Metasynthesis: Experiences of Women with Severe Maternal Morbidity and Their Perception of the Quality of Health Care

Health care experiences and expectations of individuals with severe maternal morbidity in high-income countries: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to describe the health care experiences and expectations of people living in high-income countries (HICs) who have had severe maternal morbidity (SMM). It will expand on findings from 2 earlier reviews highlighting structural and systemic factors influencing care to inform health care recommendations.

INTRODUCTION

SMM describes conditions and complications during pregnancy, birth, and postpartum associated with severe illness, debilitation, prolonged hospitalization, and high fatality rates. In higher-income countries, SMM is an important indicator of health care quality. With rates of SMM increasing around the world (disproportionately so among some populations), and recognizing suboptimal care as an important modifiable risk factor, this review will focus on the health care experiences and expectations of people who have had SMM to reveal opportunities for maternal health care improvement.

INCLUSION CRITERIA

This review will include qualitative studies published from 1999 to 2024 involving individuals in HICs who have experienced SMM. Studies will describe participants' health care experiences and expectations (or both) during pregnancy, birth, and postpartum.

METHODS

Using the JBI approach for qualitative systematic reviews, we will search MEDLINE (Ovid), Embase, Web of Science, CINAHL, and ProQuest for qualitative studies available in English. We will then screen titles and abstracts using the predetermined inclusion criteria to select articles for full-text review and critical appraisal. All relevant findings will be extracted from each included study, assessed for credibility, and then pooled and synthesized using JBI's meta-aggregation approach to develop a set of findings that can be used to make health care recommendations.

REVIEW REGISTRATION

PROSPERO (CRD42024569572).

Risk Factors for Dual Burden of Severe Maternal Morbidity and Preterm Birth by Insurance Type in California

OBJECTIVES

Among childbearing women, insurance coverage determines degree of access to preventive and emergency care for maternal and infant health. Maternal-infant dyads with dual burden of severe maternal morbidity and preterm birth experience high physical and psychological morbidity, and the risk of dual burden varies by insurance type. We examined whether sociodemographic and perinatal risk factors of dual burden differed by insurance type.

METHODS

We estimated relative risks of dual burden by maternal sociodemographic and perinatal characteristics in the 2007-2012 California birth cohort dataset stratified by insurance type and compared effects across insurance types using Wald Z-statistics.

RESULTS

Dual burden ranged from 0.36% of privately insured births to 0.41% of uninsured births. Obstetric comorbidities, multiple gestation, parity, and birth mode conferred the largest risks across all insurance types, but effect magnitude differed. The adjusted relative risk of dual burden associated with preeclampsia superimposed on preexisting hypertension ranged from 9.1 (95% CI 7.6-10.9) for privately insured to 15.9 (95% CI 9.1-27.6) among uninsured. The adjusted relative risk of dual burden associated with cesarean birth ranged from 3.1 (95% CI 2.7-3.5) for women with Medi-Cal to 5.4 (95% CI 3.5-8.2) for women with other insurance among primiparas, and 7.0 (95% CI 6.0-8.3) to 19.4 (95% CI 10.3-36.3), respectively, among multiparas.

CONCLUSIONS

Risk factors of dual burden differed by insurance type across sociodemographic and perinatal factors, suggesting that care quality may differ by insurance type. Attention to peripartum care access and care quality provided by insurance type is needed to improve maternal and neonatal health.

How communication can help women who experience a maternal near-miss: a qualitative study from Tanzania

OBJECTIVES

This study aimed to explore experiences of communication as an element of quality of care, among women surviving a maternal near-miss event, thus women who nearly died but survived haemorrhage, or pre-eclampsia complication during pregnancy, childbirth or within 42 days of termination of pregnancy.

DESIGN

A descriptive, phenomenological, qualitative study using semistructured interviews with women who survived a maternal near-miss in Southern Tanzania.

SETTING

The participants were recruited from two selected hospitals in Mtwara Region, where women sought child birth care and developed near-miss condition.

PARTICIPANTS

Participants for this study were women who experienced and survived a maternal near-miss event and who had lived in the study area for at least 1 year. Women were recruited using an adapted version of the WHO criteria for maternal near-miss.

