Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models

Evolution and determinants of antenatal care services utilization among women of reproductive age in Rwanda: a scoping review

BACKGROUND

Maternal and child health remains a global priority, with antenatal care (ANC) recognized as essential for ensuring positive pregnancy outcomes. Despite significant improvements, in low- and middle-income countries, ANC service utilization remains low in Sub-Saharan Africa. This paper contributes to the understanding of the evolution and determinants of ANC service utilization among women of reproductive age in Rwanda.

METHODS

This review focused on studies published between 2010 and 2024 and examined the factors associated with ANC utilization in Rwanda. Two reviewers independently performed screening of the abstracts and full texts and conducted data extraction and synthesis. The aggregated odds ratios for various factors associated with ANC service utilization were presented in forest plots, created using GraphPad Prism version 10.

RESULTS

The review included 11 studies and 1 report on ANC service utilization in Rwanda. By 2019-2020, 47% of women had received ANC in the first trimester, and 59% had four or more visits. Higher education levels, better wealth status, health insurance coverage, and small household size are associated with adequate ANC service utilization. Conversely, a significant distance from health facilities and unwanted pregnancies were associated with lower odds of adequate ANC utilization. Delayed ANC was more likely among women with higher parity, those who lacked social support, and those with no or only primary education.

CONCLUSION

Rwanda has made considerable strides in improving ANC services. Addressing barriers such as distance to healthcare facilities, education, and economic disparities is crucial for enhancing maternal and child health outcomes. This review underscores the need for targeted interventions to achieve the World Health Organization recommendations of 8 antenatal care visits and sustainable development goals related to maternal and child health in Rwanda.

[Evidence synthesis and recommendations: clinical practice guidelines on drug treatment for hypertension in pregnancySíntese de evidências e recomendações: diretrizes de prática clínica para o tratamento farmacológico da hipertensão arterial na gravidez]

Introduction

Hypertensive disorders during pregnancy are a major cause of severe morbidity, long-term disability, and death. Appropriate pharmacological treatment is essential in the management of these disorders.

Objectives

Synthesize the recommendations developed by the World Health Organization (WHO) to improve the quality of care and health outcomes of adults with high blood pressure, and address aspects of how to implement these recommendations.

Methods

A synthesis was conducted of WHO recommendations: drug treatment for severe hypertension in pregnancy and WHO recommendations: drug treatment for non-severe hypertension in pregnancy. The WHO recommendations follow the GRADE methodology (Grading of Recommendations, Assessment, Development, and Evaluation) for the preparation of guidelines, as described in the WHO Handbook for Guideline Development. In addition, a systematic search for studies carried out in the Region of the Americas was conducted in PubMed, Lilacs, Health Systems Evidence, Epistemonikos, and gray literature to identify barriers, facilitators, and implementation strategies.

Results

Four recommendations were formulated for women with hypertensive disorders. Implementation barriers and facilitators were identified, and indicators were created to assess adherence and outcomes.

Conclusions

The formulated recommendations provide guidance on how to approach drug treatment of hypertension in pregnancy, with considerations for implementation in Latin America and the Caribbean.

A mixed-method study examined the reasons why pregnant women late initiate antenatal care in Northeast Ethiopia

BACKGROUND

Timely initiation of antenatal care visits is crucial for ensuring optimal care and health outcomes for women and children. However, late antenatal care initiation among pregnant women in low-income countries including Ethiopia is acknowledged in the literature. Therefore, this study examined why pregnant women initiate antenatal care late in Northeast Ethiopia.

METHODS

This study was done using a mixed design approach that included phenomenology and retrospective cross-sectional designs. A retrospective cross-sectional study was deployed among randomly selected 632 medical charts of women who had antenatal care visit in Legambo District primary hospital and health centers. Kaplan Meier curve was used to estimate survival time. Bi-variable and multivariable Cox-proportional hazard regression models were fitted using R-studio-1.2.5033 to identify independent predictors of antenatal care initiation time. Six vignette-based focused group discussions were held with pregnant women who had been purposefully selected. Then, a qualitative content analysis that was informed by the phenomenological theory was done.

