Midwifery 31 (2015) 512–518
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Antenatal telephone support intervention and uterine artery Doppler screening: A qualitative exploration of women's views Vikki J. Snaith, BSc, RM, MSc, PhD (Senior Research Midwife/Sonographer)a,n, Stephen C. Robson, MD, MRCOG, MBBS (Professor of Fetal Medicine)c, Jenny Hewison, BA (Hons), MSc, PhD (Professor of the Psychology of Healthcare and Faculty Lead for Health Services Research)b a b c
Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne, UK Leeds Institute of Health Sciences, University of Leeds, Clarendon Road, Leeds, UK Institute of Cellular Medicine, Uterine Cell Signalling Group, Newcastle University, William Leech Building, The Medical School, Newcastle upon Tyne, UK
art ic l e i nf o
a b s t r a c t
Article history: Received 6 August 2014 Received in revised form 7 January 2015 Accepted 12 January 2015
Objectives: to gain insight into low risk nulliparous women's experiences of a telephone support intervention (TSI) and TSI with uterine artery Doppler screening (UADS) intervention and their views of the structure of current antenatal care provision. Design: postnatal semi-structured interviews were analysed using a thematic framework approach. The interviews formed a subset of data from a mixed methods study. Setting and participants: participants were 45 low risk nulliparous women who had consented to take part in a randomised controlled trial of two antenatal support interventions; the trial was conducted at a large maternity unit in the North East of England, UK from 2004 to 2007. Findings: most of the women in the study expressed positive views about the telephone support intervention (TSI) and the antenatal care they had received. Uterine artery Doppler screening was acceptable to women but did not feature highly when women recalled their antenatal experiences. Those who viewed their pregnancy as complicated by medical, social or emotional difficulties would have preferred more frequent antenatal visits. Views of antenatal care provision were influenced by women's perception of their pregnancy progression and the relationship developed with their midwife. Key conclusions and implications for practice: although the TSI was viewed positively by women, it was valued most by those who required additional support. The intervention was not a substitute for face to face midwifery visits. Future research is needed to investigate the potential of utilising telephone contact to provide antenatal care for women who have pregnancies complicated by physical, psychological or emotional issues. The findings were consistent with previous evidence to show that the relationship between women and midwives is fundamental to women's experience of antenatal care. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Pregnancy Antenatal Telephone Support Doppler Midwives
Introduction Low risk nulliparous women had been offered the same number of antenatal visits for decades, until a substantial review of antenatal guidelines in England and Wales in 2003. As a result, the number of antenatal visits offered was reduced from 10 to seven visits after 20 weeks gestation. The reduction in the number of routine antenatal visits was implemented in response to a systematic review of seven trials to address the impact of reduced antenatal visit schedules. The review concluded that the recommended n Corresponding author at : Research Midwives Office, 6th floor Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NE 4LP. Tel.: (0191) 2228239. E-mail addresses: [email protected] (V.J. Snaith), [email protected] (S.C. Robson), [email protected] (J. Hewison).
http://dx.doi.org/10.1016/j.midw.2015.01.007 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
antenatal visit schedule for low risk women could be reduced without any adverse impact on maternal and perinatal outcomes (Dowswell et al., 2010) but this may affect women's satisfaction with care (Sikorski et al., 1996). The guidelines identified the need for further research to investigate alternative methods of providing women with information and support during pregnancy (National Collaborating Centre for Women's and Children's Health, 2008). In response to these findings, a mixed methods study was designed incorporating a randomised controlled trial (RCT) and semi-structured interviews to test the hypotheses that provision of a telephone support intervention, with or without supplemental uterine artery Doppler screening (UADS) at 20 weeks of pregnancy, would reduce the total number of antenatal visits (routine plus additional visits), reduce anxiety and increase social support and satisfaction with antenatal care when compared with usual antenatal care (National Collaborating
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Centre for Women's and Children's Health, 2008). UADS provides the opportunity to screen low risk nulliparous women for the major causes of maternal and fetal morbidity. For women, the knowledge that they have a reduced chance of developing these complications could provide reassurance during pregnancy, although being deemed at high risk has the potential to increase levels of anxiety (Cnossen et al., 2008). It was recognised that although the RCT design offered the best option for assessing the effectiveness of the interventions, the use of qualitative semi-structured interviews would provide valuable information regarding contextual factors that might impact on the implementation of the interventions and women's experiences of receiving the TSI and UADS interventions. The interview schedule was designed to explore women's perceptions of antenatal care and identify which aspects of care they valued or felt could be improved. This paper will focus on the analysis and discussion of 45 semi-structured interviews carried out with a purposive subsample of study participants. A detailed overview of trial methods and results has been previously published (Snaith et al., 2014). Ethical approval was obtained from the Joint Ethics Committee of the Newcastle and North Tyneside Health (ref. no: 2003/208).
Methods Low risk nulliparous women were approached for recruitment between February 2004 and January 2007 when attending the hospital for their 20 week fetal anomaly scan. Recruitment was undertaken by a team of four research midwives, none of whom were involved in the provision of clinical care to the participants. Nulliparous women were suitable for inclusion if they met the definition of low risk as defined by the NICE guidelines (National Collaborating Centre for Women's and Children's Health, 2003).
Sample In total, 840 women took part in the trial and consented to be contacted postnatally to discuss whether they would take part in an interview. Women who were unable to speak English and those planning to move from the area during their pregnancy were excluded from the study. Teenage women who were receiving support from the hospital-based teenage pregnancy support team were also excluded.
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A subsample of 15 women from each trial group were purposively selected on the basis of their trial group, age, highest educational level and ethnic origin (Table 1). It was necessary to determine the sample size prior to commencement of the study; the sample size was chosen in a bid to provide a diverse sample of women while being pragmatic about the time constraints involved. To achieve the subsample required, 61 participants were contacted by telephone at around six weeks post partum to ask if they were willing to be interviewed, 16 women declined and 45 women consented to be interviewed. The women in the intervention groups had all received the telephone intervention, although some women were not successfully contacted at all three time points. One woman in each of the intervention groups received one call, in the telephone support group (T) 10 women received all three calls and four women were contacted on two occasions. In the telephone support and Doppler (T þD) group, nine women received three calls and five women were contacted twice; all of the interviewed participants had received UADS. Interventions Women randomised to the control group (C) received standard antenatal care (National Collaborating Centre for Women's and Children's Health, 2003). Women randomised to the telephone support group (T) received the TSI at 29, 33 and 37 weeks gestation in addition to usual care. A maximum of two attempts were made to contact women by telephone at each time point. A telephone discussion guide was utilised to ensure a consistent approach to the intervention calls, whilst maintaining flexibility in the discussion to make sure that it addressed individual's needs. The TSI was delivered by a midwife who had previous experience of providing advice and support via the telephone and had received training specific to the study. Women in the telephone support and Doppler (T þ D) group had UADS performed during the routine 20 week anomaly scan and the TSI as previously described. Participants with normal UADS (mean pulsatility index (PI) below 1.45 and unilateral/no diastolic notching of the waveform) received verbal and written information about their reduced risk of developing pre-eclampsia and delivering a small-for-gestational-age baby. Women who were screen positive were offered a repeat scan at 24 weeks gestation, if there was persistent raised PI and/or bilateral notching, a fetal growth scan was performed at 32 weeks (Snaith et al., 2014). Data collection
Table 1 Demographic characteristics of women interviewed. Group C n ¼ 15
T n ¼ 15
Tþ D n ¼15
Age at time of interview (years)
16–19 20–25 26–30 31–36 37–40
0 3 2 10 0
1 6 5 3 0
1 1 4 7 2
Highest educational attainment
GCSE A level Degree Higher degree
6 3 5 1
7 4 4 0
6 6 2 1
Ethnic origin
White British Indian Pakistani White-Czech
13 1 1 0
14 0 0 1
14 0 1 0
C ¼Control; T¼ Telephone intervention; T þ D¼ Telephone þDoppler intervention.
