E van Teijlingen

“Choice” and place of delivery: a qualitative study of women in remote and rural Scotland

Objective: To explore women’s perceptions of “choice” of place of delivery in remote and rural areas where different models of maternity services are available. Setting and methods: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. Results: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from “acceptors” to “active choosers.” The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in “choice.” Conclusions: Provision of different models of maternity services may not be sufficient to convince women they have “choice.” The paper raises fundamental questions about the meaning of “choice” within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training

Objectives: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. Design: Interview and postal survey. Setting: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). Participants: Staff proportionally representative of professional groups involved in maternity care. Results: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for “generalists” in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. Conclusions: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

A national survey of obstetric early warning systems in the United Kingdom: five years on

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists’ Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Rural maternity care: Can we learn from Wal-Mart?

In many countries rural maternity care is under threat. Consequently rural pregnant women will have to travel further to attend larger maternity units to receive care and deliver their babies. This trend is not dissimilar from the disappearance of other rural services, such as village shops, banks, post offices and bus services. We use a comparative approach to draw an analogy with large-scale supermarkets, such as the Wal-Mart and Tesco and their effect on the viability of smaller rural shops, depersonalisation of service and the wider community. The closure of a community-maternity unit leads to women attending a different type of hospital with a different approach to maternity care. Thus small community-midwifery units are being replaced, not by a very similar unit that happens to be further away, but by a larger obstetric unit that operates on different models, philosophy and notions of risk. Comparative analysis allows a fresh perspective on the provision of rural maternity services. We argue that previous discussions focusing on medicalisation and change in maternity services can be enhanced by drawing on experience in other sectors and taking a wider societal lens.

Understanding Afghan healthcare providers: a qualitative study of the culture of care in a Kabul maternity hospital

To analyse the culture of a Kabul maternity hospital to understand the perspectives of healthcare providers on their roles, experiences, values and motivations and the impact of these determinants on the care of perinatal women and their babies.

Sexual health information and uptake of sexual health services by African women in Scotland: a pilot study.

Abstract UK sub-Saharan African immigrants are disproportionably affected by HIV (Human Immunodeficiency Virus) and there is little evidence that they are utilising sexual health facilities effectively. Information is lacking on how African women utilise sexual health services. Research shows that they report late for diagnosis of Sexually Transmitted Infections (STIs) especially HIV. Many are diagnosed in antenatal clinics or general hospital settings rather than in sexual health clinics. These routes of diagnosis have implications for their sexual health well being. First, only pregnant women are likely to be diagnosed early and secondly others are diagnosed late, when they show HIV-related symptoms. They lack up-to-date information regarding STIs including HIV/AIDS. This paper identifies sources of sexual health information available to African women and assesses its effects on their uptake of sexual health services. A two-phase research was conducted with African women living in Scotland. Phase 1 consists of a survey and Phase 2 focus group discussions. We surveyed African women living in Scotland in 2007 aged between 16 and 55. The questionnaire covered knowledge of STIs, perception of risk of infections, attitude and sources of STI information. Of the 700 questionnaires, 96 women from 13 African countries completed the questionnaires. Analysis showed that 79% of the participants have university qualification, 74.2% (employed), 54.4% (married or living with partners), 68.8% had sexual relationships and 47% are recent migrants (<5 years). Their knowledge of STI varied and fewer than 15% use sexual health services. Most (73%) do not perceive themselves to be at risk of infection. Greatest threat to their sexual health is partners behaviour. Their main source of sexual health information is from non-health care sources. There is very little contact with health professionals. There is urgent need for health promotional activities and research to identify social and cultural issues that contribute to non use of sexual health services.

PS21 Evaluation of Maternity Care Intervention in Rural Nepal: Can a Health Promotion Exercise Improve Maternal Health and Service uptake in Rural Nepal?

Background In developing countries, where the majority of the world’s maternal deaths occur it is recognised that to target maternal mortality within limited resources, safe motherhood strategies need to be targeted to rural areas and to the poor in order to increase access to antenatal care and delivery care. In these populations, a lack of understanding of local beliefs and practices, and the reasons for them, can hinder the development of appropriate interventions. The Green Tara Nepal intervention, Pharping, Nepal, aims to improve the uptake of maternal care practices in rural Nepal via health promotion activities in the community. The expectation is that the measured aspect of health-seeking behaviour should improve in the intervention area relative to the control. Methods In 2008, Green Tara Nepal (GTN), a Nepalese Non-Governmental Organisation implemented a 5 year health promotion intervention to improve maternal and neonatal health in 2 rural village development communities (VDC) in Pharping, Nepal. The GTN programme works with midwives and community health workers to target fertile women, in health promotion groups and on a one-to-one basis. During this interaction, women receive advice on health behaviours and care-seeking practice. Two surveys were conducted a baseline (2008) and a midline (2010) on the intervention communities and in 2 control communities.; 833 women of childbearing age with their last child of less than 2 years old, were interviewed in this controlled before and after, cross-sectional study. Results After the intervention the proportion of women, during their last pregnancy, attending antenatal care, at least once, increased by from 84.6% to 96.8% (p=0.00). The proportion of women who had their first prenatal visit in the first trimester was increased from 39.9% to 58.1% (p=0.00). Women attending more than 4 visits increased from 37.1% to 42.6% (p=0.28). Conclusion This ongoing community intervention providing health promotion shows an improvement on women’s attendance of antenatal care.