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Table of Contents
REVIEW ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 1-10

The concept of maternal care quality for women with low-risk pregnancy in the maternity ward: An integrative review


1 Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
2 Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Public Health Nursing, Nursing Faculty, Aja University of Medical Sciences, Tehran, Iran

Date of Submission04-Jan-2021
Date of Acceptance08-Jul-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Fatemeh Abbaszadeh
Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tohid Sq., Nostrat St., Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nms.nms_2_21

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  Abstract 


Background: Improving the quality of maternal care is considered a key strategy for improving maternal and neonatal outcomes. However, available definitions do not clearly define this concept. Objective: The aim of this study was to clarify the concept of maternal care quality (MCQ) for women with low-risk pregnancy in the maternity ward and to determine its attributes. Methods: This integrative review was conducted using Whitmore and Knafl's method. An online literature search was done in Medline, Embase, Web of Sciences, Scopus, SID, Magiran, and IranMedex databases as well as the websites of health-care and midwifery organizations and associations. Data were analyzed in the four steps of data reduction, data display, data comparison, and conclusion drawing and verification. Results: The two main attributes of MCQ are effective communication and interaction and professional care. Effective communication and interaction between the care provider and pregnant women in the maternity ward is the most important attribute of MCQ. The first category included three subcategories, namely informational interaction, human interaction, and participatory interaction. The two subcategories of the second category were adherence to standards during care delivery and delivering accessible care. Conclusion: MCQ in maternity ward is defined as “the process of delivering safe, fair, accessible, and standard professional care to women during childbirth through human, informational, and participatory interactions.”

Keywords: Care quality, Integrative review, Low-risk pregnancy, Maternal care, Maternity


How to cite this article:
Khakbazan Z, Damghanian M, Zareiyan A, Abbaszadeh F. The concept of maternal care quality for women with low-risk pregnancy in the maternity ward: An integrative review. Nurs Midwifery Stud 2022;11:1-10

How to cite this URL:
Khakbazan Z, Damghanian M, Zareiyan A, Abbaszadeh F. The concept of maternal care quality for women with low-risk pregnancy in the maternity ward: An integrative review. Nurs Midwifery Stud [serial online] 2022 [cited 2022 May 24];11:1-10. Available from: https://www.nmsjournal.com/text.asp?2022/11/1/1/340532

Table 2: Attributes of the concept of MCQ

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Table 2: Attributes of the concept of MCQ

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  Introduction Top


Maternal and neonatal disability and death are among the major health-care challenges. Despite the wide accessibility to competent health-care providers in many health-care settings, many women and neonates still experience lifelong disability or death.[1] The World Health Organization (WHO) estimates that each year, 303000 women and 2.7 million neonates die at the time of childbirth.[2] These deaths are mostly due to preventable problems such as bleeding, hypertension, premature delivery, asphyxia, and infection.[3] MCQ has a significant role in reducing preventable maternal and neonatal complications and death,[4] reducing unnecessary interventions, and improving psychosocial outcomes and public health.[5]

A key step to MCQ improvement is to provide a clear definition for the concept of MCQ. Some previous studies provided definitions for the concept of MCQ in the maternity ward. For instance, a study noted that care quality is far beyond supplying medications and supervising women during the process of labor and defined MCQ as the emotional presence of midwives for women to reassure them through providing guidance, support, and counseling.[6] In another study, researchers considered that the concept of respectful maternity care is broader than a reduction of disrespectful care or mistreatment of women during childbirth. They explained the 12 dimensions of respectful maternity care during childbirth in health centers.[7] Although these studies provided data about some aspects of the concept of MCQ, there is still no clear and comprehensive definition for the concept, particularly about MCQ in the maternity ward. Therefore, comprehensive studies are still needed to further clarify the concept and its dimensions.

Objectives

The present study aimed at clarifying the concept of MCQ for women with low-risk pregnancy in the maternity ward and at determining its attributes.