DATA COLLECTION

We identified 16 women and were able to conduct 10 in-depth interviews with women at their homes, 4 weeks after they were discharged. The interviews were audiorecorded and transcribed and translated word for word from Kiswahili. Thematic analysis was used to identify emerging themes.

RESULTS

Three major themes evolved: (1) Being informed about the care and interaction, (2) Being engaged and encouraged and (3) Being afraid to ask questions. The study highlighted that good communication with women during the provision of care helped women feel grateful, supported and cared for. Women who were unconscious during care were often not informed later of what happened. This created some negative feelings and anxiety.

CONCLUSION

This study highlights the importance of communication, and of being informed of what happened and why. Empathetic communication with sufficient explanation on what happened and why created trust among women-a positive finding which should encourage the development of consistent approaches to strengthen healthcare provider communication skills.

Is quality maternal healthcare all about successful childbirth? Views of mothers in the Wa Municipality, Ghana

Introduction

In spite of the countless initiatives of the Ghana government to improve the quality of maternal healthcare, Upper West Region still records poor childbirth outcomes. This study, therefore, explored women’s perception of the quality of maternal healthcare they receive in the Wa Municipality of the Upper West Region of Ghana.

Materials and methods

This is a qualitative cross-sectional study of 62 women who accessed maternal healthcare in the Wa Municipality of Ghana. We analysed the transcripts using the analytic inductive technique. An inter-coding technique (testing for inter-coding agreement) was employed. The iterative coding process resulted in a coding scheme with four main themes. We used peer-debriefing technique in ensuring credibility and trustworthiness.

Results

Logistics and equipment; referral service; empathic service delivery; inadequacy of care providers; affordability of service; satisfaction with services received; as well as experience and service delivery were the parameters used by the women in assessing quality maternity care. A number of gaps were reported in the healthcare system including limited healthcare providers, limited beds and inefficient referral system. Conversely, some of them reported that some healthcare providers offered empathetic healthcare. Contrary views were expressed with respect to satisfaction with maternity care.

Conclusion

Government and all stakeholders seeking to enhance quality of maternal health and accelerate the attainment of the third Sustainable Development Goal need to reconsider the financing of service delivery at health institutions. Indeed, our findings have illustrated that routine workshops on empathetic healthcare are required in efforts to increase the rate of facility-based childbirth, and thereby subside maternal mortality and all adverse pregnancy outcomes.

Severe maternal morbidity in preterm cesarean delivery: A systematic review and meta-analysis

OBJECTIVE

More than half of extremely preterm infants are delivered by cesarean section. Few data are available about severe maternal morbidity (SMM) of these extremely preterm cesarean. The objective was to determine whether gestational age under 26 weeks of gestation (weeks) was associated with an increased risk of SMM compared with gestational age between 26 and 34 weeks in women having a cesarean delivery.

MATERIAL AND METHODS

We searched MEDLINE, ISI Web of Science, the Cochrane Database, PROSPERO, and ClinicalTrials.gov on January 31, 2020. The search strategy clustered terms describing SMM and preterm cesarean delivery. No restrictions on language, publication status, and study design were applied. Abstracts were included if there was sufficient information to assess study quality. The authors of all identified studies were contacted to request for aggregated data. Relative risks (RR) were calculated using the inverse variance method. The primary outcome was SMM as defined in each study. We analyzed data on preterm cesarean deliveries between 22 and 34 weeks. The protocol was registered in PROSPERO (registration: CRD42019128644).

RESULTS

Six studies involving 45,572 women (3,440 delivering < 26 weeks; 42,132 delivering between 26 and 34 weeks) were included. SMM occurred in 607 women (17.6 %) < 26 weeks and 4,483 women (10.6 %) between 26 and 34 weeks. Gestational age < 26 weeks was associated with an increased risk of SMM (RR, 1.65; 95 % CI [Confidence Interval], 1.52-1.78; I² = 40 %). Gestational age < 26 weeks remained associated with SMM in the subgroup analyses depending on the type of the study (prospective or retrospective), country of the study (European or non-European), and high quality of the study. A sensitivity analysis showed that gestational age < 25 weeks was also associated with SMM in preterm cesarean delivery (RR, 1.66; 95 % CI, 1.50-1.83; I² = 3%).

