Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis

Community midwives' perspectives on perinatal care for asylum seekers and refugees in the Netherlands: A survey study

BACKGROUND

The rise of forced migration worldwide compels birth care systems and professionals to respond to the needs of women giving birth in these vulnerable situations. However, little is known about the perspective of midwifery professionals on providing perinatal care for forcibly displaced women. This study aimed to identify challenges and target areas for improvement of community midwifery care for asylum seekers (AS) and refugees with a residence permit (RRP) in the Netherlands.

METHODS

For this cross-sectional study, data were collected through a survey aimed at community care midwives who currently work or who have worked with AS and RRP. We evaluated challenges identified through an inductive thematic analysis of respondents' responses to open-ended questions. Quantitative data from close-ended questions were analyzed descriptively and included aspects related to the quality and organization of perinatal care for these groups.

RESULTS

Respondents generally considered care for AS and RRP to be of lower quality, or at best, equal quality compared to care for the Dutch population, while the workload for midwives caring for these groups was considered higher. The challenges identified were categorized into five main themes, including: 1) interdisciplinary collaboration; 2) communication with clients; 3) continuity of care; 4) psychosocial care; and 5) vulnerabilities among AS and RRP.

CONCLUSIONS

Findings suggest that there is considerable opportunity for improvement in perinatal care for AS and RRP, while also providing direction for future research and interventions. Several concerns raised, especially the availability of professional interpreters and relocations of AS during pregnancy, require urgent consideration at legislative, policy, and practice levels.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

Access to care during labor and delivery and safety to maternal health

Objective:

to analyze the time of access to care during labor and delivery and the safety of maternal health.

Method:

cross-sectional analytical study, carried out in five maternity hospitals, four of which are of habitual and intermediate risk and one of high risk. For data collection, data from the maternal medical record and interviews with the puerperal woman were used. In the data analysis, the Chi-square test (p≤0.05) was performed to search for possible associations between the independent variables - model three delays and dependents [Adverse maternal outcomes], [Knowledge about labor/delivery] and [Service satisfaction].

Results:

statistical significance was observed between the adverse maternal outcome and the delay in looking for a health service (p = 0.005) and the delay in transport to the maternity hospital (p = 0.050), while the outcome knowledge about labor/delivery showed statistical association with delay in looking for a health service (p = 0.048). There was no statistically significant difference between the three delays model and satisfaction with the care.

Conclusion:

the women’s knowledge about labor and delivery and the time of access to obstetric care negatively interferes with the maternal outcome at delivery, which directly impacts maternal health safety.

Clinical Capital and the Risk of Maternal Labor and Delivery Complications: Hospital Scheduling, Timing, and Cohort Turnover Effects

The establishment of interventions to maximize maternal health requires the identification of modifiable risk factors. Toward the identification of modifiable hospital-based factors, we analyze over 2 million births from 2005 to 2010 in Texas, employing a series of quasi-experimental tests involving hourly, daily, and monthly circumstances where medical service quality (or clinical capital) is known to vary exogenously. Motivated by a clinician's choice model, we investigate whether maternal delivery complications (1) vary by work shift, (2) increase by the hours worked within shifts, (3) increase on weekends and holidays when hospitals are typically understaffed, and (4) are higher in July when a new cohort of residents enter teaching hospitals. We find consistent evidence of a sizable statistical relationship between deliveries during nonstandard schedules and negative patient outcomes. Delivery complications are higher during night shifts (OR = 1.21, 95% CI: 1.18-1.25), and on weekends (OR = 1.09, 95% CI: 1.04-1.14) and holidays (OR = 1.29, 95% CI: 1.04-1.60), when hospitals are understaffed and less experienced doctors are more likely to work. Within shifts, we show deterioration of occupational performance per additional hour worked (OR = 1.02, 95% CI: 1.01-1.02). We observe substantial additional risk at teaching hospitals in July (OR = 1.28, 95% CI: 1.14-1.43), reflecting a cohort-turnover effect. All results are robust to the exclusion of noninduced births and intuitively falsified with analyses of chromosomal disorders. Results from our multiple-test strategy indicate that hospitals can meaningfully attenuate harm to maternal health through strategic scheduling of staff.

Links between patient safety and fear of childbirth-A meta-study of qualitative research

AIM

To conduct a meta-study of qualitative empirical research to explore the links between patient safety and fear of childbirth in the maternity care context. The review questions were: How are patient safety and fear of childbirth described? and What are the links between patient safety and fear of childbirth in the maternity care context?

DESIGN

Meta-study.

DATA SOURCES

The CINAHL, Cochrane, PubMed, Webb of Science, Proquest and Medline (Ovid) electronic databases were searched for articles published between June 2000-June 2016.

REVIEW METHODS

A meta-study of qualitative research with a thematic analysis followed by a synthesis.

RESULTS

Four descriptive themes emerged: "Physical risks associated with giving birth vaginally"; "Control and safety issues"; "Preventing psychological maternal trauma and optimizing foetal well-being"; and "Fear of the transition to motherhood due to lack of confidence". The two overarching analytical themes: "Opting for safety" and "An insecure environment breeds fear of childbirth", represent a deeper understanding and constitute the synthesis of the links between patient safety and fear of childbirth. This meta-study indicates the need for increased commitment to safe care and professional support to reduce risks and prevent unnecessary harm in maternity care.

How good is collaboration between maternity service providers in the Netherlands?

AIMS

To examine the experiences of inter-professional collaboration of maternity service providers in the Netherlands and to identify potential enhancing and inhibiting factors for inter-professional collaboration within maternity care in the Netherlands.

