Suze Jans

Opinions of maternity care professionals about integration of care during labor for "moderate risk" indications: a Delphi study in the Netherlands

BACKGROUNDnThe percentage of referrals during labor from primary midwife-led care to obstetrician-led care has increased over the past years in The Netherlands. Most women are referred for indications with a moderate increase in risk and are looked after by clinical midwives. This study aims to provide insight into the opinions of maternity care professionals about integration of care and involvement of primary care midwives in the intrapartum care of women with moderate risk factors.nnnMETHODSnA Delphi study consisting of three rounds was conducted. A purposively selected heterogenic panel of 50 professionals, including obstetricians, primary care midwives, clinical midwives, and obstetric nurses, answered questions anonymously.nnnRESULTSnAlthough primary care midwives would like to expand their responsibilities and tasks with respect to moderate risk indications, consensus among panel members was only reached concerning prolonged rupture of membranes for which the primary care midwife could remain the caregiver.nnnCONCLUSIONnThis study shows that most participants support more integration of care during labor. The lack of consensus among Dutch maternity care professionals with regard to the distribution of responsibilities and tasks for moderate risk indications is a challenge. Further studies should explore how to deal with differences in opinions among professionals when integrating maternity care systems.

Intrapartum referral from primary to secondary care in the Netherlands: a retrospective cohort study on management of labor and outcomes

BACKGROUNDnIn the Dutch maternity care system, primary care midwives provide care to low-risk women and refer to obstetricians if risks or complications occur. We examined reasons for referral, management of labor, and maternal and neonatal outcomes among women who were referred during labor.nnnMETHODSnIn a retrospective cohort study, descriptive analyses were performed on data obtained from patient records. Six purposively chosen hospitals in The Netherlands participated in the study from June 2011 to February 2012. The study population included 600 pregnant women who were referred during labor from primary to secondary care.nnnMAIN OUTCOME MEASURESnReasons for referral, interventions after referral, mode of delivery, and maternal and neonatal outcomes.nnnRESULTSnOf women who were referred during labor, three out of four women were referred for moderate risk indications: request for pain relief (30.5%), meconium-stained liquor (25.3%), failure to progress during first stage of labor (14.0%), and prolonged ruptured membranes without contractions (12.5%). Of all women, 65.7 percent had a spontaneous vaginal delivery and 59.7 percent received some kind of pain relief. Acute referral, meaning fetal distress, occurred in 5.5 percent. Of the newborns, 2.7 percent had an Apgar score of 7 or less after 5xa0minutes and 1.2 percent had an umbilical cord pH <xa07.05. Postpartum complications occurred among 11.0 percent of women.nnnCONCLUSIONnWomen who are referred during labor have a high probability of spontaneous vaginal delivery. To improve continuity of care and satisfaction for this group of women, management of labor could be continued by trained primary care midwives.

Opinions of maternity care professionals and other stakeholders about integration of maternity care: a qualitative study in the Netherlands

BackgroundThis study aims to give insight into the opinions of maternity care professionals and other stakeholders on the integration of midwife-led care and obstetrician-led care and on the facilitating and inhibiting factors for integrating maternity care.MethodsQualitative study using interviews and focus groups from November 2012 to February 2013 in the Netherlands. Seventeen purposively selected stakeholder representatives participated in individual semi-structured interviews and 21 in focus groups. One face-to-face focus group included a combined group of midwives, obstetricians and a paediatrician involved in maternity care. Two online focus groups included a group of primary care midwives and a group of clinical midwives respectively. Thematic analysis was performed using Atlas.ti. Two researchers independently coded the interview and focus group transcripts by means of a mind map and themes and relations between them were described.ResultsThree main themes were identified with regard to integrating maternity care: client-centred care, continuity of care and task shifting between professionals. Opinions differed regarding the optimal maternity care organisation model. Participants considered the current payment structure an inhibiting factor, whereas a new modified payment structure based on the actual amount of work performed was seen as a facilitating factor. Both midwives and obstetricians indicated that they were afraid to loose autonomy.ConclusionsAn integrated maternity care system may improve client-centred care, provide continuity of care for women during labour and birth and include a shift of responsibilities between health care providers. However, differences of opinion among professionals and other stakeholders with regard to the optimal maternity care organisation model may complicate the implementation of integrated care. Important factors for a successful implementation of integrated maternity care are an appropriate payment structure and maintenance of the autonomy of professionals.