  Methods Top


This integrative review was conducted using Whitmore and Knafl's method. The integrative review is “the broadest type of research review”[8] that provides a framework for the comprehensive assessment of complex concepts or theories[9] and allows the inclusion of studies with different methodologies in the review.[10] After problem identification, this method includes a literature search, data evaluation, data analysis, and presentation.

Literature search

In this stage, an online search was done in the following databases: Medline, Embase, Web of Sciences, Scopus, SID, Magiran, and IranMedex as well as the websites of midwifery and health-care organizations and associations, including the WHO and the International Confederation of Midwives. Moreover, the reference lists of the retrieved documents were assessed for relevant documents. The search protocol was developed through consulting an experienced librarian and was limited to date between 2000 and 2020. A literature search was done through both a keyword-based search and a subject-based search using headings extracted from the Medical Subject Headings. Search keywords included “midwife,” “nurse midwifery,” “maternal-child nursing,” “maternity,” “obstetric,” “maternity nursing,” “neonatal nursing,” “prenatal nursing,” “antenatal,” “maternity care,” “healthcare quality,” “care quality,” “midwifery care,” “quality of midwifery care,” and “antenatal care” [Appendix S1],[Appendix S2][Appendix S3],[Appendix S4]. Retrieved documents were assessed for eligibility.

Inclusion criteria

Inclusion criteria were publications in Persian or English, inclusion of the search keywords in title, abstract, or keywords, relevance to MCQ for women with low-risk pregnancy in the maternity ward, and the use of a descriptive, observational, and interventional meta-analysis, survey, systematic review, qualitative, or mixed-methods design.

The primary search produced 15506 records. Duplicate records were identified and excluded using the EndNote software (n = 7846) and then, the titles and the abstracts of the remaining 7660 documents were assessed. Accordingly, 351 documents with keywords in title, abstract, or keywords section were identified. Eight more studies were retrieved from relevant websites and the reference list of these 359 documents. After that, 321 documents were excluded due to irrelevance to MCQ (n = 281), inaccessible full-text (n = 2), publication in languages other than English or Persian (n = 7), or being commentaries, editorials, or conference abstracts (n = 31). Finally, 38 documents were included in the study [Figure 1]. Eligibility assessment was independently performed by two of the study authors. Disagreements between them were resolved by the third author.
Figure 1: Flow diagram of the review selection process

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Data evaluation

The 38 documents included in the present study were 22 qualitative studies, 12 review studies, one mixed-methods study, one cross-sectional study, and two guidelines [Table 1]. None of these documents was excluded during data evaluation. We used the Mixed-Methods Appraisal Tool to evaluate qualitative, mixed methods, and cross-sectional studies. This tool is appropriate for both quantitative and qualitative studies[11] and has been used in former systematic and[12],[13] integrative reviews. The two guidelines included in the study were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE), which is a standard tool for critiquing clinical guidelines.[14] The quality of review studies included in the present study was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.[15] In order to ensure the reliability of the findings, the data evaluation forms completed by two of the authors were checked and confirmed by two more authors.
Table 1: Characteristics of studies that were included

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Data analysis

For data analysis, primary codes were extracted from the included studies and then, the codes were compared and categorized. Generated categories were also compared and categorized into larger categories.[51] We used original excerpts from the documents included in data analysis. For ensuring the validity of data analysis, two of the authors independently analyzed the data and then, compared their findings and generated final findings. They resolved their disagreements through consulting the third author.

The Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran, approved this study (code: IR.TUMS.FNM.1398.053).


  Results Top


The attributes of MCQ included the two main categories of effective communication and interaction and professional care, which are shown in [Table - 2] and explained in what follows.{Table 2}

Effective communication and interaction

Effective communication and interaction between midwife and pregnant women in the maternity ward is the most important attribute of MCQ and is considered as the core and the essence of humanistic care.[37] This main category included three subcategories, namely informational interaction, human interaction, and participatory interaction.

Informational interaction

Women in labor need to receive information that care providers should pay attention to and provide. Informational interaction is considered as one of the key components of MCQ.[19],[21],[23],[32] It has a significant role in empowering pregnant women, facilitating their acceptance of health-care providers' recommendations, and enhancing their satisfaction with care.[21] Moreover, it improves their self-confidence in the process of childbirth.[20] This category had two subcategories:, unexpressed information needs and expressed information needs.