RESULTS

This study indicated that only 195 (30.9%) of women timely initiated their antenatal care follow-up. In a survival analysis, all 632 women contributed 12,474 person-weeks giving a timely antenatal care initiation rate of 15.6 per 1000 person-weeks. According to the multivariable Cox regression models, late antenatal are initiation was found among pregnant women with an unknown last normal menstruation period, no living children, no bad obstetric history, not accompanied by their partner during antenatal care visit, and who lived in a >5-kilometer radius of health facility. In a qualitative analysis, being uncertain whether the pregnancy had occurred, believing that they have a very low probability of experiencing any complications, negative experience with healthcare providers, negative influence from their immediate contacts such as the mother and mother-in-law, and socio-cultural beliefs like "Qare" were found as major reasons why they started antenatal care follow-up late.

CONCLUSION

Most pregnant women in Legambo district, northeastern Ethiopia, initiate their antenatal care visits late. Based on the findings of this study, strengthening the pregnant women identification program and performing regular pregnant women's conference will help to achieve early initiation of antenatal care visits. To lessen the negative influence of their immediate contacts, it will also good to include these old moms and husbands in the conference of pregnant women.

The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature

PROBLEM

Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice.

BACKGROUND

Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences.

AIMS

To perform a scoping review of the literature to map out the role and scope of contemporary midwifery practice in Australia To identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context METHODS: A scoping review of the literature guided by the Arksey and O'Malley's five-stage methodological framework, and the 'best fit' framework synthesis using the Nursing and Midwifery Board of Australia's Midwifery Standards for Practice.

FINDINGS

Key themes that emerged from the review included Partnership with women; The professional role of the midwife; and Contextual influences upon midwifery practice.

DISCUSSION

Tensions were identified between the midwifery scope of practice associated with optimal outcomes for women and babies supported by current evidence and the actual role and scope of most midwives employed in models of care in the current Australian public healthcare system.

CONCLUSIONS

There is a mismatch between the operational parameters for midwifery practice in Australia and the evidence-based models of continuity of midwifery carer that are associated with optimal outcomes for childbearing women and babies and the midwives themselves.

Antenatal depression is associated with perceived stress, family relations, educational and professional status among women in South of China: a multicenter cross-sectional survey

Background

Antenatal depression is a commonly seen mental health concern for women. This study introduced a multicenter cross-sectional survey with a large sample to provide new insights into pregnant women's depression, its socio-demographic and obstetric characteristics correlates, and its perceived stress among Chinese pregnant women.

Methods

This study conducted an observational survey according to the STROBE checklist. The multicenter cross-sectional survey was performed from August 2020 to January 2021 by distributing paper questionnaires among pregnant women from five tertiary hospitals in South China. The questionnaire included socio-demographic and obstetrics information, the Edinburgh Postnatal Depression Scale, and the 10-item Perceived Stress Scale. For the analyses, the Chi-square test and Multivariate logistic regression were utilized.

Results

Among 2014 pregnant women in their second/third trimester, the prevalence of antenatal depression was 36.3%. 34.4% of pregnant women reported AD in their second trimester of pregnancy, and 36.9% suffered from AD in third trimester of pregnancy. A multivariate logistic regression model indicated that unemployed women, lower levels of education, poor marital relationships, poor parents-in-law relationships, concerns about contracting COVID-19, and higher perceived stress could aggravate antenatal depression among participants (p<0.05).

Conclusion

There is a high proportion of antenatal depression among pregnant women in South China, so integrating depression screening into antenatal care services is worthwhile. Maternal and child health care providers need to evaluate pregnancy-related risk factors (perceived stress), socio-demographic factors (educational and professional status), and interpersonal risk factors (marital relations and relationship with Parents-in-law). In future research, the study also emphasized the importance of providing action and practical support to reduce the experience of antenatal depression among disadvantaged sub-groups of pregnant women.

A modular systematic review of antenatal interventions targeting modifiable environmental exposures in improving low birth weight

BACKGROUND

Low birth weight (LBW) increases the risk of short- and long-term morbidity and mortality from early life to adulthood. Despite research effort to improve birth outcomes the progress has been slow.

