key: cord-0805987-nod3k0nz
authors: Perrella, Sharon Lisa; Miraudo, Jennifer; Rea, Alethea; Geddes, Donna Tracy; Prosser, Stuart Anthony
title: Maternal Evaluation of a Team-Based Maternity Care Model for Women of Low Obstetric Risk
date: 2022-04-11
journal: J Patient Exp
DOI: 10.1177/23743735221092606
sha: 82bb1d2e72eda9f4ea3a4d16caac5a854d7186cf
doc_id: 805987
cord_uid: nod3k0nz

In response to the need for affordable and comprehensive maternity care, a multidisciplinary team-based maternity care service led by general practitioners with obstetric training (GPOs) and midwives was established for women of low obstetric risk. We evaluated maternal satisfaction with this model of care. All women that attended the service and gave birth in 2020 were approached. Participants used an online survey to rate their satisfaction with aspects of their pregnancy, hospital stay and postpartum care and were invited to provide additional written feedback. Fifty percent (81/162) of women (33 ± 3.9 years) responded, with 59% primiparous. Proportions of participants that were very satisfied with their overall pregnancy, hospital stay, and postpartum care were 91%, <50%, and 85%, respectively. Both survey and qualitative data identified high satisfaction with emotional care and time afforded to discuss concerns during appointments. High levels of satisfaction can be achieved in women of low obstetric risk through the provision of GPO-midwife led multidisciplinary care throughout the maternity journey.

Traditional private and public models account for 92.7% of maternity care practices in Australia, with responsibilities for pregnancy, birth, and postnatal care shifting between different providers (1, 2) . Fragmentation of care between providers and across locations may negatively impact the experience and outcomes of women and their families (1) . By contrast, continuity of care throughout the maternity pathway is associated with beneficial outcomes, enables the development of relationships between women and their care providers over time, and is highly valued by women (1, 3) . Although Australian women's satisfaction ratings for private obstetrician and midwife-led pregnancy care models are significantly higher than that of public hospital and shared care models (4, 5) , levels of satisfaction with hospitalbased postpartum care are reportedly low across all sectors (6) . Physical and emotional changes and a 90% incidence of health problems characterize the months after birth, yet there is a disparity between desired and provided care (7) (8) (9) . Postpartum care has been described as the most neglected aspect of maternity care (10) . Access to midwifery care beyond discharge is highly variable (7) , and a recommendation made 15 years ago to schedule a medical review well before the traditional 6-week postnatal check has not been adopted (11) . As new models of maternity care emerge to meet women's needs, evaluation and targeted research is recommended to identify strengths and areas for improvement (3) .

One For Women (OFW) is a private maternity care provider located in Perth, Western Australia; a city of 2.1 million people with a birth rate of 63.4 per 1000 women. The majority of women (97.5%) give birth in a hospital setting (12) . Perth has 6 public and 5 private maternity hospitals, with private obstetric care accounting for 45% of maternity care (12) . OFW offers an integrated interdisciplinary approach for women of low obstetric risk, with out-of-pocket costs capped at $1000 AUD. A team of general practitioners with obstetric training (GPOs) and midwives provide pregnancy and postpartum care, with screening and referral to allied health professionals and education sessions offered. An essential selection criterion in recruiting staff was "exceptional communication skills." Further, all clinical staff completed Possums & Co workshops (13) that build skills in a cross-disciplinary, integrated approach to care including breastfeeding, infant sleep, and mental health issues, and collaboration with parents (14) . These skills can be applied across the maternity care journey. Typical durations of GPO consultations are 25 min for GPOs, 45 min for midwives, and 60 min for allied health care providers. Women of high risk (including BMI > 40, complex medical or obstetric history) are referred for specialist obstetric care. For pregnancy complications such as restricted fetal growth or commencement of insulin to manage diabetes, the woman's medical care is transferred to a consultant obstetrician. Women are booked to birth at a private hospital with intrapartum care managed by a OFW GPO or obstetrician. Following discharge, postpartum care includes GPO consultations at 2 and 6 to 8 weeks with review of maternal recovery, infant health, breastfeeding, and adjustment to parenting. Medical care is transferred back to the woman's general practitioner after this. Across the maternity pathway women can access physiotherapy, dietetics, lactation consultancy, and family and child health nursing services at the one clinic.

