The acceptability of implementing patient-reported measures in routine maternity care: A systematic review

Experiences of health professionals in screening for postpartum depressive symptoms: a qualitative systematic review

OBJECTIVE

The objective of this review is to assess and synthesize the available qualitative evidence on health professionals' experiences in screening for postpartum depression (PPD).

INTRODUCTION

PPD is a significant public health problem. Clinical screening is essential to develop appropriate interventions to meet the needs of women and their families. The findings of this review have important implications for decision-making and policy development for continuous professional development programs that promote evidence-based PPD screening.

INCLUSION CRITERIA

This review considered studies that explore the experiences of health professionals who screen for PPD in any geographic location at any health care facility, scenario, or setting. The review focused on qualitative data, including methods such as phenomenology, grounded theory, ethnography, action research, and feminist research.

METHODS

The review followed a 3-step search strategy in line with JBI methodology for systematic reviews of qualitative evidence. The databases searched included PubMed, CINAHL (EBSCOhost), Embase (Elsevier), Scopus, LILACS (BVS), ScienceDirect (Elsevier), PsycINFO (Ovid), Index Psi Journals (BVS-PSI), and PePsic (IPUSP). Unpublished studies were searched for in Google Scholar, Cybertesis, Dart-E, EthOS, and Open Access Theses and Dissertations (OATD). Two independent reviewers evaluated the included studies for methodological quality and extracted data using the JBI data extraction and synthesis tools. Studies published in English, Portuguese, and Spanish from database inception until October 2023 were included.

RESULTS

Twenty-four qualitative studies from 14 countries across 5 continents involving 392 health professionals were included. A total of 113 findings were extracted and grouped into 5 categories: i) education and training; ii) responsibility of PPD screening, referral, and follow-up: role of the job and work overload; iii) screening, referral, and follow-up; iv) disclosure, judgment, culture; v) and health system structure. Two synthesized findings evolved from these categories: i) The need for training and ongoing education, professional role, professional practice, and ways of caring in screening postpartum women for depressive symptoms; ii) External barriers, facilitating factors, and health system issues.

CONCLUSIONS

Health professionals' experiences caring for women and families concerning PPD are influenced by their culture, practices, training, and worldview. Regular workshops and practical training sessions that emphasize the development of PPD-screening skills, particularly in recognizing subtle signs of depression and conducting culturally sensitive assessments, could be highly effective for health professionals. Policymakers should collaborate with health care professionals to develop and implement policies tailored to different contexts and cultures. Providing educational subsidies and ensuring monitoring and follow-up after PPD screening are fundamental for the sustainability of PPD screening and management.

Conceptualizing perinatal health-related quality of life for decision making

Increased health care needs during the perinatal period can significantly impact a patient's quality of life. Health-related quality of life (HRQoL) reflects the impact of a patient's health on their physical, mental and social wellbeing. Research has focused on development of tools suitable to measure HRQoL. These can be applied across the perinatal period from conception to postnatal care for use in clinical care, as an aid to shared decision making, in research and as an input to cost-effectiveness analyses used for resource allocation. HRQoL tools are a subset of Patient Reported Outcome Measures (PROMs), which help clinicians/researchers understand patient's experience of health. This essay serves as a primer to review the availability, validity and evidence of HRQoL tools for use in perinatal care. While some PROMs are routinely being implemented in pregnancy care, gaps remain regarding the specific impact of HRQoL tools on decision making and their potential use in family planning and neonatal care. Future research is needed to determine whether routine perinatal implementation of HRQoL tools will lead to stronger decision making for patients and providers. Involvement of parents in this process is essential to better understand how HRQoL tools can benefit decision making and perinatal care.

Improving UK data on avoidable perinatal brain injury: review of data dictionaries and consultation

BACKGROUND

High quality data is important to understanding epidemiology and supporting improvement efforts in perinatal brain injury. It is not clear which data items relevant to brain injury are captured across UK sources of routinely collected data, nor what needs to be done to ensure that those sources are fit for purpose in improving care.

METHODS

We reviewed data dictionaries of four main UK perinatal data sources and consulted a multi-professional group (N = 27) with expertise in neonatal/maternity care, statistics, and clinical negligence.

RESULTS

None of the data sources we reviewed currently captures, on its own, the range of items relevant to brain injury. Data items lack common definitions and ongoing linkage across the different sources. Our consultation identified the need for standardising the definition of avoidable perinatal brain injury, resolving inconsistencies in capturing data, improving linkage of data across existing data sources, and co-designing a strategy for meaningful use of data.

CONCLUSIONS

Limited standardisation and linkage across UK data sources are key problems in using data to guide improvement efforts aimed at reducing risk of avoidable perinatal brain injury. A programme involving co-design with healthcare professionals and families to improve capture and use of data is now needed.