An interview topic guide was developed to ensure consistency in the way the interviews were conducted. It incorporated questions to explore women's expectations and experiences of antenatal care provision including their views of the quantity of visits they received, the content of antenatal visits, the location and timing of visits, antenatal classes, potential improvements to care, support networks available and their experiences of the study interventions. Face-to-face, semi-structured interviews were undertaken in participants' own homes at 8–10 weeks post-childbirth. The interviews were conducted with only the interviewer and participant present. The discussion was digitally recorded and written notes were made by the interviewer to facilitate analysis of the data. The duration of the interviews ranged from 20 to 90 minutes with the average interview lasting 60 minutes. All of the interviews were digitally recorded and transcribed verbatim. Transcripts were not returned to participants for comment because it was felt that it would make additional demands on participants' time. It was accepted that the interviewer's background as a midwife and sonographer might impact on both the interview process and
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the inferences made as a result. In order to minimise the impact on the interviewees, the researcher discussed her professional background prior to commencing the interview and explained to the participant that she was not employed by the NHS trust at that time and any information provided would be treated confidentially and would not affect their care in any way. The interviewer had not been involved in the provision of clinical care to the women who were interviewed.
Data analysis The interview data was analysed by the primary author using a thematic framework approach. The methodology was selected because of its appropriateness for the mixed methods design of the study. It facilitated the inclusion of a priori themes which were required for the purposes of this study to ensure that women's views of the interventions were explored, as well as the identification and inclusion of emerging concepts (Ritchie and Spencer, 1994; Pope et al., 2000). All of the interviews and coding were undertaken by the primary author, which resulted in familiarisation with the data at the time of data collection. In order to enhance this process further, each of the transcripts were read in full and notes made on emerging concepts and themes. The thematic framework was initially constructed using the a priori themes which formed the interview topic guide. The analysis was supported by the use of NVivo software. As the familiarisation process was undertaken the following emerging themes were incorporated into the framework: personality of midwife; the importance of an individualised approach to antenatal care; normalising of the pregnancy experience; acknowledgement of pregnancy as a significant event and the impact of ultrasound examinations during pregnancy. The data was examined using the thematic framework and indexing was done by making notes on the interview transcripts. This part of the process allowed the construction of the first stage charts where sections of text were copied from the transcripts and inserted under broad theme headings. This made viewing of the relevant text more straightforward due to the relatively large number of interviews included in the analysis. The charting stage of the analysis was achieved by the creation of individual charts for each broad theme. The themes were then further defined by being broken down into a number of subheadings. For each theme subheading the interpretation of the data was achieved by the identification of commonalities between participants' responses and themes that emerged in order to appreciate the range of women's experiences. The themes were examined across the trial groups and different age and educational level groupings to determine whether these factors had an influence on women's experiences. No new ideas emerged during the final interviews suggesting that saturation was achieved.
Findings Seven major themes were identified relating to women's experiences of the antenatal care they received and how they perceived the research interventions. The women in all three trial groups who participated in the interviews expressed similar views about their experiences of antenatal care therefore the analysis is presented for the whole sample rather than as a comparison of groups. The findings relating to the study interventions are derived from interviews with women who were in the specific intervention groups. Participants were not asked to provide feedback on the findings.
Quantity of antenatal visits During the course of the interviews, women were asked how they felt about the quantity of visits offered and most women stated that they were content with the number of visits they had received. A third of the women interviewed stated that they had received fewer antenatal visits than they anticipated and there were times during their pregnancies when they would have preferred to see their midwife more often: Probably a few more (visits) because I was a bit confused to be honest. I was kind of the opinion that once you got, later on, that it was every week you are seeing the Midwife, it was every 2 or 3 weeks, that I seen her, and obviously the nerves start kicking in and things like that, because of the time and making sure he is alright and whatever, and I would have been maybe a bit better if I had been able to go every week. Telephone intervention group: Participant 9 Women who would have preferred more antenatal visits were more likely to describe their relationship with the midwife as suboptimal compared to those women who were content with the number of visits. Women's perceptions of how their pregnancy was progressing also impacted on their view of the appropriateness of the quantity of visits received. Those who described their pregnancy as being complicated by physical, psychological and emotional issues with or without additional social challenges stated that they would have preferred more visits with their midwife: .. the last couple of weeks I thought I could have done with a couple more because she said to go every fortnight and I really wanted, I was, my greatest concern was the problems of having the symphysis pain around would have caused during labour, because I wanted to have a natural birth. Telephone intervention group: Participant 13
Content and organisation of antenatal visits Women's views were sought regarding the content of visits and it was evident that the focus of visits varied, with some women describing consultations that focussed solely on physical aspects of health whilst other midwives incorporated discussions about emotional well-being and the provision of support: She gave me lots of advice and sort of websites and stuff for where I should be legally with work and things so no she was very good like that, you know she was very informative. Control group: Participant 1 Women who had not experienced any specific difficulties during their pregnancy were content with care that focussed on the monitoring of their physical health and well-being of the fetus. Women who had experienced emotional or physical challenges expressed a preference for their care to incorporate additional support and reassurance from midwives. The way in which routine antenatal visits are delivered did vary but for most women there was little flexibility in the day and time of day that visits were available. Overall, most women were happy with the way in which their antenatal visits were organised: There wasn't really much room for any discussion or anything, they did Mondays between nine and half past ten, and that was it. Control group: Participant 9
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Relationship with community midwife It was apparent from the analysis of data that women's perception of their antenatal care was significantly influenced by their relationship with their community midwife or midwives. It was clear that this relationship held great significance for many women. The data highlighted a number of concepts relating to the success of the woman/ midwife relationship including the personal characteristics of the midwife, how effective the midwife was at normalising the pregnancy experience, timely and appropriate information provision, an individualised approach, continuity of midwifery care and an acknowledgement of the pregnancy as a significant event. Women who had developed a positive relationship with their midwife used terms that emphasised the desirable characteristics of approachability, being of a pleasant disposition and easy to talk to. Some women felt that being able to identify with the midwife as an individual enhanced the relationship: She was like myself, she reminded us you know……very approachable but giggly and nice you know you could chat to her about anything and she wouldn't use like medical words she'd use words that you'd understood. Control group: Participant 2 The minority of women in the interview sample who had a poor relationship with their midwife described the negative impact that it had on their perceptions of antenatal care provision. They depicted their midwives as being unhelpful, difficult to talk to and dismissive of their concerns. There was a clear interaction between whether women felt there were time constraints on visits, their satisfaction with the quantity of visits and how confident they felt about asking the midwife questions: She wasn't very helpful shall I say as far as being a first time mum obviously you don't know what to expect. Like a lot of the time she just made you feel a bit stupid or feel in some way or asking is this normal, she wasn't ideal. She's not somebody I really liked to speak to… you could be waiting, you had your appointment, you'd be waiting half an hour. And then when you finally got in it was like she was trying to rush you back out again. So had no time really talk to you, chat to you. Telephone and Doppler group: Participant 10 Women valued midwives who familiarised themselves with their notes and found it frustrating to have to repeat themselves to different staff members. This was often compounded by seeing a number of different midwives over the duration of the pregnancy. An individualised approach to care was greatly appreciated and the relationship was further enhanced when midwives made an effort to get to know women: I felt like I was explaining myself over and over again. And they said ‘hang on, I'll just read through your notes.’ And then you have to sit there while they read through your notes. Control group: Participant 9 A proportion of women felt it was important that their pregnancy was acknowledged as a significant life event. From the perspective of some women, the number of antenatal visits offered was correlated with how much their pregnancy was valued by health professionals with some women describing a lack of visits as an indication that the importance of their pregnancy was not acknowledged: I think it's just nice it would have been nice I think specifically the first pregnancy, somebody just to sort of acknowledge you're pregnant and ask Are you excited? Are you scared? You know, how are things going?