The service commenced in February 2019 and has expanded to 4 clinics across the Perth metropolitan area. An independent evaluation of maternal satisfaction with care at OFW was conducted to determine levels of maternal satisfaction with pregnancy and postnatal care services provided to OFW maternity patients.

Researchers contacted all eligible women that accessed OFW for their maternity care and gave birth between January 1, 2020, and December 31, 2020, and invited them to complete a maternity care evaluation survey at 6 to 8 weeks postpartum. Invitations were sent between February 2020 and February 2021.Inclusion criteria: Women ≥18 years that birthed a live infant. Exclusion criteria: Women unable to read and speak English without assistance. Medical records were accessed to identify all women that gave birth during the study period, to confirm birth dates and live-born status, and to access email addresses. We excluded women with stillbirth as they have specific perinatal care needs, and it was considered insensitive to present them with questions regarding breastfeeding and infant care. We had initially planned to recruit women from the clinic waiting room and provide electronic links to the study information, consent form and survey. However, with the onset of the COVID-19 pandemic, we changed to electronic recruitment, study data collection and management using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at The University of Western Australia (15, 16) . REDCap is a secure web-based software platform designed to support data capture for research studies, providing an intuitive interface for validated data capture, audit trails for tracking data manipulation, and automated export procedures. Therefore, all recruitment was conducted electronically, so all eligible women were emailed an invitation to participate, with links to the online study information, consent form, and survey.

Sample size: We recruited a convenience sample of all women who attended OFW for maternity care and birthed a live infant between January 1, 2020, and December 31, 2020.

The survey was based on a validated questionnaire designed to evaluate women's satisfaction with their pregnancy, hospital-based perinatal care, and post-discharge postnatal care (17) . Twenty-four survey items addressed areas such as satisfaction with the quality of relationships with care providers, information, explanations, and clinical care received. Each item was rated using a 5-point Likert scale (17) . Reverse-scored questions in the original survey were reworded to positively worded questions, as pilot feedback suggested these were confusing, and the reverse-scoring method is ineffective in reducing response bias (18) . Reasons for choosing OFW for their maternity care, age, parity, and mode of birth were recorded. Participants were invited to provide qualitative feedback on positive and negative aspects of their maternity care by responding to the questions "What aspects of your maternity care have been most valuable to you?" and "Please tell us what we can do to improve the maternity care provided at One For Women." The questionnaire can be completed in under 10 min. To encourage honest feedback, we chose to distribute the survey electronically from a university email address after women had completed their maternity care, and we assured women of confidentiality.

Analysis of demographic data was performed using descriptive statistics. All quantitative data were analyzed using R (R Development Core Team, 2021). Differences in responses between women <30 years and ≥30 years of age, parity and birth mode were analyzed using Fisher exact test. Qualitative responses were analyzed thematically, with responses coded based on theme development from the content. Percentages were reported for each theme found within the responses for each question.

Ethics approvals were obtained from the Human Research Ethics Committee of the University of Western Australia (RA/4/20/5890) and board of directors of One For Women. All participants provided signed informed consent.

During the study period, 163 women accessed OFW for their maternity care; of these 162/163 (99%) met the study criteria and were invited to participate. No women were excluded due to an inability to read and speak English without assistance. Of the 162 invitations sent, 81 (50%) were completed. Participants were 33 ± 3.9 years of age, with 48 (59%) primiparous. Birth modes were spontaneous vaginal birth (n = 29, 36%), assisted vaginal birth (vacuum or forceps, n = 13, 16%), elective cesarean (n = 24, 30%), and nonelective cesarean (n = 15, 18%).

The most frequently cited reason for choosing OFW for maternity care was cost (n = 49, 61%), with recommendations from the family doctor or other health professional (n = 28, 35%) followed by that of family or friends (n = 27, 33%). Reasons added by participants were the model of care (n = 11, 14%) and having all services in one location (n = 3, 4%). Survey ratings of pregnancy, hospital-based care, and postpartum care are shown in Figure 1 . The lowest care satisfaction ratings were "time spent waiting for appointments" for pregnancy care, and "the breastfeeding help received from hospital staff" (both 29% strongly agreed). Most women strongly agreed they were "overall very pleased" with the quality of both pregnancy (91%) and postpartum care (86%). The highest "strongly agree" responses related to care providers' interest in the woman's emotional well-being and having enough time to discuss any concerns during appointments.