Unexpressed information needs

Pregnant women need information about labor progression, the process of childbirth,[6],[21] breathing techniques,[19],[26],[32] pain-relief techniques, relaxation techniques, family planning, vaccination, episiotomy care,[19],[32] and child care.[30] Although pregnant women may not express this need, providing them with accurate information can improve their relationships with midwives during labor, make women calm, and create a positive birth experience for them.[29] Before each therapeutic or diagnostic intervention in the maternity ward, pregnant women should be provided with clear explanations about the intervention. After the intervention, they should also be informed about its results and necessary recommendations.[22],[28]

Expressed information needs

These needs are mostly revealed when the clients ask health-care providers questions. All clients in health-care settings, including women in the maternity ward, have the right to ask their questions and express their concerns. Therefore, health-care providers should allocate adequate time to respond to their clients' questions and provide them with the requested information. In other words, responding to their questions and addressing their concerns are among the primary components of care delivery.[21],[32] An important point to establish effective communication and interaction is the use of an understandable jargon-free language for communication.[6]

Human interaction

Human interaction refers to a bilateral relationship for altruistic purposes. The two components of human interaction for MCQ are emotional interaction and respect for human dignity.

Emotional interaction

Respectful and friendly relationships between midwives and pregnant women have significant effects on MCQ.[7],[19],[21],[23],[28] Mutual confidence and respect,[46] empathy,[16],[19],[52] and reassurance[20] are essential for protecting the health of women and their neonates.

Respect for human dignity

The two components of respect for human dignity in order to ensure MCQ in the maternity ward are respect for women's privacy and respect for their culture, values, and beliefs. Respect for privacy is a basic need of pregnant women in the ward.[7],[16],[19],[21],[28],[43] Health-care providers in the maternity ward also need to respect women's culture, values, and beliefs.[50] Most women, particularly Muslim women, prefer to receive care from female health-care providers in the maternity ward.[53]

Participatory interaction

Participatory interaction means patient participation in the treatment decisions and nursing care procedures. Both midwives and pregnant women should actively participate in the process of childbirth. Midwives should respect women's preferences and choices and use their opinions throughout childbirth.[21] This category included two subcategories, namely promoting women's participation and promoting their companions' participation.

Promoting women's participation

Women should actively participate in the process of decision making about labor position,[17],[30] their companions' presence during labor, and labor pain relief methods.[30]

Promoting companions' participation

A trained companion during labor can provide pregnant women with physical and emotional support and thereby, bring them calmness.[54] Family members' and friends' support during labor can reduce women's stress, promote positive thinking, and enhance their confidence.[20],[23] Women often prefer to receive their husbands' support during labor and believe that sharing the process of childbirth with the husband is important for having a positive childbirth experience. Contrarily, some women do not prefer their husbands to be present during labor because they are concerned about their husbands' probable interference in the process of labor due to their lack of knowledge or misunderstanding about some labor-related techniques.[20],[39]

Professional care

Professional care supports the client in the processes of identifying, determining, and acting upon experiences relevant to health and healing. In this study, professional care is the second main category of the attributes of MCQ in the maternity ward. The two subcategories of this main category were adherence to standards during care delivery and delivering accessible care.

Adherence to standards during care delivery

Care delivery based on standards consisted of three subcategories, namely performing essential interventions, avoiding unessential interventions, and adhering to care-related models.