OBJECTIVE

This systematic search and review of English language scientific literature on clinical trials aimed to compare the efficacy antenatal interventions to reduce environmental exposures including a reduction of toxins exposure, and improving sanitation, hygiene, and health-seeking behaviors, which target pregnant women to improve birth outcomes.

METHODS

We performed eight systematic searches in MEDLINE (OvidSP), Embase (OvidSP), Cochrane Database of Systematic Reviews (Wiley Cochrane Library), Cochrane Central Register of Controlled Trials (Wiley Cochrane Library), CINAHL Complete (EbscoHOST) between 17 March 2020 and 26 May 2020.

RESULTS

Four documents identified describe interventions to reduce indoor air pollution: two randomised controlled trials (RCTs), one systematic review and meta-analysis (SRMA) on preventative antihelminth treatment and one RCT on antenatal counselling against unnecessary caesarean section. Based on the published literature, interventions to reduce indoor air pollution (LBW: RR: 0.90 [0.56, 1.44], PTB: OR: 2.37 [1.11, 5.07]) or preventative antihelminth treatment (LBW: RR: 1.00 [0.79, 1.27], PTB: RR: 0.88 [0.43, 1.78]) are not likely to reduce the risk of LBW or Preterm birth (PTB). Data is insufficient on antenatal counselling against caesarian-sections. For other interventions, there is lack of published research data from RCTs.

CONCLUSIONS

We conclude that there is a paucity of evidence from RCT on interventions that modify environmental risk factors during pregnancy to potentially improve birth outcomes. Magic bullets approach might not work and that it would be important to study the effect of the broader interventions, particularly in LMIC settings. Global interdisciplinary action to reduce harmful environmental exposures, is likely to help to reach global targets for LBW reduction and sustainably improve long-term population health.

Interventions to improve enablers and/or overcome barriers to seeking care during pregnancy, birthing and postnatal period for vulnerable women in high-income countries: a systematic review and meta-analysis

OBJECTIVE

To reduce maternal morbidity and mortality, World Health Organization recommendations include: commencing pregnancy care before 12-weeks', at least eight antenatal and four postnatal visits, and attendance of skilled care at birthing. While lower adherence to the recommendation predominates in low- and middle-income countries, it also occurs in some settings in high-income countries. Globally, various strategies are used to optimise maternity care, in line with these recommendations. This systemic review aimed to determine if enhanced care improves maternal care-seeking, thus improving clinical outcomes for women and babies living with vulnerabilities, in high-income countries.

DESIGN, SETTING AND PARTICIPANTS

We searched the Cochrane Central Registers of Controlled Trials and Cochrane Pregnancy and Childbirth, MEDLINE, CINAHL, Proquest Dissertation and Thesis and reference lists of relevant articles. The latest search was performed June 20, 2022. Randomised controlled trials, non-randomised intervention trials and cohort studies comparing effects of interventions designed to increase utilisation of maternal health services with routine care, for women at increased risk of maternal mortality and severe maternal morbidity in high-income countries were included. Two authors selected, extracted, assessed and analysed data. Additional information was sought from study authors. This systematic review and meta-analysis was registered with PROSPERO(CRD42021256811).

FINDINGS

Nine studies with 5,729 participants were included. Interventions to enhance care significantly increased utilisation of health services, increasing attendance at antenatal classes (Odds Ratio[OR]=15·23, 95%Confidence Interval[CI] 10·73-21·61, p<0·0001) and postnatal visits by 6-8 weeks (OR=2·66, 95%CI 1·94-3·64, p<0·0001), compared to routine care. Infants in the intervention groups were significantly less likely to be: born preterm (OR=0·68, 95%CI 0·56-0·82, p<0·0001); low birthweight (OR=0·78, 95%CI 0·64-0·95, p = 0·01) or; require neonatal intensive care (OR=0·80, 95%CI 0·66-0·96, p = 0·02).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Among women living with vulnerabilities in high-income countries, interventions to enhance care increases utilisation of maternal health services and improves outcomes.