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Like that but from the moment you are booked, to the first check-up I think it was sixteen weeks or something. Control group: Participant 1. Antenatal classes and preparation for the postnatal period Women's views of antenatal classes were determined by how the classes were presented and the relevance of the information provided. Sessions that were described positively were led by midwives who exhibited enthusiasm and were viewed as friendly and well prepared. Classes that were less successful were depicted as being poorly designed and women felt that the level and presentation of information was inappropriate for their needs: The lady was fantastic. She was so informative and really upbeat about it all and by that point you're quite pregnant and you think ‘I'm going to have push this baby out’ and I was beginning to get a bit nervous about it…Telephone and Doppler group: Participant 1 I'm not being horrible or anything but I thought it was boring I was nearly falling asleep because they were showing you this video and I think it was before I was born this video what was on…. I was thinking you need to get something up to date. Control group: Participant 8 Women described the need to feel that they had something in common with the other women/couples in the group. It was apparent that the success of the group dynamics had a significant effect on the overall experience of antenatal education. A positive aspect of a class with strong group cohesion was the opportunity for women to socialise with others who were at a similar stage of pregnancy, and some women valued this aspect of the classes, above the opportunity to gain information: There was a huge variation in age you know there were loads of 16 year olds right up to I was the oldest at 34 and that makes you feel really rubbish when your 34… that may well have been why I was embarrassed to ask questions at the antenatal. Control group: Participant 6 The focus of the antenatal classes was appropriate for most women, but for some there was a lack of information on how they would feel after they had given birth and advice on how to care for their new baby. This was compounded by the perception that there were too few visits postnatally and in some cases a suboptimal relationship with the midwife. Most women viewed classes as an important component of antenatal care; those whose expectations were not fulfilled by the experience were left frustrated by their inability to obtain the information they required to face the challenges ahead: They showed me how to bath him and that's been fine, but just things like I didn't know how often he should be feeding, I didn't know how often I should be changing him. You know, how often should he be sleeping? Should I wake him to feed him? Should I wait until he wakes? I just didn't know. Telephone group: Participant 5 They didn't actually tell us anything about how I was going to feel once I had the baby……I just felt really emotional and that why isn't everything falling into place so I just felt like that a lot. Control group: Participant 14 Telephone support intervention Women in the two intervention groups of the trial were specifically asked their views of the TSI. The majority of women viewed the intervention as a positive addition to their care. There was no negative feedback about the TSI with only two women
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feeling that the intervention did not enhance the care that they were already receiving from their community midwife. Both of these women described their pregnancies as being uncomplicated and as a result they had few concerns or worries. Women who thought the intervention was useful discussed the benefit of having someone who was interested in how they felt and the opportunity to chat about their pregnancy experience: It's always nice thing when people ask when you're pregnant, when people ask how are you, is everything alright, just in case there is something, you just think ‘oh, well actually’. So it was nice just to get another phone call, like ‘do you have any other problems?’ So that was nice just to know there was somebody there. Telephone and Doppler group: Participant 3. Women who valued the proactive nature of the intervention discussed how they wouldn't have initiated contact with health professionals to ask ‘trivial questions’ and found it beneficial to be contacted as a part of the study TSI. Some women suggested an alternative type of TSI, stating that they would have liked have been offered a dedicated telephone line to contact a midwife antenatally in addition to the proactive calls. One woman said she would have benefitted from telephone calls during the postnatal period: Like I say it's down to personality type I'm definitely the kind of person who could do with the odd phone call just to say how are you getting on you know rather than relying on me to phone up and go look, I'm having a problem. Telephone and Doppler: Participant 4. When asked if they would choose to have the telephone support intervention if pregnant again, the majority of women interviewed said that they felt it would be a useful addition to their antenatal care and they would value its inclusion. Two women in each group felt that they would not require an additional support intervention in a subsequent pregnancy because they would have fewer concerns.
Women's views about UADS were only elicited when they were asked directly during the course of the interviews, suggesting that although women described the intervention in positive terms, it did not seem to feature highly in their recall of events relating to their antenatal care. Uterine artery Doppler screening seems to have little detrimental effect on women's experience of pregnancy but the reassuring effect of this screening method varied between women. Impact of ultrasound scans The women interviewed described the reassuring value of ultrasound scans during pregnancy and the visualisation of the baby to be a positive experience: It was like it was still me getting fat rather than there being somebody growing inside me and when you see the scan you see like somebody moving around, little heartbeats and little spines and, oh wow. I think it was really important actually and I think it probably makes you look after yourself as well because you think you've got to look after somebody else too. Telephone and Doppler group: Participant: 1 Some women felt that the gap between their anomaly scan at around 20 weeks gestation and giving birth was too long and that they would have welcomed the inclusion of an ultrasound scan later in the pregnancy to reassure them that things were progressing normally. When asked if there was anything they felt was lacking in their antenatal care provision, the most frequent suggestion from participants was for an extra ultrasound scan during the third trimester: It's an awful long time to go because you go on virtually half your pregnancy without checking that everything's alright. I mean I know I could feel the baby moving but just that extra reassurance. Telephone group: Participant 5
Uterine artery Doppler screening
Discussion
None of the women interviewed expressed any concerns about the experience of having UADS performed and most said they would welcome any test that has the potential to provide reassurance in relation to the well-being of the baby:
This study was designed to evaluate interventions designed to provide low risk nulliparous women with additional support and reassurance during pregnancy, following the implementation guidelines recommending a reduction in the number of routine antenatal visits (National Collaborating Centre for Women's and Children's Health, 2008). The support interventions implemented did not affect the mean total number of antenatal visits that women required and there was no difference between the trial groups for any of the psychological outcomes measured (Snaith et al., 2014). The analysis and discussion of the interview data has provided an improved understanding of why the trial had a negative outcome and the factors that are most salient to women in relation to antenatal care provision. Limitations of the study include the length of time that has elapsed since the data was collected, although there have been no significant changes in the provision of antenatal care to low risk women since that time. The sample of women interviewed were predominantly White British, which does raise questions about the generalisability of the findings to other populations. The timing of the interviews (8–10 weeks postnatally) may also have affected women's perception and recall of antenatal events. Although women discussed the trial interventions in positive terms, it is clear that the interventions were not a substitute for face-to-face contacts. Data from the trial showed that the majority of non-scheduled visits were required because of pregnancy complications, with reduced fetal movements and raised blood pressure being the most common (Snaith et al., 2014). These
It was reassuring in a way knowing that the blood supply and all that was getting into the placenta okay. That made you feel a bit better because you know sometimes you think to yourself, because you read up on placentas not being healthy placentas and not having enough and that's how this has happened to the baby and whatever. Telephone and Doppler group: Participant 10 I think it's quite important to do probably anything, I mean, god, I'll do anything that helps or anything that's going to be better for the baby’. Telephone and Doppler group: Participant 15 One woman who had received a risk positive result at 20 weeks discussed how she had been anxious until her scan at 24 weeks when the uterine artery Doppler waveform was found to be normal. Another participant whose uterine artery Doppler screening result was normal, expressed how she was surprised when she developed PE in the latter part of her pregnancy but still thought the intervention was worth having: I had one of those extra scans, the Doppler and they said it was unlikely that I would ever get pre-eclampsia, but I did, so I was surprised. I mean it was still worth it because it was to see if the blood was getting to the placenta and everything, so it was still worth having. Telephone and Doppler group: Participant 6
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findings demonstrate that a significant proportion of additional visits are unlikely to be substituted for, by the introduction of a support intervention. Telephone contact provided some women with the feeling of being ‘looked after’ and they valued the recognition by health professionals that their pregnancy was a significant event. These findings are consistent with a previous study focussing on women's experiences of antenatal care (Bondas, 2002) and also a finding of a proactive postnatal support intervention (Fenwick et al., 2013). Women valued the TSI because it gave them the opportunity to discuss issues that caused them concern but they thought may be considered trivial by health-care professionals. It emerged that some women felt they would have liked an antenatal telephone helpline or access to a postnatal telephone support intervention. The findings provide reassuring evidence that most women who took part in interviews felt their needs were met by routine antenatal care. It was evident that women's experiences were predominantly determined by the quality of the relationship with their midwife and their own perception of the progression of their pregnancy. Women who described experiencing pregnancy complaints and complications, psychological difficulties such as anxiety, worry and depression and/or social challenges, were more likely to express a preference for more antenatal visits, this is consistent with previous research findings (Clement et al., 1996). The results of this study reiterate previous research findings showing that successful interactions between women and midwives are a fundamental determinant of the perception of care (Proctor, 1998; Walsh, 1999; Hildingsson et al., 2002; Hunter, 2006). The analysis showed that midwives exhibiting an approachable disposition and an engaging and enthusiastic communication style were viewed positively by women, which is in keeping with previous research findings (Seefat-van Teeffelen et al., 2011). Women who perceive the relationship with their midwife negatively may have less confidence in the midwife's ability to provide good quality care, which could result in the need for reassurance in the form of additional visits. Although the inclusion of uterine artery Doppler screening in antenatal care appeared to be well received by women, it was not mentioned spontaneously during interviews, possibly because the intervention was viewed as an integral part of their anomaly scan. When asked about their experience of receiving UADS, women did not have any concerns about having the additional ultrasound measurement performed and had not experienced any discomfort during the ultrasound examination. It was evident that most women valued the opportunity for additional information relating to the progression of the pregnancy and fetal well-being. The possible negative psychological consequences of introducing screening in a low risk population cannot be ignored and there was some evidence that women who had abnormal uterine artery Doppler waveforms were anxious as a result or misunderstood the predictive power of the test. This demonstrates the importance of ensuring that risk information is provided in a way that is easy for women to understand (Zechmeister, 2001; Green et al., 2004), particularly when the screening test is relatively new or has not been used in a low risk pregnant population. Women discussed the reassuring value of ultrasound scans at all stages of pregnancy. When asked if they would like to change anything about the care they received, the most frequent response was to state that they would have liked additional ultrasound examinations in the second and third trimester, this was also a finding of a previous study (Goberna-Tricas et al., 2011). Although it is clear that some women would welcome more ultrasound scans or antenatal visits, current evidence suggests that neither of these interventions would confer any clinical benefits to low risk women. Indeed, some authors suggest that increased antenatal surveillance
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results in unnecessary medicalisation of pregnancy and an over reliance on technology by pregnant women (Zechmeister, 2001; Jordan and Aikins Murphy, 2009).