Performing essential interventions

Essential interventions are interventions that should be performed in the maternity ward for women with a low-risk pregnancy. These interventions include fetal monitoring, vaginal examination, administration of oral fluids during labor,[30],[31] administration of food stuffs during labor,[30],[31],[32] encouraging women to have mobility during labor,[30],[31],[32],[41] giving them the right to have a companion during labor, helping them to choose the best position, administrating epidural analgesia and opioids, nonpharmacological pain relief, administering relaxation techniques,[30],[31] using techniques to reduce perineal trauma,[30] encouraging and supporting women to follow their own urge to push during delivery,[30],[31] controlled cord traction (CCT),[30] administering oxytocin in the third stage of labor, delayed umbilical cord clamping, encouraging breastfeeding in the first postnatal hour, performing careful postnatal assessment for women and their neonates, encouraging skin-to-skin contact, warming neonates,[22],[30] and administering vitamin K for neonates.[30]

Avoiding unessential interventions

Unessential interventions include interventions that are recommended not to be used for women with a low-risk pregnancy. These interventions include cardiotocography at the time of admission, continuous cardiotocography during labor,[30],[31] enema at the time of admission, perineal shaving before vaginal delivery, vaginal disinfection using chlorhexidine, pain relief in order to postpone delivery,[30] amniotomy just to prevent delay in childbirth, administering intravenous fluids to shorten labor, restricting the intake of fluid and foods during labor,[30],[41] premature amniotomy and induction using oxytocin, administering oxytocin to prevent delay in childbirth in women with epidural analgesia, using antispasmodic agents to prevent delay in childbirth, routine use of episiotomy, fundal pressure in the second stage of labor, forcing women to assume the supine position, oral and nasal suctioning of neonates, postnatal continuous massage of the uterine fundus in women who have received prophylactic oxytocin, administration of prophylactic antibiotics, and mother–neonate separation.[30]

Adhering to care-related strategies

Among the attributes of midwifery care is adherence to continuous care,[6],[27],[47],[48] one-to-one care,[17],[22],[26] and woman-centered care.[30],[55] These care-related models can promote and support normal vaginal delivery. Therefore, health-care policy makers and providers need to consider them during perinatal care.

Delivering available care

Care provider should be available all the time in the maternity ward. Quality maternal care necessitates continuous attendance of midwives at the women's bedside during labor[37] and women's easy access to them. Care providers should be present in the maternity ward for delivering fair and safe care.

Delivering fair care

Delivering fair care means ensuring that all people have equal opportunities, regardless of their abilities, background, and lifestyle. Therefore, all pregnant women should have access to fair care irrespective of their age, ethnicity, religion, or other characteristics.[49] Care services should be provided in a timely manner[32] and without any prejudice.[54] Moreover, health-care providers should not judge women in the maternity ward, particularly those with the human immunodeficiency virus.[21]

Delivering safe care

Normal delivery should be performed with minimum possible interventions,[34],[56] without any damage and misconduct,[7],[21] and with regular monitoring of the process of labor.[22]


  Discussion Top


Maternal care is part of the health care provided to the mothers in maternity units. Although the concept of care exists in the philosophy, vision, and mission of most health-care organizations and institutes, it is still a complex concept in health-care systems with no clear and precise definition.[52] Study findings revealed that the two main attributes of the concept of MCQ are effective communication and interaction and professional care. These two attributes refer to the process component of Donabedian's model. He introduces a process as how to deliver care services or as interpersonal processes in care delivery.[57] The professional care attribute of MCQ refers to the performance of midwives and the process of their care delivery. Adherence to standards during care delivery and provision of accessible care are the two key aspects of professional care delivery. Our findings revealed that continuous care, one-to-one care, evidence-based care, and woman-centered care are among the strategies for improving care quality in the maternity ward, which should be taken into account by health-care policy makers and providers. A former study provided valuable data about respectful care, health-care providers' relationships with pregnant women, and physical structures in maternity wards[7]; however, that study provided no data about professional care and just reviewed qualitative studies. Contrarily, we addressed two main attributes of MCQ and reviewed qualitative, quantitative, and review studies as well as the newest guidelines on maternal care.

Effective communication and interaction, as a key attribute of MCQ, should be considered in defining the process of any type of quality care. Communication skills are key elements in quality midwifery care delivery.[18] Women expect midwives to act like a mother for them, warmly accept them, reassure them, encourage them to have a good delivery,[6] and empathize with them during care delivery.[29] A former study also showed that perinatal care mostly includes supportive and emotional care.[6]

To the best of our knowledge, this is the first integrative review of its kind into the concept of MCQ in the maternity ward. The findings of the study can be used for MCQ improvement in different settings and also for developing instruments to measure MCQ.

