of women find quality-related aspects most important when choosing a maternity care provider and are willing to accept limitations in their choice of provider. These insights are relevant for policy makers in order to be able to design a bundled payment model which justify the preferences of all pregnant women.

Understanding Midwives' Preferences for Providing Information About Newborn Bloodspot Screening

Background: Understanding preferences for information provision in the context of health care service provision is challenging because of the number of potential attributes that may influence preferences. This study aimed to identify midwives’ preferences for the process and outcomes of information provision in an expanded national newborn bloodspot screening program. Design: A sample of practicing midwives completed a hybrid-stated preference survey including a conjoint analysis (CA) and discrete choice experiment to quantify preferences for the types of, and way in which, information should be provided in a newborn bloodspot screening program. Six conjoint analysis questions captured the impact of different types of information on parents’ ability to make a decision, and 10 discrete choice experiment questions identified preferences for four process attributes (including parents’ ability to make a decision). Results: Midwives employed by the UK National Health Service (n = 134) completed the survey. All types of information content were perceived to improve parents’ ability to make a decision except for the possibility of false-positive results. Late pregnancy was seen to be the best time to provide information, followed by day 3 postbirth. Information before 20 weeks of pregnancy was viewed as reducing parents’ ability to make a decision. Midwives preferred information to be provided by an individual discussion and did not think parents should receive information on the Internet. Conclusion: A hybrid stated preference survey design identified that a wide variety of information should be provided to maximize parents’ ability to make a decision ideally provided late in pregnancy or on day 3 postbirth.

Preferences for a third-trimester ultrasound scan in a low-risk obstetric population: a discrete choice experiment

OBJECTIVE

Establish maternal preferences for a third-trimester ultrasound scan in a healthy, low-risk pregnant population.

DESIGN

Cross-sectional study incorporating a discrete choice experiment.

SETTING

A large, urban maternity hospital in Northern Ireland.

PARTICIPANTS

One hundred and forty-six women in their second trimester of pregnancy.

METHODS

A discrete choice experiment was designed to elicit preferences for four attributes of a third-trimester ultrasound scan: health-care professional conducting the scan, detection rate for abnormal foetal growth, provision of non-medical information, cost. Additional data collected included age, marital status, socio-economic status, obstetric history, pregnancy-specific stress levels, perceived health and whether pregnancy was planned. Analysis was undertaken using a mixed logit model with interaction effects.

MAIN OUTCOME MEASURES

Women's preferences for, and trade-offs between, the attributes of a hypothetical scan and indirect willingness-to-pay estimates.

RESULTS

Women had significant positive preference for higher rate of detection, lower cost and provision of non-medical information, with no significant value placed on scan operator. Interaction effects revealed subgroups that valued the scan most: women experiencing their first pregnancy, women reporting higher levels of stress, an adverse obstetric history and older women.

CONCLUSIONS

Women were able to trade on aspects of care and place relative importance on clinical, non-clinical outcomes and processes of service delivery, thus highlighting the potential of using health utilities in the development of services from a clinical, economic and social perspective. Specifically, maternal preferences exhibited provide valuable information for designing a randomized trial of effectiveness and insight for clinical and policy decision makers to inform woman-centred care.

Designing a package of sexual and reproductive health and HIV outreach services to meet the heterogeneous preferences of young people in Malawi: results from a discrete choice experiment

BACKGROUND

This article examines young people's preferences for integrated family planning (FP) and HIV services in rural Malawi. Different hypothetical configurations for outreach services are presented using a Discrete Choice Experiment (DCE). Responses are analysed using Random Parameters Logit and Generalised Mixed Logit (GMXL) models in preference space and a GMXL model parameterised in willingness-to-pay space. Simulations are used to estimate the proportion of respondents expected to choose different service packages as elements are varied individually and in combination.