Unplanned visits and midwife-led antenatal care

INTRODUCTION

Midwives provide antenatal care to women to ensure the health of both mother and baby, according to women's needs. This study aims to investigate demographic and social, clinical and obstetrical factors that may be associated with unplanned visits to the emergency by nulliparous and multiparous women who received midwifery care during the antenatal period.

METHODS

This was a retrospective cohort study with data collection from medical records of the CHU Saint-Pierre hospital. A total of 971 women gave birth between 1 January and 31 December 2017 and received midwifery-led care during their pregnancy. Descriptive statistics and multivariable logistic regression models with 95% confidence intervals (95% CI) were performed separately for nulliparous and multiparous women.

RESULTS

For nulliparae (n=246), the odds of visiting emergency services during pregnancy were 1.45 times (95% CI: 1.08-2.27) higher in women with more previous pregnancies than women with less previous pregnancies, 3.57 times (95% CI: 1.43-11.11) more likely in women without than with high-level hypertension, and 1.09 times (95% CI: 1.01-1.25) more likely in women with less previous midwifery-led visits than women with more previous midwifery-led visits. For multiparae (n=444), the odds of visiting emergency services during pregnancy were 2.12 times (95% CI: 1.06-6.07) higher in women presenting risk factors at first consultation than women without such factors.

CONCLUSIONS

For nulliparous and multiparous women, some characteristics seem to be associated with unplanned visits. Spontaneous visits may be driven by a need for care perceived by women and/or their partner but not specifically by urgent or unfavorable medical conditions.

Study protocol for a modified antenatal care program for pregnant women with a low risk for adverse outcomes-a stepped wedge cluster non-inferiority randomized trial

BACKGROUND

It is crucial to provide care based on individual needs. Swedish health care is obliged to give care on equal conditions for the entire population. The person with the greatest need should be given the most care, and the health care system should strive to be cost-efficient. Medical and technical advances have been significant during the last decades and the recent Covid-19 pandemic has caused a shift in health care, from in-person visits to virtual visits. The majority of pregnant women with a low risk assessment have an uncomplicated antenatal course without adverse events. These women probably receive excessive and unnecessary antenatal care. This study will investigate if an antenatal care program for healthy pregnant women with a low risk for adverse outcomes could be safely monitored with fewer in-person visits to a midwife, and with some of them replaced by virtual visits.

METHODS

This is a non-inferiority trial where a stepped wedge cluster randomized controlled design will be used. Data collection includes register data and questionnaires that concern antenatal, obstetric and neonatal outcomes, patient- and caregiver-reported experiences, healthcare-economy, and implementation aspects. The modified antenatal care (MAC) study is performed in parts of the southeast of Sweden, which has approximately 8200 childbirths annually. At the start of the study, all antenatal care centers included in the study will use the same standard antenatal care (SAC) program. In the MAC program the in-person visits to a midwife will be reduced to four instead of eight, with two additional virtual meetings compared with the SAC program.

DISCUSSION

This presented study protocol is informed by research knowledge. The protocol is expected to provide a good structure for future studies on changed antenatal care programs that introduce virtual visits for healthy pregnant women with a low risk for adverse outcomes, without risking quality, safety, and increased costs.

TRIAL REGISTRATION

The study is registered the 21th of April 2021 in the ISRCTN registry with trial ID: ISRCTN14422582 , retrospectively registered.

Effects of health literacy education on adaptation to pregnancy, self-efficacy, fear of childbirth and health literacy in Turkish pregnant women: A randomized, controlled trial

This research aims to evaluate the effects of health literacy (HL) education on Turkish pregnant women's adaptations to pregnancy, self-efficacy, fear of childbirth and HL levels. This was a randomised, controlled trial. The research was carried out in the Marmara region of Turkey between July 2018 and April 2019. This research was conducted with three groups including one control (n = 73) and two intervention (n = 109) groups. One of the intervention groups was given antenatal education (AE) for improving HL (HL-AE) (n = 53), and the other was provided AE (n = 56) only. A Pregnancy Information Form, Prenatal Self-Evaluation Questionnaire, Fear of Childbirth and The Postpartum Period Scale, General Self-Efficacy Scale and Turkey Health Literacy Scale-32 were used for data collection. Results show that adaptation to pregnancy, general self-efficacy and HL levels significantly improved while fear of childbirth decreased in the group that was provided HL-AE intervention group. Additional when the pre-education and post-education scale scores were compared in the AE group, it was found that there was a significant difference in other scale scores, but not for fear of childbirth.

