Transforming maternity care: obstetric partnerships as a policy instrument for integration

Bridging Perspectives, Building Resilience: Safety-II Guided Reflexive Dialogues Between Care Professionals and Clients as Part of Developing Integrated Maternity Care

Background

Limitations of traditional structures and approaches to further enhance patient safety, satisfaction, and systemic sustainability in healthcare, are becoming increasingly visible. Embedding reflexivity is a proposed strategy to promote progress. We aimed to explore the potential of creating reflexive spaces for promoting integration and client-centeredness in maternity care specifically.

Methods

In this participatory action research (PAR), two multidisciplinary and multiorganizational groups of maternity care professionals and clients (n = 28) from two Dutch regions, participated in 'reflexive dialogues'. Cases were discussed from a Safety-II perspective. In total, 22 meetings took place from 2020-2022, mostly online. Additionally, 23 participants were interviewed. Data were audio-recorded, transcribed, and thematically analyzed.

Findings

Participants were generally positive about the reflexive dialogues and Safety-II approach. They felt both safe and challenged to critically reflect on their own and each other's care practices. Exchanging perspectives, experiences, and approaches fostered trust, well-being, and repertoire, and through this, resilience.

Conclusions

By structurally stimulating, facilitating, and embedding Safety-II guided reflexive dialogues between professionals and clients from multiple organizations and disciplines, healthcare leaders could promote resilience and reinforce the transformation towards integrated, relation-centered maternity care.

Exploring perceptions of vulnerability among women facing psychosocial adversity before, during and after pregnancy: A qualitative interview-study using thematic analysis

OBJECTIVE

The term 'vulnerable' is often used to describe women facing psychosocial adversity during pregnancy, implying a heightened risk of experiencing suboptimal pregnancy outcomes. While this label might facilitate the pathway to appropriate care, it can be perceived as stigmatizing by the women it intends to help, which could deter their interaction with healthcare services. This study explores how women facing psychosocial adversity before, during and after pregnancy perceive the concept of vulnerability and experience being labeled as such.

METHODS

We conducted a thematic analysis of semi-structured, in-depth interviews. Through purposive sampling targeting maximum variation, ten women of diverse backgrounds were included.

RESULTS

Three central themes emerged: defining vulnerability, embracing vulnerability and the feeling of being stigmatized. Women perceived vulnerability as an inability to adequately care for themselves or their children, necessitating additional support alongside routine antenatal care. Acceptance of the 'vulnerable' label came when it also acknowledged their proactive efforts and strengths to improve their situation. Conversely, if discussions surrounding vulnerability failed to recognize women's agency - specifically, their personal journeys and the courage needed to seek support - the label was perceived as stigmatizing.

CONCLUSIONS

Addressing vulnerability effectively in maternity care requires a nuanced, patient-centered approach, acknowledging both the challenges and strengths of women facing psychosocial adversities. Emphasizing personal narratives and their courage in seeking support can mitigate the stigmatizing effects of the 'vulnerable' label. Integrating these narratives into maternal healthcare practices can foster deeper connections with the women involved, enhancing the overall quality of care.

The Dutch Solid Start program: describing the implementation and experiences of the program's first thousand days

BACKGROUND

In 2018, the Dutch government initiated the Solid Start program to provide each child the best start in life. The program focuses on the crucial first thousand days of life, which span from preconception to a child's second birthday, and has a specific focus towards (future) parents and young children in vulnerable situations. A key program element is improving collaboration between the medical and social sector by creating Solid Start coalitions. This study aimed to describe the implementation of the Dutch Solid Start program, in order to learn for future practice and policy. Specifically, this paper describes to what extent Solid Start is implemented within municipalities and outlines stakeholders' experiences with the implementation of Solid Start and the associated cross-sectoral collaboration.

METHODS

Quantitative and qualitative data were collected from 2019 until 2021. Questionnaires were sent to all 352 Dutch municipalities and analyzed using descriptive statistics. Qualitative data were obtained through focus group discussions(n = 6) and semi-structured interviews(n = 19) with representatives of care and support organizations, knowledge institutes and professional associations, Solid Start project leaders, advisors, municipal officials, researchers, clients and experts-by-experience. Qualitative data were analyzed using the Rainbow Model of Integrated Care.

RESULTS

Findings indicated progress in the development of Solid Start coalitions(n = 40 in 2019, n = 140 in 2021), and an increase in cross-sectoral collaboration. According to the stakeholders, initiating Solid Start increased the sense of urgency concerning the importance of the first thousand days and stimulated professionals from various backgrounds to get to know each other, resulting in more collaborative agreements on cross-sectoral care provision. Important elements mentioned for effective collaboration within coalitions were an active coordinator as driving force, and a shared societal goal. However, stakeholders experienced that Solid Start is not yet fully incorporated into all professionals' everyday practice. Most common barriers for collaboration related to systemic integration at macro-level, including limited resources and collaboration-inhibiting regulations. Stakeholders emphasized the importance of ensuring Solid Start and mentioned various needs, including sustainable funding, supportive regulations, responsiveness to stakeholders' needs, ongoing knowledge development, and client involvement.

CONCLUSION

Solid Start, as a national program with strong local focus, has led to various incremental changes that supported cross-sectoral collaboration to improve care during the first thousand days, without major transformations of systemic structures. However, to ensure the program's sustainability, needs such as sustainable funding should be addressed.

Institutionalizing Reflexivity for Sustainability: Two Cases in Health Care

Unsustainability in health care comprises diminishing returns and misalignment between the health care regime and the needs of the population. To deal with complex sustainability problems, niche solutions can be collaboratively designed and implemented through reflexive methods. For second-order sustainability, however, the institutionalization of the reflexive element itself is also needed. This paper aims to provide insight into the possibilities of embedding reflexivity into institutions to support second-order sustainability by reporting on two consecutive participatory research programs that sought to address unsustainability in terms of misalignment and diminishing returns. The first case study reflexively monitored the system’s innovation toward an integrated perinatal care system. Reflection within the project and implementation was supported successfully, but for stronger embedding and institutionalization, greater alignment of the reflexive practices with regime standards was needed. Building on these lessons, the second case study, which was part of the IMI-PARADIGM consortium, collaboratively built a structured tool to monitor and evaluate “the return on engagement” in medicine development. To institutionalize reflexivity, the creation of “reflexive standards” together with regime actors appears to be most promising. Broader and deeper institutionalization of reflexive standards can be attained by building enforcement structures for reflexive standards in the collaborative process as part of the reflexive methodologies for addressing complex sustainability problems.