BACKGROUND

Good collaboration between health care professionals is a key element of safe, effective care, but creating a collaborative culture can be challenging. Good collaboration requires, among other things, negotiating different professional orientations and the organizational constraints of hierarchies and scheduling. Good collaboration is especially important in maternity care. In the Netherlands, suboptimal collaboration has been cited as a significant factor in maternal deaths and in adverse incidents occurring in hospitals during evenings, nights, and weekends. In spite of its importance for effective maternity care, little is known about the nature and quality of collaboration between maternity care professionals. In order to fill this gap, we examined the inter-professional collaboration within multi-disciplinary teams (MDTs) providing maternity services in the Netherlands.

METHODS

Online survey of MDTs (consisting of hospital and PCMs, doctors, and carers) involved in the provision of maternity services in the Netherlands. We used a validated measure of collaboration (the Leiden Quality of Work Questionnaire) to analyze the attitudes of those involved in the provision of maternity services about multi-disciplinary collaboration in their work. We used descriptive and inferential statistics to assess differences between the groups.

RESULTS

40% of all respondents were not satisfied with collaboration within their MDT. Overall, mean collaboration scores (MCS) were low. We found significant differences in MCS between professional groups. Midwives - community and hospital based - were pessimistic about collaboration in future models of maternity care.

DISCUSSION

In the Netherlands, collaboration in maternity care is less than optimal. Poor collaboration is associated with negative consequences for patient safety and quality of care. Strategies to address suboptimal collaboration exist; however, no one-size-fits-all approach is identified in the literature.

CONCLUSION

Suboptimal collaboration exists within the midwifery model of care in the Netherlands and the relationship between care providers is under pressure. This could affect patient safety and quality of care, according to the literature.

PRÉCIS

This paper presents an in-depth examination of the nature of, and attitudes about, collaboration between members of the MDT involved in the provision of maternity services in the Netherlands.

Simulation-based team training for multi-professional obstetric care teams to improve patient outcome: a multicentre, cluster randomised controlled trial

OBJECTIVE

To investigate whether simulation-based obstetric team training in a simulation centre improves patient outcome.

DESIGN

Multicentre, open, cluster randomised controlled trial.

SETTING

Obstetric units in the Netherlands.

POPULATION

Women with a singleton pregnancy beyond 24 weeks of gestation.

METHODS

Random allocation of obstetric units to a 1-day, multi-professional, simulation-based team training focusing on crew resource management (CRM) in a simulation centre or to no such team training. Intention-to-treat analyses were performed at the cluster level, including a measurement 1 year prior to the intervention.

MAIN OUTCOME MEASURES

Primary outcome was a composite outcome of obstetric complications during the first year post-intervention, including low Apgar score, severe postpartum haemorrhage, trauma due to shoulder dystocia, eclampsia and hypoxic-ischaemic encephalopathy. Maternal and perinatal mortality were also registered.

RESULTS

Each study group included 12 units with a median unit size of 1224 women, combining for a total of 28 657 women. In total, 471 medical professionals received the training course. The composite outcome of obstetric complications did not differ between study groups [odds ratio (OR) 1.0, 95% confidence interval (CI) 0.80-1.3]. Team training reduced trauma due to shoulder dystocia (OR 0.50, 95% CI 0.25-0.99) and increased invasive treatment for severe postpartum haemorrhage (OR 2.2, 95% CI 1.2-3.9) compared with no intervention. Other outcomes did not differ between study groups.

CONCLUSION

A 1-day, off-site, simulation-based team training, focusing on teamwork skills, did not reduce a composite of obstetric complications.

TWEETABLE ABSTRACT

1-day, off-site, simulation-based team training did not reduce a composite of obstetric complications.

What is normal progress in the first stage of labour? A vignette study of similarities and differences between midwives and obstetricians

OBJECTIVE

intrapartum referrals are high-risk situations. To ensure patient safety, care professionals need to have a shared understanding of a labouring woman's situation. We aimed to gain insight into similarities and differences between midwives and obstetricians in the assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting in the Netherlands.

DESIGN

factorial survey.

SETTING

in the Netherlands, the main caregivers for women with low risks of pathology are primary-care midwives working in the locality. Approximately half of all women start labour under supervision of primary-care midwives. Roughly 40% of these women are referred to a hospital during labour, where obstetricians take over responsibility. In 2013, the reason for referral for 5161 women (14.1% of all referrals during labour) was a prolonged first stage of labour.

PARTICIPANTS

respondents consisted of primary-care midwives (N=69), obstetricians (N=47) and hospital based midwives, known as clinical midwives (N=31).

MEASUREMENTS

each respondent assessed seven hypothetical vignettes. The assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting based on this indication were used as outcome measures, rated on a 7-point Likert scale (1=very unlikely to 7=very likely). Data were analysed using a linear multilevel model with a two-level hierarchy.

FINDINGS

compared to primary-care midwives, obstetricians were more likely to define a prolonged first stage of labour when progress in cervical dilation was slow (b: 1.11; 95% CI: 0.66 - 1.57). The attributes parity, progress, intensity of uterine contractions and the woman's state of mind, were used by all three groups in the decision to refer a woman to clinical setting based on a prolonged first stage of labour. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: we found relevant interprofessional differences and similarities in the assessment of a prolonged first stage of labour and consequent referral. Further interprofessional alignment of clinical assessments, for instance through interprofessional discussions and a review of professional guidelines, might help to improve collaborative care.