The impact of COVID-19 on pregnant womens' experiences and perceptions of antenatal maternity care, social support, and stress-reduction strategies

Background

The COVID-19 pandemic has impacted on maternity care, supports and women’s mental health.

Aim

The aim of this study was to assess pregnant women’s satisfaction with antenatal care and social support and to examine stress-reduction strategies women used during the pandemic.

Methods

An online survey was conducted between June and July 2020. Pregnant women, aged over 18 years were recruited. The survey included closed and open-ended questions to assess women’s perceptions and satisfaction with their antenatal care, social support, and stress-reduction strategies. Descriptive statistics and multivariate analysis were used for quantitative analyses; qualitative content analysis was used for open-ended questions.

Findings

573 pregnant women completed the survey. Women reported low levels of social support which was predicted by women’s mental health and demographic factors and was related to public health and maternity service restrictions. Women reported that restrictions implemented in the maternity services limited their face-to face interactions with healthcare professionals and meant their partners could not attend antenatal appointments or support them in the postpartum period in the maternity setting. The lack of information on COVID-19 and pregnancy meant women had greater uncertainty about pregnancy and birth.

Discussion

Our findings indicate how the lack of access to antenatal care and reduced perceived social support as a result of the restrictions implemented in response to the COVID-19 pandemic, potentially intensifies pregnancy specific stress.

Conclusions

There is a need for the provision of supportive care, both formally and informally, particularly with women who may be more vulnerable during a pandemic.

Association between Adherence with Recommended Antenatal Care in Low-Risk, Uncomplicated Pregnancy, and Maternal and Neonatal Adverse Outcomes: Evidence from Italy

Antenatal care (ANC) aims of monitoring wellbeing of mother and foetus during pregnancy. We validate a set of indicators aimed of measuring the quality of ANC of women on low-risk, uncomplicated pregnancy through their relationship with maternal and neonatal outcomes. We conducted a population-based cohort study including 122,563 deliveries that occurred between 2015 and 2017 in the Lombardy Region, Italy. Promptness and appropriateness of number and timing of gynaecological visits, ultrasounds and laboratory tests were evaluated. We assessed several maternal and neonatal outcomes. Log-binomial regression models were used to estimate prevalence ratio (PR), and corresponding 95% confidence interval (95% CI), for the exposure→outcome association. Compared with women who adhered with recommendations, those who were no adherent had a significant higher prevalence of maternal intensive care units admission (PR: 3.1, 95%CI: 1.2-7.9; and 2.7, 1.1-7.0 respectively for promptness of gynaecological visits, and appropriateness of ultrasound examinations), low Apgar score (1.6, 1.1-1.2; 1.9, 1.3-2.7; and 2.1, 1.5-2.8 respectively for appropriateness and promptness of gynaecological visits, and appropriateness of ultrasound examinations), and low birth weight (1.8, 1.5-2.3 for appropriateness of laboratory test examinations). Benefits for mothers and newborn are expected from improving adherence to guidelines-driven recommendations regarding antenatal care even for low-risk, uncomplicated pregnancies.

The Role of Antenatal Education in Promoting Maternal and Family Health Literacy

BACKGROUND

Antenatal education (ANE) supports expectant parents in developing their knowledge, skills, and confidence in preparing for childbirth and early parenting. This is called health literacy, and it is part of the global healthcare system agenda that empowers women to participate fully in making decisions about their health and care before, during, and after birth. The aim of this study was to examine the perspectives of educators and ANE class participants on the extent to which existing courses are meeting this goal.