CONCLUSIONS

Gestational age < 26 weeks was associated with an increased risk of SMM in women having a preterm cesarean delivery. Obstetricians and neonatologists should be aware of the increased risk of SMM in cesarean.

Journey to facility birth in Zanzibar: a questionnaire-based cohort study of patients' perspectives on preparedness, access and quality of care

INTRODUCTION

Tackling substandard maternity care in health facilities requires engaging women's perspectives in strategies to improve outcomes. This study aims to provide insights in the perspectives of women with severe maternal morbidity on preparedness, access and quality of care in Zanzibar's referral hospital.

METHODS

In a prospective cohort from April 2017 to December 2018, we performed semistructured interviews with women who experienced maternal near-miss complications and matched controls. These focused on sociodemographic and obstetric characteristics, perceived accessibility to and quality of facility care with 15 domains, scored on a one-to-five scale. Participants' comments and answers to open questions were employed to illustrate quantitative outcomes. Zanzibar's Medical Research and Ethics Committee approved the study (ZAMREC/0002/JUN/17).

RESULTS

We included 174 cases and 151 controls. Compared with controls, patients with a near-miss had less formal education (p=0.049), perceived their wealth as poor (p=0.002) and had a stillbirth more often (p<0.001). Many experienced a delay in deciding to seek care. More than controls, near-miss patients experienced barriers in reaching care (p=0.049), often of financial nature (13.8% vs 4.0%). Quality of care was perceived as high, with means above 3 out of 5, in 14 out of 15 domains. One-fifth had an overall suboptimal experience, mostly regarding informed choice and supplies availability. Additional comments were expressed by a minority of participants.

CONCLUSION

Most patients promptly sought, accessed and received maternity care in Zanzibar's referral hospital. A minority experienced barriers, mostly financial, in reaching care and more so among patients with near-miss complications. Quality of facility care was generally highly rated. However, some reported insightful critical perceptions. This study highlights the impact of sociodemographic differences on health, the value of involving patients in decisions regarding maternity care and the need to ensure availability of medical supplies, all which will contribute to improved maternal well-being.

Racial and Ethnic Disparities in Severe Maternal Morbidity: A Qualitative Study of Women's Experiences of Peripartum Care

INTRODUCTION

Racial and ethnic disparities in rates of maternal morbidity and mortality in the United States are striking and persistent. Despite evidence that variation in the quality of care contributes substantially to these disparities, we do not sufficiently understand how experiences of perinatal care differ by race and ethnicity among women with severe maternal morbidity.

METHODS

We conducted focus groups with women who experienced a severe maternal morbidity event in a New York City hospital during their most recent pregnancy (n = 20). We organized three focus groups by self-identified race/ethnicity ([1] Black, [2] Latina, and [3] White or Asian) to detect any within- and between-group differences. Discussions were audiotaped and transcribed. The research team coded the transcripts and used content analysis to identify key themes and to compare findings across racial and ethnic groups.

RESULTS

Participants reported distressing experiences and lasting emotional consequences after having a severe childbirth complication. Many women appreciated the life-saving care they received. However, poor continuity of care, communication gaps, and a perceived lack of attentiveness to participants' physical and emotional needs led to substantial concern and disappointment in care. Black and Latina women in particular emphasized these themes.

CONCLUSIONS

This study highlights missed opportunities for improved clinician communication and continuity of care to address emotional trauma when severe obstetric complications occur, particularly for Black and Latina women. Enhancing communication to ensure that women feel heard and informed throughout the birth process and addressing implicit bias, as a part of the more systemic issue of institutionalized racism, could both decrease disparities in obstetric care quality and improve the patient experience for women of all races and ethnicities.