Women that had a forceps or vacuum-assisted vaginal birth were less likely to strongly agree that OFW reception staff were welcoming and helpful (P = .045), and less likely to strongly agree that they stayed in the hospital as long as they wanted (P = .017) when compared with other birth modes. Although not statistically significant we observed that when compared to women ≥30 years of age, women <30 years were more likely to strongly agree that their support person felt included at antenatal appointments (P = .051). No significant differences were observed between the responses of primiparous and multiparous women.

Feedback on aspects of OFW care that could be improved was received from 46/81 (57%) of which 10 (21%) stated they were happy with all services and could not identify any areas for improvement. They were not included in further qualitative coding. Of the remaining 36/81 (44%) responses 8/36 (22%) indicated that they would have liked more consistent communication between OFW and hospital staff. A further 8/36 (22%) indicated they would like further management and support, including continuation of appointments beyond the postpartum period. Participants' suggestions included "Maybe have an appt at 2 weeks post, 2 months post and 4 months post to ensure the mother is still flowing with motherhood ok" and "Perhaps set up optional mothers' groups." Another 8/36 (22%) suggested greater efficiency with operational matters, such as days available for appointments, improved clarity of text message reminders, and being able to easily contact the clinic by telephone to make appointments.

Feedback was provided by 71/81 (88%) of respondents on aspects of OFW maternity care found to be most valuable. High quality of care, including the exceptional support of medical and midwifery staff, the child health nurse, and members of the allied health and reception staff were reported by 57/71 (80%) of respondents. Respondents felt listened to and supported at all stages of their pregnancy and gained confidence throughout their pregnancy and into parenthood. The following quote typifies much of the feedback on valuable aspects of care: "I was able to build a strong rapport with OFW staff; I felt my wishes were always prioritised and any concerns I had were met with genuine empathy and care and I felt listened to; I felt more than just a number." Respondents who had previous birth trauma acknowledged how the high degree of personalized care assisted them in overcoming this and it was often mentioned that OFW and the "entire team" was exceptional.

The convenience of all services being located in one place and the symbiotic nature of the OFW services (13/71, 18%), appreciation of the attention to prenatal education, including gestational diabetes mellitus, breastfeeding, and birth (11/71, 16%), and the positive inclusion of partners in education and support during pregnancy were all commented on. Further participants expressed appreciation for the high degree of support received following birth and throughout the postpartum, including lactation support and follow-up with specific midwives and child health nurses (10/71, 14%). Less frequently reported valuable aspects included the continued quality of care during the hospital stay (6/71, 8%), the reasonable price for the high quality of care and services delivered (4/71, 6%), and consistent access to ultrasounds and pathology (3/71, 4%) in one location.

Women of low obstetric risk that attended OFW for their maternity care indicated high levels of satisfaction with their pregnancy and postpartum care and moderate satisfaction with hospital-based care. The high levels of satisfaction with pregnancy care (91%) were higher than that of Australian women accessing private obstetrics (82%), midwifery continuity (78%), and public maternity care models (58%) (19) . Ratings of aspects of postpartum care also indicated high levels of satisfaction, including aspects relating to care providers' interest in the woman's emotional well-being, opportunity to discuss concerns and have needs met. This contrasts with a report that Australian women's needs for information and psychosocial support are lacking in postpartum care, particularly from the private obstetric model (20) . Our results suggest the OFW model was successful in meeting the care needs of women in pregnancy and across the postpartum period.

The highest levels of maternity care satisfaction were related to care providers' interest in the woman's emotional well-being and having enough time to discuss any concerns, while qualitative data emphasized the importance of genuine, caring relationships. Our findings concur with evidence that Australian women's satisfaction with maternity care is associated with relational aspects including sensitive, respectful relationships with staff that strive to provide woman-centered care (21, 22) . To foster supportive relationships, care providers may consider offering longer consultations and undertaking professional skill development in empathy and Acceptance and Commitment Therapy such as that offered by Possums & Co. (13, 23) .

The most commonly reported reasons for choosing the OFW model of care were the lower financial cost and recommendations from care providers. This finding is consistent with a previously reported Australian study that found the cost was the most important factor, and care provider information was the most influential in choosing a maternity care model (24) . Although the model of care, convenience, and availability of multiple services at one location was valued by women that attended OFW for their maternity care, it is not surprising that these factors were not frequently cited as reasons for choosing OFW as the service had been in operation for <12 months and was not widely known at the time of commencement of this study.