We defined MCQ in the maternity ward as “the process of delivering safe, fair, accessible, and standard professional care to women during childbirth through humanistic, informational, and participatory interactions.” One of the strengths of the present study is the provision of a clear definition of the concept of MCQ in the maternity ward. The definition provided in this study is based on the comprehensive review of the existing literature and, hence, is comprehensive and provides a deep understanding of MCQ. Along with its strengths, this study had some limitations. For instance, it addressed MCQ in relation to women with a low-risk pregnancy. Future studies are recommended to analyze the concept of MCQ in relation to women with a high-risk pregnancy. Moreover, as this was the first study into the analysis of the concept of MCQ in the maternity ward, there was no definition and study for the purpose of comparison.


  Conclusion Top


Based on the findings of the present study, the concept of MCQ in the maternity ward is defined as “the process of delivering safe, fair, accessible, and standard professional care to women during childbirth through humanistic, informational, and participatory interactions.”

Acknowledgement

This article was derived from a Ph.D thesis of reproductive health of Tehran University of Medical Sciences with project number 9611151005, 6/04/2019, Tehran University of Medical Sciences, Tehran, Iran. The authors would like to acknowledge the research deputy at Tehran University of medical sciences for their support. They are also thankful to all patients who participated in this study.

Financial support and sponsorship

This study was supported by the research deputy at Tehran University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.





Appendix S3. Scopus search strategy

(TITLE-ABS (“Obstetric Labor” OR “Obstetric Deliveries” OR “Obstetric Delivery” OR “Delivery Rooms” OR “Delivery Room” OR “Hospital Birthing Centers” OR “Hospital Birthing Center” OR “Hospital Birth Center” OR “Hospital Birth Centers” OR “Hospital Birthing Center” OR “delivery unit” OR labour OR labor OR “delivery ward” OR “delivery wards”)) AND (TITLE-ABS (“maternity care” OR “Health Care Quality” OR “Quality of Healthcare” OR “Healthcare Quality” OR “Quality of Care” OR “Care Quality” OR “Quality of Health Care” OR “quality of midwifery care” OR “quality midwifery care” OR “midwifery care” OR “quality of maternity care” OR “Antenatal Care”)) AND (TITLE-ABS (midwives OR “nurse midwifery” OR “nurse midwives” OR midwife OR “maternal-child nursing” OR maternity OR obstetrics OR obstetric OR “Maternal Child” OR nursing OR “Maternity Nursing” OR “Neonatal Nursing” OR “Prenatal Nursing” OR “Nurse-Midwife” OR “Nurse Midwife” OR antenatal).

Appendix S4. Search strategy Web of Science

TOPIC: (Midwives OR Midwive OR “nurse midwifery” OR “nurse midwives” OR Midwife OR “maternal-child nursing” OR maternity OR Obstetrics OR Obstetric OR “Maternal Child” OR nursing OR “Maternity Nursing” OR “Neonatal Nursing” OR “Prenatal Nursing” OR “Nurse-Midwife” OR “Nurse Midwife” OR antenatal) AND TOPIC: (“maternity care” OR “Health Care Quality” OR “Quality of Healthcare” OR “Healthcare Quality” OR “Quality of Care” OR “Care Quality” OR “Quality of Health Care” OR “quality of midwifery care” OR “quality midwifery care” OR “midwifery care” OR “quality of maternity care” OR “Antenatal Care”) AND TOPIC: (“Obstetric Labor” OR “Obstetric Deliveries” OR “Obstetric Delivery” OR “Delivery Rooms” OR “Delivery Room” OR “Hospital Birthing Centers” OR “Hospital Birthing Center” OR “Hospital Birth Center” OR “Hospital Birth Centers” OR “Hospital Birthing Center” OR “delivery unit” OR labour OR labor OR “delivery ward” OR “delivery wards”)



 
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