Implications for practice Although most women valued the interventions as an extra component of their antenatal care, the intervention packages did not have an impact on women's requirement for face-to-face midwifery visits. The telephone contact was most valued by women who felt that they were not receiving adequate support from their community midwife. There is no evidence to suggest that the implementation of the interventions resulted in changes in care utilisation or substantially affected women's experience of antenatal care. There were significant challenges in implementing the telephone support intervention in its entirety, which raises questions about the feasibility of successfully implementing a TSI into routine antenatal care provision. The findings were consistent with previous evidence to show that the relationship between women and midwives is the most fundamental determinant of women's evaluation of antenatal care. It is evident that further research is needed to determine strategies to optimise midwives' relationships with women, by identifying the barriers to effective communication and providing midwives' with appropriate skills and resources. Alternative methods of contacting women other than face-toface visits offer health-care providers with opportunities to redirect resource use while providing the flexible care that women value. Future research is needed to investigate the use of innovative antenatal care provision by appropriately utilising new technologies, considering alternative care settings and organising care with the aim of providing a service that is responsive, progressive and woman-centred. The economic impact of utilising different technologies should be thoroughly evaluated.
Conclusion Although viewed positively, for most women the study interventions were much less influential on their evaluation of antenatal care than their own perception of the pregnancy event and the effect of having a positive relationship with a midwife. The findings of this study do not support the implementation of a telephone support intervention into routine antenatal care provision for low risk women.
Conflict of interest There are no conflicts of interest.
Details of ethics approval Ethical approval was obtained from the Joint Ethics Committee of the Newcastle and North Tyneside Health (ref no: 2003/208).
Funding Vikki J. Snaith was funded by a National Institute for Health Research, Nursing and Allied Health Professional Researcher Development award. This article/paper/report presents independent research funded by the National Institute for Health Research (NIHR). The views
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expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Acknowledgements The authors would like to thank all of the women who took part in the study and the ultrasonographers, midwives and clerical staff from antenatal clinic and antenatal ultrasound department who supported the study at The Newcastle upon Tyne Hospitals NHS Foundation Trust. Special thanks to Catherine McParlin who provided the telephone support intervention. References Bondas, T., 2002. Finnish women's experiences of antenatal care. Midwifery 18, 61–71. Clement, S., Sikorski, J., Wilson, J., Das, S., Smeeton, N., 1996. Women's satisfaction with traditional and reduced antenatal visit schedules. Midwifery 12, 120–128. Cnossen, J.S., Morris, R.K., Gerben ter Riet, B.W.J., et al., 2008. Use of uterine artery Doppler ultrasonography to predict pre-eclampsia and intrauterine growth restriction: a systematic review and bivariable meta-analysis. CMAJ 178, 701–711. Dowswell, T., Carroli, G., Duley, L., et al., 2010. Alternative versus standard packages of antenatal care for low risk pregnancy. Cochrane Database Syst. Rev (10). Fenwick, J., Gamble, J., Creedy, D., Barclay, L., Buist, A., Ryding, E., 2013. Women's perceptions of emotional support following childbirth: a qualitative investigation. Midwifery 29, 217–224. Goberna-Tricas, J., Banus-Gimenez, R., Palacio-Tauste, A., Linares-Sancho, S., 2011. 'Satisfaction with pregnancy and birth services: the quality of maternity care services as expereinced by women'. Midwifery 27, e231–e237. Green, J.M., Hewison, J., Bekker, H.L., Bryant, L.D., Cuckle, H.S., 2004. Psychosocial aspects of genetic screening of pregnant women and newborns: a systematic review. Health Technol. Assess. 8 (33).
Hildingsson, I., Waldenstrom, U., Radestad, I., 2002. Women's expectations on antenatal care as assessed in early pregnancy: number of visits, continuity of caregiver and general content. Acta Obstet. Gynecol. Scand. 81, 118–125. Hunter, B., 2006. The importance of reciprocity in relationships between community-based midwives and mothers. Midwifery 22, 308–322. Jordan, R., Aikins Murphy, P., 2009. Risk assessment and risk distortion: finding the balance. J. Midwifery Women's Health 54, 191–200. National Collaborating Centre for Women's and Children's Health, 2003. Antenatal Care: Routine Care for the Healthy Pregnant Woman. RCOG Press, London. National Collaborating Centre for Women's and Children's Health, 2008. Antenatal Care: Routine Care for the Healthy Pregnant Woman (CG62). RCOG Press, London. Pope, C., Ziebland, S., Mays, N., 2000. Analysing qualitative data. Br. Med. J. 320, 114–116. Proctor, S., 1998. What determines quality in maternity care? Comparing the perceptions of childbearing women and midwives. Birth 25, 85–93. Ritchie, J., Spencer, K., 1994. Qualitative data analysis for applied policy research. In: Bryman, R., Burgess, R. (Eds.), Analyzing Qualitative Data. Routledge, Abingdon, pp. 173–195. Seefat-van Teeffelen, A., Nieuwenhuijze, M., Korstjens, I., 2011. Women want proactive psychosocial support from midwives during transition to motherhood: a qualitative study. Midwifery 27, e123–e127. Sikorski, J., Wilson, J., Clement, S., Das, S., Smeeton, N., 1996. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. Br. Med. J. 312, 546–553. Snaith, V., Hewison, J., Steen, I., Robson, S., 2014. Antenatal telephone support intervention with and without uterine artery Doppler screening for low risk nulliparous women: a randomised controlled trial. BMC Pregnancy Childbirth 14, 121. Walsh, D., 1999. An ethnographic study of women's experience of partnership caseload midwifery practice: the professional as a friend. Midwifery 15, 165–176. Zechmeister, I., 2001. Foetal images: the power of visual technology in antenatal care and the implications for women's reproductive freedom. Health Care Anal. 9, 387–400.
