Understanding delayed access to antenatal care: a qualitative study Rosalind Haddrill
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2.3.3 Discussion 582.3.3.1 Limitations of the CIS method2.4 Conclusions, aims and objectives for the study 63 Appendices relating to this chapter 2.1 Database search histories 2.2 Quality checklists for the 54 studies included in the literature synthesis 2.3 Quality table for the 54 studies included in the literature synthesis 2.4 Study details and key themes for the 54 studies included in the literature synthesis
3.1.1 Why qualitative research? 66 The research question
3.1.2.1 Inductivism 3.1.2.2 Constructivism 3.1.2.3 Interpretivism 3.1.2.4 The influence of grounded theory
3.1.3.1 Focus on emic perspective 3.1.3.2 Data has primacy 3.1.3.3 Context is important 3.1.3.4 Reflexivity and critical thinking are important 3.1.3.5 A flexible research strategy 3.2 Determining the research methods 83 3.2.1 Sampling 83 3.2.1.1 Sample size and saturation 3.2.1.2 Sampling methods
3.2.2.1 Individual interviews 3.2.3 Data analysis 91 3.3 Considerations of bias and quality 95 3.3.1 Bias 95 3.3.2 Quality 96 3.3.2.1 Commitment to multiple perspectives 3.3.2.2 Triangulation 3.3.2.3 Clarity of presentation 3.3.2.4 Reflexivity 3.3.2.5 Relevance 3.4 Conclusions 103 Chapter 4: Methods used in the qualitative study 4.1 Introduction 104 4.2 Background to the study 105 4.2.1 Referring for antenatal care in Sheffield 105 4.2.2 Project management, research governance and ethical approval 106 4.3 The study methods 108 4.3.1 Sampling 108 Figure 4.3.1: flow chart for the study Figure 4.3.2: sampling frame for initial purposive sampling of the women 4.3.2 Recruitment 111 Table 4.3.3: outcomes of the recruitment process for the study 4.3.3 The interview setting 113 4.3.4 Collection of demographic data 115 Table 4.3.4: demographic data collected from the women interviewed 4.3.5 The interviews 115 4.3.5.1 My relationship with the women 4.3.5.2 Recording and transcribing
4.3.6.1 Informed consent and respect for autonomy 4.3.6.2 Right to privacy and confidentiality 4.3.6.3 Non-maleficence and beneficence 4.3.6.4 Fairness and justice
4.3.7.1 Stage 1: becoming familiar with the data 4.3.7.2 Stage 2: generating initial codes 4.3.7.3 Stage 3: searching for themes 4.3.7.4 Stage 4: reviewing and refining themes 4.3.7.5 Stage 5: defining themes, developing theories 4.3.7.6 Stage 6: presenting the findings
4.1 Study protocol (November 2005) 4.2 NHS Research Ethics Committee application form (October 2005) 4.3 North Sheffield Local Research Ethics Committee approval letters (December 2005 and June 2007) 4.4 Sheffield Health and Social Research Consortium funding and research governance approval decision letters (July 2005, September 2006) 4.5 Project authorisation letter from Sheffield Teaching Hospitals NHS Foundation Trust (STH) (January 2006) 4.6 STH Research Project Flowchart 4.7 Patient information sheet 4.8 Parent/guardian information sheet 4.9 Patient Consent Form (telephone contact) 4.10 Patient Consent Form (interview) 4.11 The Semi Structured Interview Schedule 4.12 The participant proforma for demographic data collection 4.13 Screencasts from NVIVO illustrating major nodes and interview data 4.14 Example of a diagram produced during the analytical process 4.15 Chart mapping themes and subthemes and their frequency
5.2.1.1 Realisation 139 5.2.1.1.1 Delayed confirmation of pregnancy 5.2.1.1.2 Women’s misinterpretation or misdiagnosis of symptoms 5.2.1.1.3 The influence of others 5.2.1.2 Belief 145 5.2.1.2.1 Age affecting fertility 5.2.1.2.2 Past illness affecting fertility 5.2.1.2.3 Using contraception 5.2.1.2.4 Not planning, expecting to be pregnant 5.2.2 Knowing 148 5.2.2.1 Avoidance 148 5.2.2.1.1 Fear and ambivalence 5.2.2.1.2 Coping mechanisms 5.2.2.2 Postponement 151 5.2.2.2.1 Fear and ambivalence 5.2.2.2.2 Considering termination 5.2.2.2.3 Pressure to have a termination 5.2.2.2.4 Early antenatal care not a priority
5.2.3.1 Professional failures in primary care 5.2.3.2 System failures 5.2.3.3 Women’s knowledge and empowerment issues 5.2.4 Triggers for accessing care 165 5.2.4.1 The influence of mothers 5.2.4.2 Needing positive/official confirmation of pregnancy
5.2.5.1 Guilt, regret 5.2.5.2 Pleased to have ‘missed’ early pregnancy
5.1 Full demographic details for the women interviewed Chapter 6: Discussion of the findings from the qualitative study 6.1 Introduction 170 6.2 Not knowing: accepting the personal pregnancy 172 6.2.1 Recognising the pregnancy 172 6.2.1.1 Lack of reproductive knowledge 6.2.1.2 Misinterpretation