METHODS

A qualitative study, conceptualized within the health literacy framework, was conducted in Australia with 10 antenatal educators and 8 participants from antenatal classes. Data were collected through individual interviews and were analyzed using interpretive description.

RESULTS

The findings revealed five themes relating to the participants' experiences in either providing or attending antenatal classes. These included: “balancing provider influences with participant expectations,” “accommodating participant learning styles and preferences,” “influence of the environment on pedagogy and practice,” “empowering participants for decision-making,” and “reflections on what is and is not meaningful and effective.”

CONCLUSIONS

Findings from this study strongly suggest that to meet the needs of class participants, educators need to be mindful of their expectations. They should adopt a flexible approach to accommodate participants' knowledge, goals, and preferences as well as characteristics of the context. Conceptualizing ANE within the framework of health literacy provides a clear, targeted approach to meeting the information needs of this important population that is focused on evidence-based safe practice across the birthing continuum and beyond.

Systematic review of the measurement properties of indices of prenatal care utilization

Background

An accurate assessment of the adequacy of prenatal care utilization is critical to inform the relationship between prenatal care and pregnancy outcomes. This systematic review critically appraises the evidence on measurement properties of prenatal care utilization indices and provides recommendations about which index is the most useful for this purpose.

Methods

MEDLINE, EMBASE, CINAHL, and Web of Science were systematically searched from database inception to October 2018 using keywords related to indices of prenatal care utilization. No language restrictions were imposed. Studies were included if they evaluated the reliability, validity, or responsiveness of at least one index of adequacy of prenatal care utilization. We used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. We conducted an evidence synthesis using predefined criteria to appraise the measurement properties of the indices.

Results

From 2664 studies initially screened, 13 unique studies evaluated the measurement properties of at least one index of prenatal care utilization. Most of the indices of adequacy of prenatal care currently used in research and clinical practice have been evaluated for at least some form of reliability and/or validity. Evidence about the responsiveness to change of these indices is absent from these evaluations. The Adequacy Perinatal Care Utilization Index (APNCUI) and the Kessner Index are supported by moderate evidence regarding their reliability, predictive and concurrent validity.

Conclusion

The scientific literature has not comprehensively reported the measurement properties of commonly used indices of prenatal care utilization, and there is insufficient research to inform the choice of the best index. Lack of strong evidence about which index is the best to measure prenatal care utilization has important implications for tracking health care utilization and for formulating prenatal care recommendations.

Community-based maternal and child health project on 4+ antenatal care in the Democratic Republic of Congo: a difference-in-differences analysis

Background

Despite efforts to achieve the Millennium Development Goals, the maternal mortality ratio in the Democratic Republic of Congo was 693 per 100,000 in 2015—the 6th highest in the world and higher than the average (547 per 100,000) in sub-Saharan Africa. Antenatal care (ANC) service is a cost-effective intervention for reducing the maternal mortality ratio in low-income countries. This study aimed to identify the intervention effect of the maternal and child health care (MCH) project on the use of four or more (4⁺) ANC services.

Methods

The MCH project was implemented using the three delays model in Kenge city by the Ministry of Public Health (MoPH) of the DRC with technical assistance from Korea International Cooperation Agency (KOICA) and the Yonsei Global Health Center from 2014 to 2017. Furthermore, Boko city was selected as the control group. A baseline and an endline survey were conducted in order to evaluate the effectiveness of this project. We interviewed 602 and 719 participants in Kenge, and 150 and 614 participants in Boko in the baseline and endline surveys, respectively. We interviewed married reproductive-aged women (19–45 years old) in both cities annually. The study instruments were developed based on the UNICEF Multiple Indicator Cluster Surveys. This study used the homogeneity test and the binary logistic regression difference-in-differences method of analysis.

Results

The odds of reproductive-aged women’s 4+ ANC service utilization at the intervention site increased 2.280 times from the baseline (OR: 2.280, 95% CI: 1.332–3.902, p = .003) as compared to the control site.