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Antenatal telephone support intervention and uterine artery Doppler screening: A qualitative exploration of women's views Vikki J. Snaith, BSc, RM, MSc, PhD (Senior Research Midwife/Sonographer)a,n, Stephen C. Robson, MD, MRCOG, MBBS (Professor of Fetal Medicine)c, Jenny Hewison, BA (Hons), MSc, PhD (Professor of the Psychology of Healthcare and Faculty Lead for Health Services Research)b a b c
Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne, UK Leeds Institute of Health Sciences, University of Leeds, Clarendon Road, Leeds, UK Institute of Cellular Medicine, Uterine Cell Signalling Group, Newcastle University, William Leech Building, The Medical School, Newcastle upon Tyne, UK
art ic l e i nf o
a b s t r a c t
Article history: Received 6 August 2014 Received in revised form 7 January 2015 Accepted 12 January 2015
Objectives: to gain insight into low risk nulliparous women's experiences of a telephone support intervention (TSI) and TSI with uterine artery Doppler screening (UADS) intervention and their views of the structure of current antenatal care provision. Design: postnatal semi-structured interviews were analysed using a thematic framework approach. The interviews formed a subset of data from a mixed methods study. Setting and participants: participants were 45 low risk nulliparous women who had consented to take part in a randomised controlled trial of two antenatal support interventions; the trial was conducted at a large maternity unit in the North East of England, UK from 2004 to 2007. Findings: most of the women in the study expressed positive views about the telephone support intervention (TSI) and the antenatal care they had received. Uterine artery Doppler screening was acceptable to women but did not feature highly when women recalled their antenatal experiences. Those who viewed their pregnancy as complicated by medical, social or emotional difficulties would have preferred more frequent antenatal visits. Views of antenatal care provision were influenced by women's perception of their pregnancy progression and the relationship developed with their midwife. Key conclusions and implications for practice: although the TSI was viewed positively by women, it was valued most by those who required additional support. The intervention was not a substitute for face to face midwifery visits. Future research is needed to investigate the potential of utilising telephone contact to provide antenatal care for women who have pregnancies complicated by physical, psychological or emotional issues. The findings were consistent with previous evidence to show that the relationship between women and midwives is fundamental to women's experience of antenatal care. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Pregnancy Antenatal Telephone Support Doppler Midwives
Introduction Low risk nulliparous women had been offered the same number of antenatal visits for decades, until a substantial review of antenatal guidelines in England and Wales in 2003. As a result, the number of antenatal visits offered was reduced from 10 to seven visits after 20 weeks gestation. The reduction in the number of routine antenatal visits was implemented in response to a systematic review of seven trials to address the impact of reduced antenatal visit schedules. The review concluded that the recommended n Corresponding author at : Research Midwives Office, 6th floor Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NE 4LP. Tel.: (0191) 2228239. E-mail addresses: [email protected] (V.J. Snaith), [email protected] (S.C. Robson), [email protected] (J. Hewison).
http://dx.doi.org/10.1016/j.midw.2015.01.007 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
antenatal visit schedule for low risk women could be reduced without any adverse impact on maternal and perinatal outcomes (Dowswell et al., 2010) but this may affect women's satisfaction with care (Sikorski et al., 1996). The guidelines identified the need for further research to investigate alternative methods of providing women with information and support during pregnancy (National Collaborating Centre for Women's and Children's Health, 2008). In response to these findings, a mixed methods study was designed incorporating a randomised controlled trial (RCT) and semi-structured interviews to test the hypotheses that provision of a telephone support intervention, with or without supplemental uterine artery Doppler screening (UADS) at 20 weeks of pregnancy, would reduce the total number of antenatal visits (routine plus additional visits), reduce anxiety and increase social support and satisfaction with antenatal care when compared with usual antenatal care (National Collaborating
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Centre for Women's and Children's Health, 2008). UADS provides the opportunity to screen low risk nulliparous women for the major causes of maternal and fetal morbidity. For women, the knowledge that they have a reduced chance of developing these complications could provide reassurance during pregnancy, although being deemed at high risk has the potential to increase levels of anxiety (Cnossen et al., 2008). It was recognised that although the RCT design offered the best option for assessing the effectiveness of the interventions, the use of qualitative semi-structured interviews would provide valuable information regarding contextual factors that might impact on the implementation of the interventions and women's experiences of receiving the TSI and UADS interventions. The interview schedule was designed to explore women's perceptions of antenatal care and identify which aspects of care they valued or felt could be improved. This paper will focus on the analysis and discussion of 45 semi-structured interviews carried out with a purposive subsample of study participants. A detailed overview of trial methods and results has been previously published (Snaith et al., 2014). Ethical approval was obtained from the Joint Ethics Committee of the Newcastle and North Tyneside Health (ref. no: 2003/208).
Methods Low risk nulliparous women were approached for recruitment between February 2004 and January 2007 when attending the hospital for their 20 week fetal anomaly scan. Recruitment was undertaken by a team of four research midwives, none of whom were involved in the provision of clinical care to the participants. Nulliparous women were suitable for inclusion if they met the definition of low risk as defined by the NICE guidelines (National Collaborating Centre for Women's and Children's Health, 2003).
Sample In total, 840 women took part in the trial and consented to be contacted postnatally to discuss whether they would take part in an interview. Women who were unable to speak English and those planning to move from the area during their pregnancy were excluded from the study. Teenage women who were receiving support from the hospital-based teenage pregnancy support team were also excluded.
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A subsample of 15 women from each trial group were purposively selected on the basis of their trial group, age, highest educational level and ethnic origin (Table 1). It was necessary to determine the sample size prior to commencement of the study; the sample size was chosen in a bid to provide a diverse sample of women while being pragmatic about the time constraints involved. To achieve the subsample required, 61 participants were contacted by telephone at around six weeks post partum to ask if they were willing to be interviewed, 16 women declined and 45 women consented to be interviewed. The women in the intervention groups had all received the telephone intervention, although some women were not successfully contacted at all three time points. One woman in each of the intervention groups received one call, in the telephone support group (T) 10 women received all three calls and four women were contacted on two occasions. In the telephone support and Doppler (T þD) group, nine women received three calls and five women were contacted twice; all of the interviewed participants had received UADS. Interventions Women randomised to the control group (C) received standard antenatal care (National Collaborating Centre for Women's and Children's Health, 2003). Women randomised to the telephone support group (T) received the TSI at 29, 33 and 37 weeks gestation in addition to usual care. A maximum of two attempts were made to contact women by telephone at each time point. A telephone discussion guide was utilised to ensure a consistent approach to the intervention calls, whilst maintaining flexibility in the discussion to make sure that it addressed individual's needs. The TSI was delivered by a midwife who had previous experience of providing advice and support via the telephone and had received training specific to the study. Women in the telephone support and Doppler (T þ D) group had UADS performed during the routine 20 week anomaly scan and the TSI as previously described. Participants with normal UADS (mean pulsatility index (PI) below 1.45 and unilateral/no diastolic notching of the waveform) received verbal and written information about their reduced risk of developing pre-eclampsia and delivering a small-for-gestational-age baby. Women who were screen positive were offered a repeat scan at 24 weeks gestation, if there was persistent raised PI and/or bilateral notching, a fetal growth scan was performed at 32 weeks (Snaith et al., 2014). Data collection
Table 1 Demographic characteristics of women interviewed. Group C n ¼ 15
T n ¼ 15
Tþ D n ¼15
Age at time of interview (years)
16–19 20–25 26–30 31–36 37–40
0 3 2 10 0
1 6 5 3 0
1 1 4 7 2
Highest educational attainment
GCSE A level Degree Higher degree
6 3 5 1
7 4 4 0
6 6 2 1
Ethnic origin
White British Indian Pakistani White-Czech
13 1 1 0
14 0 0 1
14 0 1 0
C ¼Control; T¼ Telephone intervention; T þ D¼ Telephone þDoppler intervention.