IMPACT

Limited standardisation and linkage across UK data sources currently challenge the use of data as the basis of efforts to reduce risk of avoidable perinatal brain injury. A harmonisation programme involving consultation and co-design with healthcare professionals, families, and other specialists is needed to enable better capture and use of data in this key area. There is need to standardise the definition of avoidable perinatal brain injury, resolve inconsistencies in capturing data, improve linkage of data collected across existing data sources, and co-design a strategy for meaningful use of data.

The feasibility of implementing a digital pregnancy and postpartum support program in the Midwestern United States and the association with maternal and infant health

Objective

The benefits of mobile applications in the prenatal period remain understudied. This study assessed associations between the Pregnancy Postpartum Support Program (PPSP), a digital wraparound service, and maternal and infant outcomes in a Medicaid population.

Methods

A retrospective analysis was conducted on pregnant patients with Medicaid insurance who received care and delivered in a Midwestern United States healthcare system between 8/1/2022-8/15/2023, comparing outcomes among those who did versus did not opt for PPSP enrollment. Enrolled patients were offered a mobile device app providing weekly education, "twenty-four seven" support from a clinical team, and telehealth provider visits. Adjusted multiple covariate analyses were completed using linear and logistic regressions. Patient engagement, vendor-based interaction and perception of care data were also examined.

Results

1912 patients were evaluated: 397 in the PPSP and 1515 in the control group. PPSP cohort inclusion was associated with 4 % lower maternal length of stay (LOS) (p = 0.05), 14 % lower infant LOS (p < 0.01), higher mean infant birthweight (p < 0.01), lower odds of birthweight <2500 g (p = 0.05) and lower odds of preterm birth (p = 0.04). Nearly 85 % of all enrolled reported being "very satisfied" with the program.

Conclusions

Overall, the program was positively received by PPSP participants. Favorable outcomes associated with enrollment may be due to the program, unmeasured variables, or both. Our study shows the feasibility of offering digital support to pregnant women who voluntarily enrolled in the PPSP and adds to the evidence evaluating virtual care strategies.

Acceptability of identification and management of perinatal anxiety: a qualitative interview study with postnatal women

Background

Anxiety in pregnancy and postpartum is highly prevalent but under-recognized and few women receive adequate support or treatment. Identification and management of perinatal anxiety must be acceptable to women in the perinatal period to ensure that women receive appropriate care when needed. We aimed to understand the acceptability to women of how anxiety was identified and managed by healthcare professionals.

Method

We conducted in-depth qualitative interviews with 60 women across England and Scotland approximately 10 months after birth. Women were sampled from an existing systematically recruited cohort of 2,243 women who recorded mental health throughout pregnancy and after birth. All women met criteria for further assessment of their mental health by a healthcare professional. We analyzed the data using a theoretical framework of acceptability of healthcare interventions.

Results

Interview data fitted the seven constructs within the theoretical framework of acceptability. Women valued support before professional treatment but were poorly informed about available services. Services which treated women as individuals, which were accessible and in which there was continuity of healthcare professional were endorsed. Experience of poor maternity services increased anxiety and seeing multiple midwives dissuaded women from engaging in conversations about mental health. Having a trusted relationship with a healthcare professional facilitated conversation about and disclosure of mental health problems.

Conclusion

Women's experiences would be improved if given the opportunity to form a trusting relationship with a healthcare provider. Interventions offering support before professional treatment may be valued and suitable for some women. Clear information about support services and treatment options available for perinatal mental health problems should be given. Physiological aspects of maternity care impacts women's mental health and trust in services needs to be restored. Findings can be used to inform clinical guidelines and research on acceptable perinatal care pathways in pregnancy and after birth and future research.

Roles of different organizations in implementing patient-reported measures in routine maternity care in Finland

BACKGROUND

The integration of patient-centered care (PCC) and value-based healthcare (VBHC) principles, emphasizing personalized, responsive care and cost efficiency, is crucial in modern healthcare. Despite advocation from the International Consortium for Health Outcomes Measurement (ICHOM) for the global adoption of these principles through patient-reported measures (PRMs), their implementation, especially the pregnancy and childbirth (PCB) set, remains limited in maternity care. This study focuses on understanding the optimal organizational entity for integrating standard ICHOM-PCB-PRMs into routine maternity care in Finland. It aims to clarify the distribution of tasks among stakeholders and gather Finnish maternity healthcare professionals' perspectives on organizational responsibility in PRM collection. The emphasis was on identifying the optimal organizational framework for managing PRMs in maternity care.

RESULTS

A total of 66 maternity healthcare professionals participated in the study, reaching a consensus that public maternity care centers in Finland should be the primary entity responsible for managing PRMs in the maternity sector. Key aspects such as confidence with the role as a mother, maternal confidence with breastfeeding, and satisfaction with the result of care were identified as crucial and should be inquired about in both public maternity care centers and hospital maternity wards. The findings highlight the importance of comprehensive and consistent attention to these PRMs across public maternity care centers and hospital maternity settings to ensure holistic and effective maternal care.