A case study of haemoglobinopathy screening in the Netherlands: witnessing the past, lessons for the future

Objectives. In 2007 neonatal screening (NNS) was expanded to include screening for sickle cell disease (SCD) and beta-thalassaemia. Up until that year no formal recommendations for haemoglobinopathy (carrier) screening existed in the Netherlands. Although it has been subject to debate in the past, preconceptional and prenatal haemoglobinopathy carrier screening are not part of routine healthcare in the Netherlands. This study aimed to explore the decision-making process of the past: why was the introduction of a screening programme for haemoglobinopathy considered to be untimely, and did ethnicity play a role given the history in other countries surrounding the introduction of haemoglobinopathy screening? Design. A witness seminar was organised, inviting key figures to discuss the decision-making process concerning haemoglobinopathy screening in the Netherlands, thereby adding new perspectives on past events. The transcript was content-analysed. Results. The subject of haemoglobinopathy screening first appeared in the 1970s. As opposed to a long history of neglect of African-American health in the United States, the heritage of the Second World War influenced the decision-making process in the Netherlands. As a consequence, registration of ethnicity surfaced as an impeding factor. However, overall, official Dutch screening policy was restrained regarding reproductive issues caused by fear of eugenics. In the 1990s haemoglobinopathy screening was found to be ‘not opportune’ due to low prevalence, lack of knowledge and fear of stigmatisation. Currently the registration of ethnicity remains on the political agenda, but still proves to be a sensitive subject. Discussion. Carrier screening in general never appeared high on the policy agenda. Registration of ethnicity remains sensitive caused by the current political climate. Complexities related to carrier screening are a challenge in Dutch healthcare. Whether carrier screening will be considered a valuable complementary strategy in the Netherlands, depends partly on participation of representatives of high-risk groups in policy making.

A qualitative study on barriers in the prevention of anaemia during pregnancy in public health centres: perceptions of Indonesian nurse-midwives

BackgroundAnemia in pregnancy remains a major problem in Indonesia over the past decade. Early detection of anaemia in pregnancy is one of the components which is unsuccessfully implemented by nurse-midwives. This study aims to explore nurse-midwives’ experiences in managing pregnant women with anaemia in Public Health Centres.MethodsWe conducted a qualitative study with semi-structured face to face interviews from November 2011 to February 2012 with 23 nurse-midwives in five districts in Yogyakarta Special Province. Data analysis was thematic, using the constant comparison method, making comparison between participants and supported by ATLAS.ti software.ResultsTwelve nurse-midwives included in the interviews had less than or equal to 10 years’ working experience (junior nurse-midwives) and 11 nurse-midwives had more than 10 years’ working experience (senior nurse-midwives) in Public Health Centres. The senior nurse-midwives mostly worked as coordinators in Public Health Centres. Three main themes emerged: 1) the lack of competence and clinical skill; 2) cultural beliefs and low participation of family in antenatal care programme; 3) insufficient facilities and skilled support staff in Public Health Centres. The nurse-midwives realized that they need to improve their communication and clinical skills to manage pregnant women with anaemia. The husband and family involvement in antenatal care was constrained by the strength of cultural beliefs and lack of health information. Moreover, unfavourable work environment of the Public Health Centres made it difficult to apply antenatal care the pregnant womens’ need.ConclusionsThe availability of facilities and skilled staffs in Public Health Centre as well as pregnant women’s husbands or family members contribute to the success of managing anaemia in pregnancy. Nurse-midwives and pregnant women need to be empowered to achieve the optimum result of anaemia management. We recommend a more comprehensive approach in managing pregnant women with anaemia, which synergizes the available resources and empowers nurse-midwives and pregnant women.

A randomised controlled trial on the Four Pillars Approach in managing pregnant women with anaemia in Yogyakarta–Indonesia: a study protocol

BackgroundAnaemia is a common health problem among pregnant women and a contributing factor with a major influence on maternal mortality in Indonesia. The Four Pillars Approach is a new approach to anaemia in pregnancy, combining four strategies to improve antenatal and delivery care. The primary objective of this study is to measure the effectiveness of the Four Pillars Approach. The barriers, the facilitators, and the patients’ as well as the midwives’ satisfaction with the Four Pillars Approach will also be measured.Methods/DesignThis study will use a cluster randomised controlled trial. This intervention study will be conducted in the Public Health Centres with basic emergency obstetric care in Yogyakarta Special Province and in Central Java Province. We will involve all the Public Health Centres (24) with emergency obstetric care in Yogyakarta Special Province. Another 24 Public Health Centres with emergency obstetric care in Central Java Province which have similarities in their demographic, population characteristics, and facilities will also be involved. Each Public Health Centre will be asked to choose two or three nurse-midwives to participate in this study. For the intervention group, the Public Health Centres in Yogyakarta Special Province, training on the Four Pillars Approach will be held prior to the model’s implementation. Consecutively, we will recruit 360 pregnant women with anaemia to take part in part in the study to measure the effectiveness of the intervention. The outcome measurements are the differences in haemoglobin levels between the intervention and control groups in the third trimester of pregnancy, the frequency of antenatal care attendance, and the presence of a nurse-midwife during labour. Qualitative data will be used to investigate the barriers and facilitating factors, as to nurse-midwives’ satisfaction with the implementation of the Four Pillars Approach.DiscussionIf the Four Pillars Approach is effective in improving the outcome for pregnant women with anaemia, this approach could be implemented nationwide and be taken into consideration to improve the outcome for other conditions in pregnancy, after further research.Trial registrationCurrent Controlled Trials ISRCTN35822126.