An interview topic guide was developed to ensure consistency in the way the interviews were conducted. It incorporated questions to explore women's expectations and experiences of antenatal care provision including their views of the quantity of visits they received, the content of antenatal visits, the location and timing of visits, antenatal classes, potential improvements to care, support networks available and their experiences of the study interventions. Face-to-face, semi-structured interviews were undertaken in participants' own homes at 8–10 weeks post-childbirth. The interviews were conducted with only the interviewer and participant present. The discussion was digitally recorded and written notes were made by the interviewer to facilitate analysis of the data. The duration of the interviews ranged from 20 to 90 minutes with the average interview lasting 60 minutes. All of the interviews were digitally recorded and transcribed verbatim. Transcripts were not returned to participants for comment because it was felt that it would make additional demands on participants' time. It was accepted that the interviewer's background as a midwife and sonographer might impact on both the interview process and
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the inferences made as a result. In order to minimise the impact on the interviewees, the researcher discussed her professional background prior to commencing the interview and explained to the participant that she was not employed by the NHS trust at that time and any information provided would be treated confidentially and would not affect their care in any way. The interviewer had not been involved in the provision of clinical care to the women who were interviewed.
Data analysis The interview data was analysed by the primary author using a thematic framework approach. The methodology was selected because of its appropriateness for the mixed methods design of the study. It facilitated the inclusion of a priori themes which were required for the purposes of this study to ensure that women's views of the interventions were explored, as well as the identification and inclusion of emerging concepts (Ritchie and Spencer, 1994; Pope et al., 2000). All of the interviews and coding were undertaken by the primary author, which resulted in familiarisation with the data at the time of data collection. In order to enhance this process further, each of the transcripts were read in full and notes made on emerging concepts and themes. The thematic framework was initially constructed using the a priori themes which formed the interview topic guide. The analysis was supported by the use of NVivo software. As the familiarisation process was undertaken the following emerging themes were incorporated into the framework: personality of midwife; the importance of an individualised approach to antenatal care; normalising of the pregnancy experience; acknowledgement of pregnancy as a significant event and the impact of ultrasound examinations during pregnancy. The data was examined using the thematic framework and indexing was done by making notes on the interview transcripts. This part of the process allowed the construction of the first stage charts where sections of text were copied from the transcripts and inserted under broad theme headings. This made viewing of the relevant text more straightforward due to the relatively large number of interviews included in the analysis. The charting stage of the analysis was achieved by the creation of individual charts for each broad theme. The themes were then further defined by being broken down into a number of subheadings. For each theme subheading the interpretation of the data was achieved by the identification of commonalities between participants' responses and themes that emerged in order to appreciate the range of women's experiences. The themes were examined across the trial groups and different age and educational level groupings to determine whether these factors had an influence on women's experiences. No new ideas emerged during the final interviews suggesting that saturation was achieved.
Findings Seven major themes were identified relating to women's experiences of the antenatal care they received and how they perceived the research interventions. The women in all three trial groups who participated in the interviews expressed similar views about their experiences of antenatal care therefore the analysis is presented for the whole sample rather than as a comparison of groups. The findings relating to the study interventions are derived from interviews with women who were in the specific intervention groups. Participants were not asked to provide feedback on the findings.
Quantity of antenatal visits During the course of the interviews, women were asked how they felt about the quantity of visits offered and most women stated that they were content with the number of visits they had received. A third of the women interviewed stated that they had received fewer antenatal visits than they anticipated and there were times during their pregnancies when they would have preferred to see their midwife more often: Probably a few more (visits) because I was a bit confused to be honest. I was kind of the opinion that once you got, later on, that it was every week you are seeing the Midwife, it was every 2 or 3 weeks, that I seen her, and obviously the nerves start kicking in and things like that, because of the time and making sure he is alright and whatever, and I would have been maybe a bit better if I had been able to go every week. Telephone intervention group: Participant 9 Women who would have preferred more antenatal visits were more likely to describe their relationship with the midwife as suboptimal compared to those women who were content with the number of visits. Women's perceptions of how their pregnancy was progressing also impacted on their view of the appropriateness of the quantity of visits received. Those who described their pregnancy as being complicated by physical, psychological and emotional issues with or without additional social challenges stated that they would have preferred more visits with their midwife: .. the last couple of weeks I thought I could have done with a couple more because she said to go every fortnight and I really wanted, I was, my greatest concern was the problems of having the symphysis pain around would have caused during labour, because I wanted to have a natural birth. Telephone intervention group: Participant 13
Content and organisation of antenatal visits Women's views were sought regarding the content of visits and it was evident that the focus of visits varied, with some women describing consultations that focussed solely on physical aspects of health whilst other midwives incorporated discussions about emotional well-being and the provision of support: She gave me lots of advice and sort of websites and stuff for where I should be legally with work and things so no she was very good like that, you know she was very informative. Control group: Participant 1 Women who had not experienced any specific difficulties during their pregnancy were content with care that focussed on the monitoring of their physical health and well-being of the fetus. Women who had experienced emotional or physical challenges expressed a preference for their care to incorporate additional support and reassurance from midwives. The way in which routine antenatal visits are delivered did vary but for most women there was little flexibility in the day and time of day that visits were available. Overall, most women were happy with the way in which their antenatal visits were organised: There wasn't really much room for any discussion or anything, they did Mondays between nine and half past ten, and that was it. Control group: Participant 9
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Relationship with community midwife It was apparent from the analysis of data that women's perception of their antenatal care was significantly influenced by their relationship with their community midwife or midwives. It was clear that this relationship held great significance for many women. The data highlighted a number of concepts relating to the success of the woman/ midwife relationship including the personal characteristics of the midwife, how effective the midwife was at normalising the pregnancy experience, timely and appropriate information provision, an individualised approach, continuity of midwifery care and an acknowledgement of the pregnancy as a significant event. Women who had developed a positive relationship with their midwife used terms that emphasised the desirable characteristics of approachability, being of a pleasant disposition and easy to talk to. Some women felt that being able to identify with the midwife as an individual enhanced the relationship: She was like myself, she reminded us you know……very approachable but giggly and nice you know you could chat to her about anything and she wouldn't use like medical words she'd use words that you'd understood. Control group: Participant 2 The minority of women in the interview sample who had a poor relationship with their midwife described the negative impact that it had on their perceptions of antenatal care provision. They depicted their midwives as being unhelpful, difficult to talk to and dismissive of their concerns. There was a clear interaction between whether women felt there were time constraints on visits, their satisfaction with the quantity of visits and how confident they felt about asking the midwife questions: She wasn't very helpful shall I say as far as being a first time mum obviously you don't know what to expect. Like a lot of the time she just made you feel a bit stupid or feel in some way or asking is this normal, she wasn't ideal. She's not somebody I really liked to speak to… you could be waiting, you had your appointment, you'd be waiting half an hour. And then when you finally got in it was like she was trying to rush you back out again. So had no time really talk to you, chat to you. Telephone and Doppler group: Participant 10 Women valued midwives who familiarised themselves with their notes and found it frustrating to have to repeat themselves to different staff members. This was often compounded by seeing a number of different midwives over the duration of the pregnancy. An individualised approach to care was greatly appreciated and the relationship was further enhanced when midwives made an effort to get to know women: I felt like I was explaining myself over and over again. And they said ‘hang on, I'll just read through your notes.’ And then you have to sit there while they read through your notes. Control group: Participant 9 A proportion of women felt it was important that their pregnancy was acknowledged as a significant life event. From the perspective of some women, the number of antenatal visits offered was correlated with how much their pregnancy was valued by health professionals with some women describing a lack of visits as an indication that the importance of their pregnancy was not acknowledged: I think it's just nice it would have been nice I think specifically the first pregnancy, somebody just to sort of acknowledge you're pregnant and ask Are you excited? Are you scared? You know, how are things going?