Conclusions

This study showed that the KOICA MCH project effectively increased the 4⁺ ANC utilization by reproductive-aged women in Kenge. As the 4+ ANC services are expected to reduce maternal deaths, this project might have contributed to reducing maternal mortality in Kenge. In the future, we expect these findings to inform MCH policies of the MoPH in the DRC.

Comparison of demographic factors and selected maternity care variables in women who chose midwife-led or obstetrician-led antenatal care respectively

Introduction. The midwife profession is an independent profession, entitled to provide part of the services of gynaecology and obstetrics. Women whose pregnancy goes in a physiological way may benefit from midwife-led services as part of the benefits refunded by the National Health Fund. This model makes it possible to maintain continuity of care, considered a beneficial solution in the area of mother and child health.

Aim. Determination of the scale of the phenomenon of midwife-led antenatal care in Poland and comparison of groups of women actively using the Internet who chose midwife-led or doctor-led antenatal care.

Material and methods. The survey was carried out in February-March 2018. The research tool was an electronic questionnaire. Questions regarding socio-demographic factors of pregnancy, antenatal education, labour, intervention during labour and labour experience described by women-Internet users were used for the purpose of the analysis. The Chi-square test of independence, the Fisher’s Exact Test and the Mann-Whitney U test were used to develop the results.

Results and conclusions. The prenatal care of midwives is not a common phenomenon in Poland. Groups of women who decide on a different form of midwife-led or doctor-led antenatal care differ mainly in the material situation. Women choosing midwifeled antenatal care more often attend antenatal classes and prepare a birth plan. In order to popularize the model of antenatal care provided by midwives, attempts should be made to study the motivation of women who decide on an alternative antenatal care.

Using a quality care framework to evaluate user and provider experiences of maternity care: A comparative study

OBJECTIVE

The Quality Maternal and Newborn Care Framework describes the components and characteristics of quality care and emphasises relational and continuity elements. Continuity of care is increasingly a focus of maternity care policy in the United Kingdom. While some outcomes have been shown to be improved, there is uncertainty about why certain models of care are more effective. Our overall objective is to develop a maternity care evaluation toolkit which incorporates this Framework along with other outcome evaluations. An initial step in developing this toolkit was to use the adapted Framework to evaluate perceptions and experiences of maternity care. Our specific objective in this study was to test this adapted Framework in a series of focus groups with key stakeholders, and to compare findings between different groups. Findings related to service users (pregnant women and new mothers) are reported in our accompanying paper; this paper presents findings from focus groups with service providers (midwives and obstetricians), and then compares user and provider perspectives.

DESIGN

A qualitative comparative enquiry involving three focus groups with 26 midwives (eight newly qualified; eight working in a community midwifery unit; and ten senior tertiary-based) and two focus groups with twelve obstetricians of all grades. We used a six-phase thematic analysis to derive then compare the focus groups' principal sub-themes; we then mapped these to the original Quality Maternal and Newborn Care Framework and compared these service providers' responses with those from the pregnant women and new mothers.

SETTING

Two health boards in Scotland.

PARTICIPANTS

Midwives and obstetricians who had experience of various models of maternity care.

FINDINGS

There were significant areas of overlap in their perceptions of providing maternity care. All groups reported 'limited resources and time'; the community midwifery unit and senior midwives and one group of obstetricians provided a critique of the system. Achieving tailored care was acknowledged as a problem by the senior midwives and one group of obstetricians. Only obstetricians discussed strategies for improvement. The newly qualified midwives were most positive in their responses. There was both overlap and contrast when comparing the views of service users and providers. We found most agreement when participants discussed some of the Framework's characteristics of care in negative terms, such as (in) accessible care, (lack of) adequate resources, and (absence of) tailored care.

KEY CONCLUSIONS

Being able firstly to map the participants' responses to the Quality Maternal and Newborn Care Framework, and then to identify strengths and gaps in the provision of quality maternity care, suggests to us that the Framework, derived as it is from a comprehensive analysis of the global evidence on quality care, can indeed be used to inform an evaluation toolkit. While aware that we cannot generalise from this limited qualitative study, we are currently undertaking similar work in other countries by which we hope to confirm our findings and further develop the toolkit.