'A morass of considerations': exploring attitudes towards ethnicity-based haemoglobinopathy-carrier screening in primary care

Background. The Netherlands does not have a national haemoglobinopathy (HbP)-carrier screening programme aimed at facilitating informed reproductive choice. HbP-carrier testing for those at risk is at best offered on the basis of anaemia. Registration of ethnicity has proved controversial and may complicate the introduction of a screening programme if based on ethnicity. However, other factors may also play a role. Objective. To explore perceived barriers and attitudes among GPs and midwives regarding the registration of ethnicity and ethnicity-based HbP-carrier screening. Methods. Six focus groups in Dutch primary care, with a total of 37 GPs (n = 9) and midwives (n = 28) were conducted, transcribed and content analysed using Atlas-ti. Results. Both GPs and midwives struggled with correctly identifying ethnicities at risk for HbP. Ethical concerns regarding privacy seemed to originate from World War II experiences, when ethnic and religious registration facilitated deportation of Jewish citizens, coupled with the political climate at the time focus groups were held. Some respondents thought the ethnicity question might undermine the relationship with their clients. Software programmes prevented GPs from registering ethnicity of patients at risk. Financial implications for patients were also a concern. Despite this, respondents seemed positive about screening and were familiar with identifying ethnicity and used this for individual patient care. Conclusions. Although health professionals are generally positive about screening, ethical, financial and practical issues surrounding ethnicity-based HbP-carrier screening need to be clarified before introducing such a programme. Primary care professionals can be targeted through professional organizations but they need national policy support.

The art of vaginal breech birth at term on all fours

Despite a shift in clinical practice favouring cesarean section for breech presentation, adequate skills are still needed for a safe vaginal breech birth. This case report illustrates the physiological mechanism of vaginal breech birth. The accompanying pictures are a testimony to the “hands‐off” approach and could be used for educational purposes.

Perceived Barriers and Facilitators of a New Model in Managing Pregnant Women With Iron Deficiency Anemia: A Qualitative Study.

A new model of antenatal care to manage pregnant women with iron deficiency anemia at public health centers in Indonesia has been studied. This study aimed to explore the facilitators and the barriers of this new model introduction by using focus group discussions to nurse-midwives and nurse-midwife coordinators. Training and information booklets, the improved confidence in providing comprehensive care, and adequate support from supervisors were perceived as facilitators of the new model. Financial support and public transportation necessary to reach the optimum treatment according to the new model, limited health insurance coverage, and shortage of staff and iron tablets were the barriers. Similar barriers should be anticipated for further implementation. A lasting support of policy and decision makers therefore is essential.

The Effectiveness of a New Model in Managing Pregnant Women with Iron Deficiency Anemia in Indonesia: A Nonrandomized Controlled Intervention Study

BACKGROUNDnIndonesia has a major problem with iron deficiency anemia among pregnant women. A new model named the Four Pillars Approach was designed to improve antenatal care for these women. This study aimed to measure the effectiveness of the model in managing pregnant women with iron deficiency anemia.nnnMETHODnWe used a nonrandomized controlled intervention study. The study, with the Four Pillars Approach as intervention versus usual care as its control, was conducted in two provinces in Java (Indonesia) during the period from March 2012 until May 2013. Main outcome measures were a difference of Hb level ≥xa00.5xa0g/dL, the number of women who attended five or more antenatal care visits, and birthing with a skilled birth attendant.nnnRESULTSnThree hundred fifty-four participants were enrolled in the study. Participants in the intervention group had an adjusted odds ratio of 25.0 (95% CI 12.03-52.03, pxa0=xa00.001) for increased hemoglobin of ≥xa00.5xa0g/dL at 35-37xa0weeks of gestation, compared with the control group. In the intervention group, 95.0 percent of women had five or more antenatal care visits, compared with 57.2 percent (pxa0=xa00.001) in the control group. All births in both groups were assisted by skilled birth attendants.nnnCONCLUSIONnThe Four Pillars Approach is effective in increasing the hemoglobin level and the frequency of antenatal care visits of participants when compared with the usual care for pregnant women with anemia.