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Like that but from the moment you are booked, to the first check-up I think it was sixteen weeks or something. Control group: Participant 1. Antenatal classes and preparation for the postnatal period Women's views of antenatal classes were determined by how the classes were presented and the relevance of the information provided. Sessions that were described positively were led by midwives who exhibited enthusiasm and were viewed as friendly and well prepared. Classes that were less successful were depicted as being poorly designed and women felt that the level and presentation of information was inappropriate for their needs: The lady was fantastic. She was so informative and really upbeat about it all and by that point you're quite pregnant and you think ‘I'm going to have push this baby out’ and I was beginning to get a bit nervous about it…Telephone and Doppler group: Participant 1 I'm not being horrible or anything but I thought it was boring I was nearly falling asleep because they were showing you this video and I think it was before I was born this video what was on…. I was thinking you need to get something up to date. Control group: Participant 8 Women described the need to feel that they had something in common with the other women/couples in the group. It was apparent that the success of the group dynamics had a significant effect on the overall experience of antenatal education. A positive aspect of a class with strong group cohesion was the opportunity for women to socialise with others who were at a similar stage of pregnancy, and some women valued this aspect of the classes, above the opportunity to gain information: There was a huge variation in age you know there were loads of 16 year olds right up to I was the oldest at 34 and that makes you feel really rubbish when your 34… that may well have been why I was embarrassed to ask questions at the antenatal. Control group: Participant 6 The focus of the antenatal classes was appropriate for most women, but for some there was a lack of information on how they would feel after they had given birth and advice on how to care for their new baby. This was compounded by the perception that there were too few visits postnatally and in some cases a suboptimal relationship with the midwife. Most women viewed classes as an important component of antenatal care; those whose expectations were not fulfilled by the experience were left frustrated by their inability to obtain the information they required to face the challenges ahead: They showed me how to bath him and that's been fine, but just things like I didn't know how often he should be feeding, I didn't know how often I should be changing him. You know, how often should he be sleeping? Should I wake him to feed him? Should I wait until he wakes? I just didn't know. Telephone group: Participant 5 They didn't actually tell us anything about how I was going to feel once I had the baby……I just felt really emotional and that why isn't everything falling into place so I just felt like that a lot. Control group: Participant 14 Telephone support intervention Women in the two intervention groups of the trial were specifically asked their views of the TSI. The majority of women viewed the intervention as a positive addition to their care. There was no negative feedback about the TSI with only two women
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feeling that the intervention did not enhance the care that they were already receiving from their community midwife. Both of these women described their pregnancies as being uncomplicated and as a result they had few concerns or worries. Women who thought the intervention was useful discussed the benefit of having someone who was interested in how they felt and the opportunity to chat about their pregnancy experience: It's always nice thing when people ask when you're pregnant, when people ask how are you, is everything alright, just in case there is something, you just think ‘oh, well actually’. So it was nice just to get another phone call, like ‘do you have any other problems?’ So that was nice just to know there was somebody there. Telephone and Doppler group: Participant 3. Women who valued the proactive nature of the intervention discussed how they wouldn't have initiated contact with health professionals to ask ‘trivial questions’ and found it beneficial to be contacted as a part of the study TSI. Some women suggested an alternative type of TSI, stating that they would have liked have been offered a dedicated telephone line to contact a midwife antenatally in addition to the proactive calls. One woman said she would have benefitted from telephone calls during the postnatal period: Like I say it's down to personality type I'm definitely the kind of person who could do with the odd phone call just to say how are you getting on you know rather than relying on me to phone up and go look, I'm having a problem. Telephone and Doppler: Participant 4. When asked if they would choose to have the telephone support intervention if pregnant again, the majority of women interviewed said that they felt it would be a useful addition to their antenatal care and they would value its inclusion. Two women in each group felt that they would not require an additional support intervention in a subsequent pregnancy because they would have fewer concerns.
Women's views about UADS were only elicited when they were asked directly during the course of the interviews, suggesting that although women described the intervention in positive terms, it did not seem to feature highly in their recall of events relating to their antenatal care. Uterine artery Doppler screening seems to have little detrimental effect on women's experience of pregnancy but the reassuring effect of this screening method varied between women. Impact of ultrasound scans The women interviewed described the reassuring value of ultrasound scans during pregnancy and the visualisation of the baby to be a positive experience: It was like it was still me getting fat rather than there being somebody growing inside me and when you see the scan you see like somebody moving around, little heartbeats and little spines and, oh wow. I think it was really important actually and I think it probably makes you look after yourself as well because you think you've got to look after somebody else too. Telephone and Doppler group: Participant: 1 Some women felt that the gap between their anomaly scan at around 20 weeks gestation and giving birth was too long and that they would have welcomed the inclusion of an ultrasound scan later in the pregnancy to reassure them that things were progressing normally. When asked if there was anything they felt was lacking in their antenatal care provision, the most frequent suggestion from participants was for an extra ultrasound scan during the third trimester: It's an awful long time to go because you go on virtually half your pregnancy without checking that everything's alright. I mean I know I could feel the baby moving but just that extra reassurance. Telephone group: Participant 5
Uterine artery Doppler screening
Discussion
None of the women interviewed expressed any concerns about the experience of having UADS performed and most said they would welcome any test that has the potential to provide reassurance in relation to the well-being of the baby:
This study was designed to evaluate interventions designed to provide low risk nulliparous women with additional support and reassurance during pregnancy, following the implementation guidelines recommending a reduction in the number of routine antenatal visits (National Collaborating Centre for Women's and Children's Health, 2008). The support interventions implemented did not affect the mean total number of antenatal visits that women required and there was no difference between the trial groups for any of the psychological outcomes measured (Snaith et al., 2014). The analysis and discussion of the interview data has provided an improved understanding of why the trial had a negative outcome and the factors that are most salient to women in relation to antenatal care provision. Limitations of the study include the length of time that has elapsed since the data was collected, although there have been no significant changes in the provision of antenatal care to low risk women since that time. The sample of women interviewed were predominantly White British, which does raise questions about the generalisability of the findings to other populations. The timing of the interviews (8–10 weeks postnatally) may also have affected women's perception and recall of antenatal events. Although women discussed the trial interventions in positive terms, it is clear that the interventions were not a substitute for face-to-face contacts. Data from the trial showed that the majority of non-scheduled visits were required because of pregnancy complications, with reduced fetal movements and raised blood pressure being the most common (Snaith et al., 2014). These
It was reassuring in a way knowing that the blood supply and all that was getting into the placenta okay. That made you feel a bit better because you know sometimes you think to yourself, because you read up on placentas not being healthy placentas and not having enough and that's how this has happened to the baby and whatever. Telephone and Doppler group: Participant 10 I think it's quite important to do probably anything, I mean, god, I'll do anything that helps or anything that's going to be better for the baby’. Telephone and Doppler group: Participant 15 One woman who had received a risk positive result at 20 weeks discussed how she had been anxious until her scan at 24 weeks when the uterine artery Doppler waveform was found to be normal. Another participant whose uterine artery Doppler screening result was normal, expressed how she was surprised when she developed PE in the latter part of her pregnancy but still thought the intervention was worth having: I had one of those extra scans, the Doppler and they said it was unlikely that I would ever get pre-eclampsia, but I did, so I was surprised. I mean it was still worth it because it was to see if the blood was getting to the placenta and everything, so it was still worth having. Telephone and Doppler group: Participant 6
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findings demonstrate that a significant proportion of additional visits are unlikely to be substituted for, by the introduction of a support intervention. Telephone contact provided some women with the feeling of being ‘looked after’ and they valued the recognition by health professionals that their pregnancy was a significant event. These findings are consistent with a previous study focussing on women's experiences of antenatal care (Bondas, 2002) and also a finding of a proactive postnatal support intervention (Fenwick et al., 2013). Women valued the TSI because it gave them the opportunity to discuss issues that caused them concern but they thought may be considered trivial by health-care professionals. It emerged that some women felt they would have liked an antenatal telephone helpline or access to a postnatal telephone support intervention. The findings provide reassuring evidence that most women who took part in interviews felt their needs were met by routine antenatal care. It was evident that women's experiences were predominantly determined by the quality of the relationship with their midwife and their own perception of the progression of their pregnancy. Women who described experiencing pregnancy complaints and complications, psychological difficulties such as anxiety, worry and depression and/or social challenges, were more likely to express a preference for more antenatal visits, this is consistent with previous research findings (Clement et al., 1996). The results of this study reiterate previous research findings showing that successful interactions between women and midwives are a fundamental determinant of the perception of care (Proctor, 1998; Walsh, 1999; Hildingsson et al., 2002; Hunter, 2006). The analysis showed that midwives exhibiting an approachable disposition and an engaging and enthusiastic communication style were viewed positively by women, which is in keeping with previous research findings (Seefat-van Teeffelen et al., 2011). Women who perceive the relationship with their midwife negatively may have less confidence in the midwife's ability to provide good quality care, which could result in the need for reassurance in the form of additional visits. Although the inclusion of uterine artery Doppler screening in antenatal care appeared to be well received by women, it was not mentioned spontaneously during interviews, possibly because the intervention was viewed as an integral part of their anomaly scan. When asked about their experience of receiving UADS, women did not have any concerns about having the additional ultrasound measurement performed and had not experienced any discomfort during the ultrasound examination. It was evident that most women valued the opportunity for additional information relating to the progression of the pregnancy and fetal well-being. The possible negative psychological consequences of introducing screening in a low risk population cannot be ignored and there was some evidence that women who had abnormal uterine artery Doppler waveforms were anxious as a result or misunderstood the predictive power of the test. This demonstrates the importance of ensuring that risk information is provided in a way that is easy for women to understand (Zechmeister, 2001; Green et al., 2004), particularly when the screening test is relatively new or has not been used in a low risk pregnant population. Women discussed the reassuring value of ultrasound scans at all stages of pregnancy. When asked if they would like to change anything about the care they received, the most frequent response was to state that they would have liked additional ultrasound examinations in the second and third trimester, this was also a finding of a previous study (Goberna-Tricas et al., 2011). Although it is clear that some women would welcome more ultrasound scans or antenatal visits, current evidence suggests that neither of these interventions would confer any clinical benefits to low risk women. Indeed, some authors suggest that increased antenatal surveillance
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results in unnecessary medicalisation of pregnancy and an over reliance on technology by pregnant women (Zechmeister, 2001; Jordan and Aikins Murphy, 2009).