CONCLUSIONS

The study highlights the central role of public maternity care centers in the collection and management of PRMs within Finnish maternity care, as agreed upon by the professional consensus. It underscores the importance of a consistent and holistic approach to PRM inquiry across different care settings to enhance the quality and effectiveness of maternity care. This finding is crucial for policymakers and healthcare practitioners, suggesting that reinforcing the collaborative efforts between public maternity care centers and hospital maternity wards is vital for a patient-centric, efficient healthcare system. Aligning with PCC and VBHC principles, this approach aims to improve healthcare outcomes for pregnant and postpartum women in Finland, emphasizing the need for a unified strategy in managing maternity care.

Psychometric properties of the maternal breastfeeding evaluation scale: a confirmatory factor analysis

BACKGROUND

It has been suggested that maternal satisfaction should be included as an additional and appropriate outcome indicator in relation to the breastfeeding process. The aim of this study was to analyze the psychometric properties of various existing versions of the Maternal Breastfeeding Evaluation Scale in a Spanish sample.

METHODS

This was a longitudinal observational study, evaluated at three different time points: in the hospital after delivery, and then at five and 12 months after delivery in a Spanish sample. A total of 690 mother participated in this study.

RESULTS

Confirmatory factor analysis results indicated an improved fit of the data to the original model (CFI = 0.984; TLI = 0.982; RMSEA = 0.079). All dimensions of the Maternal Breastfeeding Evaluation Scale are positively associated with breastfeeding rates and negatively associated with perceived difficulty in continuing to breastfeed after returning to work at five months postpartum. Moreover, the scale can predict breastfeeding behavior at 12 months postpartum.

CONCLUSIONS

The results of this study indicate that the structure of the original version of the Maternal Breastfeeding Evaluation Scale mean it is a is valid and reliable tool for assessing maternal perceptions of the breastfeeding experience in Spain. This research enhances our understanding of maternal satisfaction with the breastfeeding experience and its potential implications for supporting breastfeeding practices. It is an opportunity for the academic, healthcare, and policy sectors to develop more effective interventions to improve breastfeeding rates and ensure a positive experience for mothers.

Acceptability and content validity of suicidality screening items: a qualitative study with perinatal women

Background

Suicide is a leading cause of death for perinatal women. It is estimated that up to 50% of women with mental health issues during pregnancy and/or after birth are not identified, despite regular contact with healthcare services. Screening items are one way in which perinatal women needing support could be identified. However, research examining the content validity and acceptability of suicide-related screening items with perinatal women is limited.

Aims

This study sought to: (i) assess the acceptability and content validity of 16 suicide-related items that have been administered and/or validated in perinatal populations; and (ii) explore the potential barriers and facilitators that may affect how women respond to these items when administered during pregnancy and after birth.

Methods

Twenty-one cognitive and semi-structured interviews were conducted with pregnant and postnatal women in the UK. The sample included women who had experienced self-reported mental health problems and/or suicidality during the perinatal period, and those who had not. Interviews were transcribed verbatim, and a coding framework based on the Theoretical Framework of Acceptability was applied to explore the data using deductive and inductive approaches.

Results

Findings indicated that the acceptability and content validity of suicide-related items were largely unacceptable to perinatal women in their current form. Women found terms such as 'better off dead' or 'killing myself' uncomfortable. Most women preferred the phrase 'ending your life' as this felt less confronting. Comprehensibility was also problematic. Many women did not interpret 'harming myself' to include suicidality, nor did they feel that abstract language such as 'leave this world' was direct enough in relation to suicide. Stigma, fear, and shame was central to non-disclosure. Response options and recall periods further affected the content validity of items, which created additional barriers for identifying those needing support.

Conclusions

Existing suicide-related screening items may not be acceptable to perinatal women. Maternity practitioners and researchers should consider the phrasing, clarity, context, and framing of screening items when discussing suicidality with perinatal women to ensure potential barriers are not being reinforced. The development of specific suicidality screening measures that are acceptable, appropriate, and relevant to perinatal women are warranted.

Measuring outcomes of rehabilitation among the elderly-a feasibility study

A feasible system for measuring patient outcomes of rehabilitation is required for assessing the real-world cost-effectiveness of rehabilitation. This study aims to assess the feasibility of measuring outcomes of rehabilitation among elderly individuals with early-stage Alzheimer's. We used the principles of Design Science to construct a set of metrics consisting of standardized PROM (Patient-Reported Outcome Measure) questionnaires, clinician-reported measures, and observational measures of functioning. We used standardized questionnaires whenever possible to ensure the validity and reliability of the questionnaires. The set of metrics was piloted on 16 individuals living at home with regular home care services. After the pilot, we further refined the set of metrics based on relevance, sensitivity to change, and applicability. We found that measurement was feasible and we propose the final set of metrics as a minimum set, which could be further improved upon by addition of metrics relevant to each subgroup of elderly individuals. We also found that using self-reported questionnaires in this population is not without difficulties. We therefore suggest that the role of informal caregivers be considered, and that accessibility of outcome questionnaires be improved.