Mental Health and Quality of Life of Women One Year after Maternal Near-Miss in Low and Middle-Income Countries: The Case of Zanzibar, Tanzania

Women who experienced a maternal near-miss are at risk of mental health complications and lower quality of life, but long-term consequences are largely unknown. The aim of this study is to assess whether mental health symptoms and quality of life change over time and to examine associations with risk factors among post-partum women. In this cohort study, women with maternal near-miss were matched to women without or with mild complications at Mnazi Mmoja Hospital in Zanzibar. Depressive and post-traumatic stress disorder symptoms, and quality of life were measured at three, six, and twelve-months follow-up. A linear mixed-effects model was used for data analysis. Postpartum women in Zanzibar reported low levels of depressive and post-traumatic stress disorder symptoms. While depressive symptoms and quality of life trajectories were similar among women with and without maternal near-miss, differences for trajectories of post-traumatic stress disorder symptoms and physical quality of life were found. Social support, perinatal loss, and intercurrent illness were strongly associated with both depressive symptoms and quality of life in this group of Islamic women. These findings suggest that social support, embedded in the cultural context, should be considered in helping women cope with mental health issues in the aftermath of severe maternal complications.

The Needs of Women Who Have Experienced "Maternal Near Miss": A Systematic Review of Literature

Background:

Maternal Near Miss (MNM) event is associated with emotional, psychological, and social effects on women. Determining the needs of women with these experiences is the key to programming for providing high-quality care and reducing its burden. Hence, this study was conducted to determine the needs of women who have experienced MNM.

Materials and Methods:

In this literature systematic review, to achieve the intended information, articles published in Web of Science and PubMed databases were systematically searched. The search strategy focused on three keywords or phrases: “maternal morbidity“ OR “maternal near miss“ AND “needs.“ Publication date was all relevant articles before 2019, and publication language was restricted to English. Article search was conducted by two independent reviewers. After the primary search, 2140 articles were found. Eventually, 77 articles, including 20 qualitative studies and 57 quantitative studies, were enrolled for final evaluation.

Results:

According to the results, the needs of these women could be categorized into six groups of “Management and care needs of health system,“ “Educational needs of health system,“ “Follow up and continuity of care at the primary care level,“ “Need to develop a physical, psychological and social of care packages,“ “Social support,“ and “Psychosocial support and counseling.“

Conclusions:

The near-miss events change the mothers' living conditions, and therefore, they need to receive special support, given the difficult conditions they are undergoing. It is necessary that a supportive program be designed to follow-up MNM after the discharge to be run by the primary care team.

Severe maternal morbidity and postpartum mental health-related outcomes in Sweden: a population-based matched-cohort study

We examined whether women experiencing severe maternal morbidity (SMM) are more likely to be treated for a psychiatric illness or be prescribed psychotropic medications in the postpartum year than mothers who did not experience SMM. We also examine the relationship between SMM and specific mental health-related outcomes, and the relationship between specific SMM diagnoses/procedures and postpartum mental-health-related outcomes. The national registers in Sweden were used to create a population-based matched cohort. Every delivery with SMM between July 1, 2006, and December 31, 2012 (n = 8558), was matched with two deliveries without SMM (n = 17,116). Conditional logistic regression models assessed the relationship between SMM and postpartum mental health-related outcomes. Women who experienced SMM had significantly greater odds of being treated for a psychiatric disorder (aOR 1.22; 95% CI 1.03-1.45) and being prescribed psychotropic medications (aOR 1.40; 95% CI 1.24-1.58) in the postpartum year. Specifically, they had significantly greater odds of being treated for neuroses (aOR 1.35; 95% CI 1.09-1.69) and having a prescription for anxiolytics/hypnotics (aOR 1.36; 95% CI 1.18-1.58) or antidepressants (aOR 1.35; 95% CI 1.17-1.55). Women who were diagnosed with shock or uterine rupture/obstetric laparotomy during delivery had the greatest odds of postpartum mental health-related outcomes. This study identified mothers with SMM as a group at high risk for postpartum mental illness. Postpartum mental health services should be provided to ensure the well-being of these high-risk mothers.

A population-based study to identify the prevalence and correlates of the dual burden of severe maternal morbidity and preterm birth in California

BACKGROUND

Prior studies have documented associations between preterm birth and severe maternal morbidity (SMM) but the prevalence and correlates of dual burden are not adequately understood, despite significant family implications.