Implications for practice Although most women valued the interventions as an extra component of their antenatal care, the intervention packages did not have an impact on women's requirement for face-to-face midwifery visits. The telephone contact was most valued by women who felt that they were not receiving adequate support from their community midwife. There is no evidence to suggest that the implementation of the interventions resulted in changes in care utilisation or substantially affected women's experience of antenatal care. There were significant challenges in implementing the telephone support intervention in its entirety, which raises questions about the feasibility of successfully implementing a TSI into routine antenatal care provision. The findings were consistent with previous evidence to show that the relationship between women and midwives is the most fundamental determinant of women's evaluation of antenatal care. It is evident that further research is needed to determine strategies to optimise midwives' relationships with women, by identifying the barriers to effective communication and providing midwives' with appropriate skills and resources. Alternative methods of contacting women other than face-toface visits offer health-care providers with opportunities to redirect resource use while providing the flexible care that women value. Future research is needed to investigate the use of innovative antenatal care provision by appropriately utilising new technologies, considering alternative care settings and organising care with the aim of providing a service that is responsive, progressive and woman-centred. The economic impact of utilising different technologies should be thoroughly evaluated.
Conclusion Although viewed positively, for most women the study interventions were much less influential on their evaluation of antenatal care than their own perception of the pregnancy event and the effect of having a positive relationship with a midwife. The findings of this study do not support the implementation of a telephone support intervention into routine antenatal care provision for low risk women.
Conflict of interest There are no conflicts of interest.
Details of ethics approval Ethical approval was obtained from the Joint Ethics Committee of the Newcastle and North Tyneside Health (ref no: 2003/208).
Funding Vikki J. Snaith was funded by a National Institute for Health Research, Nursing and Allied Health Professional Researcher Development award. This article/paper/report presents independent research funded by the National Institute for Health Research (NIHR). The views
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expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Acknowledgements The authors would like to thank all of the women who took part in the study and the ultrasonographers, midwives and clerical staff from antenatal clinic and antenatal ultrasound department who supported the study at The Newcastle upon Tyne Hospitals NHS Foundation Trust. Special thanks to Catherine McParlin who provided the telephone support intervention. References Bondas, T., 2002. Finnish women's experiences of antenatal care. Midwifery 18, 61–71. Clement, S., Sikorski, J., Wilson, J., Das, S., Smeeton, N., 1996. Women's satisfaction with traditional and reduced antenatal visit schedules. Midwifery 12, 120–128. Cnossen, J.S., Morris, R.K., Gerben ter Riet, B.W.J., et al., 2008. Use of uterine artery Doppler ultrasonography to predict pre-eclampsia and intrauterine growth restriction: a systematic review and bivariable meta-analysis. CMAJ 178, 701–711. Dowswell, T., Carroli, G., Duley, L., et al., 2010. Alternative versus standard packages of antenatal care for low risk pregnancy. Cochrane Database Syst. Rev (10). Fenwick, J., Gamble, J., Creedy, D., Barclay, L., Buist, A., Ryding, E., 2013. Women's perceptions of emotional support following childbirth: a qualitative investigation. Midwifery 29, 217–224. Goberna-Tricas, J., Banus-Gimenez, R., Palacio-Tauste, A., Linares-Sancho, S., 2011. 'Satisfaction with pregnancy and birth services: the quality of maternity care services as expereinced by women'. Midwifery 27, e231–e237. Green, J.M., Hewison, J., Bekker, H.L., Bryant, L.D., Cuckle, H.S., 2004. Psychosocial aspects of genetic screening of pregnant women and newborns: a systematic review. Health Technol. Assess. 8 (33).
Hildingsson, I., Waldenstrom, U., Radestad, I., 2002. Women's expectations on antenatal care as assessed in early pregnancy: number of visits, continuity of caregiver and general content. Acta Obstet. Gynecol. Scand. 81, 118–125. Hunter, B., 2006. The importance of reciprocity in relationships between community-based midwives and mothers. Midwifery 22, 308–322. Jordan, R., Aikins Murphy, P., 2009. Risk assessment and risk distortion: finding the balance. J. Midwifery Women's Health 54, 191–200. National Collaborating Centre for Women's and Children's Health, 2003. Antenatal Care: Routine Care for the Healthy Pregnant Woman. RCOG Press, London. National Collaborating Centre for Women's and Children's Health, 2008. Antenatal Care: Routine Care for the Healthy Pregnant Woman (CG62). RCOG Press, London. Pope, C., Ziebland, S., Mays, N., 2000. Analysing qualitative data. Br. Med. J. 320, 114–116. Proctor, S., 1998. What determines quality in maternity care? Comparing the perceptions of childbearing women and midwives. Birth 25, 85–93. Ritchie, J., Spencer, K., 1994. Qualitative data analysis for applied policy research. In: Bryman, R., Burgess, R. (Eds.), Analyzing Qualitative Data. Routledge, Abingdon, pp. 173–195. Seefat-van Teeffelen, A., Nieuwenhuijze, M., Korstjens, I., 2011. Women want proactive psychosocial support from midwives during transition to motherhood: a qualitative study. Midwifery 27, e123–e127. Sikorski, J., Wilson, J., Clement, S., Das, S., Smeeton, N., 1996. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. Br. Med. J. 312, 546–553. Snaith, V., Hewison, J., Steen, I., Robson, S., 2014. Antenatal telephone support intervention with and without uterine artery Doppler screening for low risk nulliparous women: a randomised controlled trial. BMC Pregnancy Childbirth 14, 121. Walsh, D., 1999. An ethnographic study of women's experience of partnership caseload midwifery practice: the professional as a friend. Midwifery 15, 165–176. Zechmeister, I., 2001. Foetal images: the power of visual technology in antenatal care and the implications for women's reproductive freedom. Health Care Anal. 9, 387–400.