RESULTS

Responses were collected from 537 young people aged 15-24. Results show that when considering attending an outreach service to access family planning young people value confidentiality and the availability of HIV services including HIV counselling and testing (HCT) and HIV treatment, though significant observable and unobservable heterogeneity is present. Female respondents and those aged 20-24 were less concerned with service confidentiality compared to male respondents and those aged 15-19; respondents who were in a relationship at the time of the survey valued confidentiality more than those who reported being single. The addition of sports and recreation for young people may also be an attractive feature of a youth-friendly service; however, preferences for this attribute vary according to respondent gender. Results of the simulation modelling indicate that the most preferred service package is one that offers confidential services, both HCT and HIV treatment and sports for youth, with up to 32% of respondents expected to choose this service over a service where clients may have concerns over confidentiality, only HCT is available and there are no additional activities for young people. Estimates of willingness-to-pay for service attributes indicate that respondents were willing to pay up to USD$1.76 for confidentiality, USD$0.65 for a service offering both HCT and HIV treatment and USD$0.26 for a service including sports for youth.

CONCLUSIONS

Young people were able to complete a complex DCE and appeared to trade between the different characteristics used to describe the outreach services. These findings may offer important insight to policy makers designing youth friendly SRH outreach services and providers aiming to improve the acceptability and uptake of FP services.

Discrete choice experiments in health economics: a review of the literature

BACKGROUND

Discrete choice experiments (DCEs) are increasingly used in health economics to address a wide range of health policy-related concerns.

OBJECTIVE

Broadly adopting the methodology of an earlier systematic review of health-related DCEs, which covered the period 2001-2008, we report whether earlier trends continued during 2009-2012.

METHODS

This paper systematically reviews health-related DCEs published between 2009 and 2012, using the same database as the earlier published review (PubMed) to obtain citations, and the same range of search terms.

RESULTS

A total of 179 health-related DCEs for 2009-2012 met the inclusion criteria for the review. We found a continuing trend towards conducting DCEs across a broader range of countries. However, the trend towards including fewer attributes was reversed, whilst the trend towards interview-based DCEs reversed because of increased computer administration. The trend towards using more flexible econometric models, including mixed logit and latent class, has also continued. Reporting of monetary values has fallen compared with earlier periods, but the proportion of studies estimating trade-offs between health outcomes and experience factors, or valuing outcomes in terms of utility scores, has increased, although use of odds ratios and probabilities has declined. The reassuring trend towards the use of more flexible and appropriate DCE designs and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results. However, qualitative research methods are being used less often to inform attribute selection, which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project.

CONCLUSIONS

The use of DCEs in healthcare continues to grow dramatically, as does the scope of applications across an expanding range of countries. There is increasing evidence that more sophisticated approaches to DCE design and analytical techniques are improving the quality of final outputs. That said, recent evidence that the use of qualitative methods to inform attribute selection has declined is of concern.

Antenatal telephone support intervention with and without uterine artery Doppler screening for low risk nulliparous women: a randomised controlled trial

BACKGROUND

The number of routine antenatal visits provided to low risk nulliparous women has been reduced in the UK, acknowledging this change in care may result in women being less satisfied with their care and having poorer psychosocial outcomes. The primary aim of the study was to investigate whether the provision of proactive telephone support intervention (TSI) with and without uterine artery Doppler screening (UADS) would reduce the total number of antenatal visits required. A secondary aim was to investigate whether the interventions affected psychological outcomes.

METHODS

A three-arm randomised controlled trial involving 840 low risk nulliparous women was conducted at a large maternity unit in North East England. All women received antenatal care in line with current UK guidance. Women in the TSI group (T) received calls from a midwife at 28, 33 and 36 weeks and women in the telephone and Doppler group (T + D) received the TSI and additional UADS at 20 weeks' gestation. The main outcome measure was the total number of scheduled and unscheduled antenatal visits received after 20 weeks' gestation.

RESULTS

The median number of unscheduled (n = 2.0), scheduled visits (n = 7.0) and mean number of total visits (n = 8.8) were similar in the three groups. The majority (67%) of additional antenatal visits were made to a Maternity Assessment Unit because of commonly occurring pregnancy complications. Additional TSI+/-UADS was not associated with differences in clinical outcomes, levels of anxiety, social support or satisfaction with care. There were challenges to the successful delivery of the telephone support intervention; 59% of women were contacted at 29 and 33 weeks gestation reducing to 52% of women at 37 weeks.