PURPOSE

To describe the prevalence and correlates of the dual burden of SMM and preterm birth and to understand profiles of SMM by dual burden of preterm birth.Approach: This retrospective cohort study included all California live births in 2007-2012 with gestations 20-44 weeks and linked to a birth cohort database maintained by the California Office of Statewide Health Planning and Development (n = 3,059,156). Dual burden was defined as preterm birth (<37 weeks) with severe maternal morbidity (SMM, defined by Centers for Disease Control). Predictors for dual burden were assessed using Poisson logistic regression, accounting for hospital variance.

RESULTS

Rates of preterm birth and SMM were 876 and 140 per 10,000 births, respectively. The most common indications of SMM both with and without preterm birth were blood transfusions and a combination of cardiac indications. One-quarter of women with SMM experienced preterm birth with a dual burden rate of 37 per 10,000 births. Risk of dual burden was over threefold higher with cesarean birth (primiparous primary aRR = 3.3, CI = 3.0-3.6; multiparous primary aRR = 8.1, CI = 7.2-9.1; repeat aRR = 3.9, CI = 3.5-4.3). Multiple gestation conferred a six-fold increased risk (aRR = 6.3, CI = 5.8-6.9). Women with preeclampsia superimposed on gestational hypertension (aRR = 7.3, CI = 6.8-7.9) or preexisting hypertension (aRR = 11.1, CI = 9.9-12.5) had significantly higher dual burden risk. Significant independent predictors for dual burden included smoking during pregnancy (aRR = 1.5, CI = 1.4-1.7), preexisting hypertension without preeclampsia (aRR = 3.3, CI = 3.0-3.7), preexisting diabetes (aRR = 2.6, CI = 2.3-3.0), Black race/ethnicity (aRR = 2.0, CI = 1.8-2.2), and prepregnancy body mass index <18.5 (aRR = 1.4, CI = 1.3-1.5).

CONCLUSIONS

Dual burden affects 1900 California families annually. The strongest predictors of dual burden were hypertensive disorders with preeclampsia and multiparous primary cesarean.

Maternity care experiences and health needs of migrant women from female genital mutilation-practicing countries in high-income contexts: A systematic review and meta-synthesis

BACKGROUND

Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high-income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM.

METHODS

We undertook a systematic review and meta-synthesis of peer-reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers.

RESULTS

Sixteen peer-reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care.

CONCLUSIONS

The findings suggest that future actions for improving maternity care quality should be focused on woman-centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high-income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman-focused policy is developed and implemented.

[Treatment itineraries of women with severe maternal morbidity]

This study aimed to identify the treatment itineraries of Brazilian women with severe maternal morbidity. This was a qualitative, descriptive, exploratory study in a university referral hospital for high-risk pregnancy in the interior of São Paulo State, Brazil. The sample included 16 women with severe complications during pregnancy, childbirth, or postpartum. Data were collected with semi-structured, taped, transcribed interviews subsequently submitted to Content Analysis. The results showed that at the onset of illness, the women take various paths to reach low and high-complexity services, while also relying on neighbor women, pharmacies, and self-medication. They encounter obstacles in the services' receptiveness, continuity of care, case-resolution capacity, and referrals within the healthcare network. Critical points were observed in obstetric care: women are frequently subjected to trekking from one health service to another to obtain care, delays in referrals, and institutional violence. The tertiary hospital was described as receptive and effective. The study identified problems in the entire chain of obstetric care, helping explain how the healthcare system is organized to deal with severe maternal complications.

Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: a qualitative interview study

Background

Providing equitable maternal care to migrants is a seriously challenging task for hosting countries. Iran, the second-most accessed country for refugees from Afghanistan, has achieved maternal health improvement. However, Afghan women with near-miss morbidity faced pre-hospital delays and disparity in maternal care at hospitals. This study explores experiences of maternal care among Afghan women surviving near-miss morbidity to increase insight into healthcare improvements for migrants.

Methods

A qualitative study was conducted at university hospitals in Tehran, from April 2013 to May 2014. A total of 11 Afghan women and 4 husbands were interviewed when women recovered from near-miss morbidity that occurred around the childbirth period. Mothers were identified prospectively using the WHO maternal near-miss approach. Thematic analysis was used along with a data-driven approach to organize data guided by the ‘three delays model’ theoretical framework.