Less than one-third of women were very satisfied with the time spent waiting for appointments in the clinic. Although published data are not available for private obstetric practices, dissatisfaction with waiting time at hospital clinics is common (25) . Across a range of health care services, long waiting times have been associated with lower ratings of satisfaction with care (26, 27) . It is important that this and other reported operational matters, such as availability and communication of appointments, are addressed as the service expands.

Regarding care received during the hospital stay, high levels of satisfaction were reported by less than half of the participants and only a third strongly agreed that they were satisfied with the breastfeeding help received. Our findings concur with reports of inadequate care, a lack of support, and contradictory breastfeeding information during the peripartum hospital stay (6, 8, 9, 28) . Consistency in individualized information and support is critical as women navigate postpartum physical and emotional changes while developing their confidence and competence in breastfeeding, infant care, and self-care (8) . There is an urgent need for maternity care providers' adoption of evidence-based education and clinical guidelines to direct the integration of breastfeeding education throughout antenatal care and substantially increase the level of breastfeeding knowledge and skills provided (29, 30) . Women that had an assisted vaginal birth were less likely to strongly agree that OFW reception staff were friendly and welcoming, and that their length of hospital stay was adequate. Although perceptions of staff interactions and hospital length of stay after instrumental vaginal birth have not been previously reported, there are negative associations with birth satisfaction, physical and psychological health, particularly for women after a forceps assisted birth (31, 32) . Interestingly there is no differentiation between spontaneous and assisted vaginal birth modes with regard to the expected length of postpartum hospital stay (33) . Careful consideration of maternal well-being after assisted birth is warranted (34) .

The strengths of this study included online recruitment and participation at the conclusion of care provided by the service that facilitated consistency in data collection and likely encouraged honest responses. Also, the use of a mixedmethods approach drew on the benefits of both quantitative and qualitative research with both breadth and depth of maternal experiences captured (35) .

With a response rate of 50% our data were limited to 81 participants of low obstetric risk, capturing maternal satisfaction with care provided by OFW in its first full calendar year of operations. Highly satisfied patients are more likely to complete and return satisfaction surveys, resulting in an upward bias in satisfaction scores (36) . Nevertheless, the satisfaction ratings were higher than that published for Australian private obstetric, shared care, and public care models (19) .

Provision of team-based multidisciplinary care throughout pregnancy and up to 6 to 8 weeks postpartum is associated with high levels of maternal satisfaction in women of low obstetric risk. Aspects of care associated with high satisfaction included the supportive interpersonal relationships developed across the team, longer clinic appointments that allowed for a full discussion of concerns, and the convenience of having a range of maternity care services available in one location.

This study provides evidence that a team-based maternity care model has the potential to successfully address longstanding gaps in postpartum care in Australia and has a positive impact on maternal well-being. The OFW model prioritizes attentive communication and support for mothers, with the goal of helping them feel empowered throughout their pregnancy, birth, and postpartum journeys. This study indicates OFW satisfaction rates are higher than those for other Australian care models which draws attention to the worthy expansion of this model to meet consumer demand. In light of this, regular monitoring of maternal perceptions of care is vital to ensure fulsome and high-quality care is maintained as the OFW service expands and as maternity care providers work to transform existing maternity care models and hospitalbased care.

This study was approved by the Human Research Ethics Committee of The University of Western Australia (2019/RA/4/20/5890). All procedures in this study were conducted in accordance with The University of Western Australia's (2019/RA/4/20/5890) approved protocols. Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Sharon Perrella and Prof Donna Geddes' salaries, and part of Dr Alethea Rea's salary are paid from an unrestricted research grant that is paid by Medela AG directly to the The University of Western Australia. Dr Stuart Prosser is a co-founder and medical doctor at One For Women. Dr Sharon Perrella is employed 1 session/week as a lactation consultant at One For Women.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Medela, Medela AG provides an unrestricted research grant to The University of Western Australia, from which Dr Sharon Perrella and Prof Donna Geddes receive salaries. We had full access to all relevant data in this study, and supporting sources were not involved in data analysis and interpretation, or in the writing of the article.

Sharon Lisa Perrella https://orcid.org/0000-0002-7727-7767 Alethea Rea https://orcid.org/0000-0003-0750-7501

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