CONCLUSIONS

Provision of additional telephone support (with or without UADS) in low risk nulliparous women did not reduce the number of unscheduled antenatal visits or reduce anxiety. This study provides a useful insight into the reasons why this client group attend for unscheduled visits.

TRIAL REGISTRATION

ISRCTN62354584.

The effectiveness of a Chinese midwives' antenatal clinic service on childbirth outcomes for primipare: a randomised controlled trial

BACKGROUND

Antenatal care is an important component of maternity care. In many parts of the world, midwives are the primary caregivers for childbearing women, providing a high level of continuity of care during a normal pregnancy. While in China, obstetricians are the primary providers of antenatal care for all childbearing women; and midwives only provide intrapartum care to labouring women. Today midwifery as a profession in China has been marginalised. Pregnant women usually lack individualised continuity of care from midwives during the perinatal period. There have been few randomised controlled trials of midwifery care practice in mainland China.

OBJECTIVE

(1) To develop and implement a model of Chinese midwives' antenatal clinic service and (2) to explore its effect on childbirth outcomes, psychological state and satisfaction, for primiparae.

DESIGN AND METHODS

Two-group randomised controlled trial. One hundred and ten pregnant women were assessed for eligibility and invited to participate in either the intervention group (midwives' antenatal clinic service) or the control group (routine antenatal care) in the Obstetrics and Gynaecology Hospital of Fudan University from September 2011 to December 2011. Baseline data were collected, and then women were randomised to individual midwives' antenatal clinic care (intervention group) or regular antenatal clinic service by obstetricians and obstetric nurse (control group). The research hypothesis was that compared with regular obstetrician-led antenatal care, the midwives' antenatal clinic service would decrease the caesarean section rate, produce more favourable birth outcomes and women's greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. The sample size of 110 was calculated to identify a decrease in caesarean birth from 70% to 40%. Birth outcomes, satisfaction and anxiety score in the two groups were compared.

SETTING

The midwives' antenatal clinic in the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.

PARTICIPANTS

55 women, attending the midwives' antenatal clinic (the intervention group) and 55 women, entering the control group.

RESULTS

Women in the intervention group were more likely than women in the control group to have a vaginal birth (35 [66.04%] versus 23 [43.40%]; 95% CI for difference 3.69-41.60). Women in the intervention group had a higher perinatal satisfaction but lower anxiety score than those in the control group. No differences were seen in neonatal Apgar score and in the amount of bleeding 2h post partum.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The midwives' antenatal clinic can decrease the rate of caesarean section and enhance women's satisfaction with midwifery care. Further research needs to be conducted to implement this model of care more widely. We will attempt to make midwifery care a true choice for Chinese women.

A public health perspective of women's experiences of antenatal care: an exploration of insights from a community consultation

OBJECTIVES

to offer a critical discussion from a public health perspective of service user's experiences of antenatal care services.

DESIGN

a qualitative, descriptive study using 18 group (n = 86) and six individual semi-structured interviews (n = 6) with thematic networks analysis conducted.

SETTING

ninety-two participants recruited from organisations/groups who work with vulnerable populations and/or community groups were consulted in the North West of England.

FINDINGS

analysis from a public health perspective suggested four key areas: antenatal care attendance, the frequency of antenatal appointments, the location of antenatal care and the provision of risk information. The benefits of universal access to antenatal care were mainly evident to participants. The need for targeting those with identified clinical risk was valued, but participants expressed frustration at a 'one-size fits all' approach for others, which failed to adequately consider their psychosocial and educational needs. In some women, this failure prompted non-compliant behaviour. Concerns were somewhat compensated for by community-based antenatal services.

CONCLUSIONS AND RECOMMENDATIONS

inequities in antenatal care persist with service users from vulnerable population groups continuing to express that these services do not meet their needs. Neither a targeted approach based on clinical needs nor a population-based approach, which service users feel limits access, meet their expectations. Proportionate universalism offers a new paradigm in public health with level of service proportionate to need. Such an approach may facilitate health-care staff to meet the expectations of vulnerable families who may require more psychosocial and educational support.