Results

Mistreatment in the form of discrimination and insufficient medical attention were key experiences. Participants commonly perceived poor women–professional communication and delays in recognizing obstetric complications despite repeated care-seeking. Financial constraints, costly care, lack of health insurance, and low literacy were experienced barriers to accessing care to a lesser extent. Non-somatic consequences of near-miss morbidity affected mothers and families for extended periods.

Conclusions

Near-miss survivors’ experiences provided remarkable insights into maternal care of Afghans in Iran. The challenge for the health system and professionals is to provide equitable care with dignity and improve communication skills with caring attitudes toward ethnic minorities. Antenatal visits provide the best and most appropriate opportunities to tackle health illiteracy in Afghan women.

The experiences of women with maternal near miss and their perception of quality of care in Kelantan, Malaysia: a qualitative study

BACKGROUND

Maternal mortality has been the main way of ascertaining the outcome of maternal and obstetric care. However, maternal morbidities occur more frequently than maternal deaths; therefore, maternal near miss was suggested as a more useful indicator for the evaluation and improvement of maternal health services. Our study aimed to explore the experiences of women with maternal near miss and their perception of the quality of care in Kelantan, Malaysia.

METHODS

A qualitative phenomenological approach with in-depth interview method was conducted in two tertiary hospitals in Kelantan, Malaysia. All women admitted to labour room, obstetrics and gynaecology wards and intensive care units in 2014 were screened for the presence of any vital organ dysfunction or failure based on the World Health Organization criteria for maternal near miss. Pregnancy irrespective of the gestational age was included. Women younger than 18 years old, with psychiatric disorder and beyond 42 days of childbirth were excluded.

RESULTS

Thirty women who had experienced maternal near miss events were included in the analysis. All were Malays between the ages of 22 and 45. Almost all women (93.3%) had secondary and tertiary education and 63.3% were employed. The women's perceptions of the quality of their care were influenced by the competency and promptness in the provision of care, interpersonal communication, information-sharing and the quality of physical resources. The predisposition to seek healthcare was influenced by costs, self-attitude and beliefs.

CONCLUSIONS

Self-appraisal of maternal near miss, their perception of the quality of care, their predisposition to seek healthcare and the social support received were the four major themes that emerged from the experiences and perceptions of women with maternal near miss. The women with maternal near miss viewed their experiences as frightening and that they experienced other negative emotions and a sense of imminent death. The factors influencing women's perceptions of quality of care should be of concern to those seeking to improve services at healthcare facilities. The addition of a maternal near miss case review programme, allows for understanding on the factors related to providing care or to the predisposition to seek care; if addressed, may improve future healthcare and patient outcomes.

Immediate and long-term relationship between severe maternal morbidity and health-related quality of life: a prospective double cohort comparison study

BACKGROUND

Given the growing interest in severe maternal morbidity (SMM), the need to assess its effects on quality of life is pressing. The objective of this study was to compare the quality of life scores between women with and without SMM at 1-month and 6-month postpartum in Kelantan, Malaysia.

METHODS

A prospective double cohort study design was applied at two tertiary referral hospitals over a 6-month period. The study population included all postpartum women who delivered in 2014. Postpartum women with and without SMM were selected as the exposed and non-exposed groups, respectively. For each exposed case identified, a non-exposed case with a similar mode of delivery was selected. The main outcome measures used were scores from the Short Form-12 Health Survey (SF-12).

RESULTS

The study measured 145 exposed and 187 non-exposed women. The group-time interaction of the repeated measure analysis of variance (RM ANOVA) showed no significant difference in the mean overall SF-12 physical component summary score changes (P = 0.534) between women with and without SMM. Similarly, the group-time interaction of the RM ANOVA showed no significant difference in the mean overall SF-12 mental component summary score changes (P = 0.674) between women with and without SMM. However, women with SMM scored significantly lower on a general health perceptions subscale at 1-month (P = 0.031), role limitations due to physical health subscale at 6-month (P = 0.019), vitality subscale at 1-month (P = 0.007) and 6-month (P = 0.008), and role limitations due to emotional problems subscales at 6-month (P = 0.008).

CONCLUSIONS

Women with severe maternal morbidity demonstrated comparable quality of life during the 6-month postpartum period compared to women without severe maternal morbidity.

Perinatal Parenting Stress, Anxiety, and Depression Outcomes in First-Time Mothers and Fathers: A 3- to 6-Months Postpartum Follow-Up Study

OBJECTIVE

Although there is an established link between parenting stress, postnatal depression, and anxiety, no study has yet investigated this link in first-time parental couples. The specific aims of this study were 1) to investigate whether there were any differences between first-time fathers' and mothers' postnatal parenting stress, anxiety, and depression symptoms and to see their evolution between three and 6 months after their child's birth; and 2) to explore how each parent's parenting stress and anxiety levels and the anxiety levels and depressive symptoms of their partners contributed to parental postnatal depression.

METHOD

The sample included 362 parents (181 couples; mothers' M Age = 35.03, SD = 4.7; fathers' M Age = 37.9, SD = 5.6) of healthy babies. At three (T1) and 6 months (T2) postpartum, both parents filled out, in a counterbalanced order, the Parenting Stress Index-Short Form, the Edinburgh Postnatal Depression Scale, and the State-Trait Anxiety Inventory.

RESULTS

The analyses showed that compared to fathers, mothers reported higher scores on postpartum anxiety, depression, and parenting stress. The scores for all measures for both mothers and fathers decreased from T1 to T2. However, a path analysis suggested that the persistence of both maternal and paternal postnatal depression was directly influenced by the parent's own levels of anxiety and parenting stress and by the presence of depression in his/her partner.

DISCUSSION

This study highlights the relevant impact and effects of both maternal and paternal stress, anxiety, and depression symptoms during the transition to parenthood. Therefore, to provide efficacious, targeted, early interventions, perinatal screening should be directed at both parents.

Perinatal Parenting Stress, Anxiety, and Depression Outcomes in First-Time Mothers and Fathers: A 3- to 6-Months Postpartum Follow-Up Study

OBJECTIVE

Although there is an established link between parenting stress, postnatal depression, and anxiety, no study has yet investigated this link in first-time parental couples. The specific aims of this study were 1) to investigate whether there were any differences between first-time fathers' and mothers' postnatal parenting stress, anxiety, and depression symptoms and to see their evolution between three and 6 months after their child's birth; and 2) to explore how each parent's parenting stress and anxiety levels and the anxiety levels and depressive symptoms of their partners contributed to parental postnatal depression.

METHOD

The sample included 362 parents (181 couples; mothers' M Age = 35.03, SD = 4.7; fathers' M Age = 37.9, SD = 5.6) of healthy babies. At three (T1) and 6 months (T2) postpartum, both parents filled out, in a counterbalanced order, the Parenting Stress Index-Short Form, the Edinburgh Postnatal Depression Scale, and the State-Trait Anxiety Inventory.

RESULTS

The analyses showed that compared to fathers, mothers reported higher scores on postpartum anxiety, depression, and parenting stress. The scores for all measures for both mothers and fathers decreased from T1 to T2. However, a path analysis suggested that the persistence of both maternal and paternal postnatal depression was directly influenced by the parent's own levels of anxiety and parenting stress and by the presence of depression in his/her partner.

DISCUSSION

This study highlights the relevant impact and effects of both maternal and paternal stress, anxiety, and depression symptoms during the transition to parenthood. Therefore, to provide efficacious, targeted, early interventions, perinatal screening should be directed at both parents.

Meta-synthesis of qualitative research: the challenges and opportunities

Synthesis of qualitative studies is an emerging area that has been gaining more interest as an important source of evidence for improving health care policy and practice. In the last decade there have been numerous attempts to develop methods of aggregating and synthesizing qualitative data. Although numerous empirical qualitative studies have been published about different aspects of health care research, to date, the aggregation and syntheses of these data has not been commonly reported, particularly in pharmacy practice related research. This paper describes different methods of conducting meta-synthesis and provides an overview of selected common methods. The paper also emphasizes the challenges and opportunities associated with conducting meta-synthesis and highlights the importance of meta-synthesis in informing practice, policy and research.