6.3.1.1 Fear of consequences 6.3.2 The pregnancy identity 188 6.3.2.1 ‘A little bit pregnant’ 6.3.3 Valuing care 190 6.3.3.1 Prioritising antenatal care 6.3.3.2 Pregnancy as wellness 6.3.3.3 Previous pregnancy experience 6.3.3.4 Location of care 6.3.3.5 Taking control, protecting the pregnancy: self-care 6.4 Delayed: barriers to care, accepting delay 203 6.5 Strengths and limitations of the research 206 Table 6.5: techniques used in the study to ensure quality 6.5.1 The women 210 6.5.2 The interviews 211 6.5.3 Reflexive considerations 213 6.6 Conclusions 214 Appendices relating to this chapter 4.15 Chart mapping themes and subthemes and their frequency 6.1 Critical appraisal of the Sheffield study, using CASP Qualitative Research Checklist 6.2 Publication from Pregnancy and Childbirth Chapter 7: Recommendations to reduce late booking and for further research 7.1 Introduction 217 7.2 Three recommendations to reduce late booking 221 7.2.1 1. Addressing unintended pregnancies 221 Recommendations for maternity care commissioners and providers 7.2.2 2. Facilitating easier access to early antenatal care 226 Recommendations for local authority public health/health promotion and NHS care providers, maternity care commissioners and providers 7.2.3 3. Providing woman-centred antenatal care 228 7.2.3.1 What does ‘woman-centred’ mean in the context of antenatal care? 7.2.3.2 Providing individualised and flexible care 7.2.3.3 Focused on listening 7.2.3.4 Targeted care 7.2.3.5 Providing psychological as well as physical care 7.2.3.6 Women as active partners in care 7.2.3.7 Facilitating real choice and autonomy 7.2.3.8 Conclusions Recommendations for commissioners of maternity research, commissioners and providers of maternity care 7.2.4 Financial incentives 248 7.3 Future research 250 7.4 Conclusions 254 References 256 Volume 2 Appendices Chapter 2: 2.1 Database search histories 2 2.2 Quality checklists for the 54 studies included in the literature synthesis 10 2.3 Quality table for the 54 studies included in the literature synthesis 96 2.4 Study details and key themes for the 54 studies included in the literature 115 synthesis Chapter 4: 4.1 Study protocol (November 2005) 133 4.2 NHS Research Ethics Committee application form (October 2005) 145 4.3 North Sheffield Local Research Ethics Committee approval letters 171 (December 2005 and June 2007) 4.4 Sheffield Health and Social Research Consortium funding and research 179 governance approval decision letters (July 2005, September 2006) 4.5 Project authorisation letter from Sheffield Teaching Hospitals NHS 183 Foundation Trust (STH) (January 2006) 4.6 STH Research Project Flowchart 185 4.7 Patient information sheet 188 4.8 Parent/guardian information sheet 192 4.9 Patient Consent Form (telephone contact) 196 4.10 Patient Consent Form (interview) 197 4.11 The Semi Structured Interview Schedule 198 4.12 The participant proforma for demographic data collection 200 4.13 Screencasts from NVIVO illustrating major nodes and interview data 202 4.14 Example of a diagram produced during the analytical process 210 4.15 Chart mapping themes and subthemes and their frequency 212
5.1 Full demographic details for the women interviewed (n = 27) 214 Chapter 6: 6.1 Critical appraisal of the Sheffield study, using CASP Qualitative Research 216 Checklist 6.2 Publication from BMC Pregnancy and Childbirth 219 Abstract Background Delayed access to antenatal care (‘late booking’) is linked to poor maternal, fetal and neonatal outcomes. There have been few studies of women’s attitudes towards the initiation of antenatal care in the UK. The aim of the study was to understand why some women delay accessing antenatal care, and ultimately to improve such access and outcomes. Methods The synthesis of a large and methodologically diverse body of evidence, around perceptions and beliefs towards late booking for antenatal care, identified that antenatal care participation behaviour is complex, with a broad range of interacting barriers. A qualitative study was undertaken in Sheffield, interviewing 27 women presenting for their first hospital booking appointment after 19 weeks gestation, in community and maternity hospital settings. The interviews were transcribed verbatim and an iterative thematic analysis completed. Results The women were diverse in terms of age, parity, socioeconomic status and educational attainment. Three key themes relating to late booking were identified:
Conclusions The analysis suggests a new taxonomy of themes around late booking, reflecting the interaction of cognitive, emotional, social and environmental factors which must be navigated prior to a woman’s first antenatal appointment. Common themes were evident across the social spectrum, including poor reproductive health knowledge and delayed recognition of pregnancy, but also the influence of a pregnancy ‘mindset’ and previous pregnancy experience, and the perceived priority of antenatal care. Three recommendations are made, namely to
In combination these will facilitate the provision of timely antenatal care for all women. Thesis outline This thesis considers the subject of the delayed initiation of antenatal care (‘late booking’). It contains three parts. The first part considers the background to late booking, including existing guidance around antenatal access and the policies that underpin this, and also reviews the literature around women’s perceptions of delayed access to antenatal care. The second part documents the method and findings of a qualitative study undertaken in Sheffield to examine late booking women’s perceptions, and their experience of becoming pregnant and accessing antenatal care. The third part discusses the study findings and considers these in relation to previous research, and makes recommendations for future changes to policy and practice, and further research, to try to reduce late booking. Antenatal care in the UK (United Kingdom) is a well-established and widely accepted programme of health screening, health education and, to a lesser extent, social support. National and international policies and clinical guidance encourage early and regular attendance during pregnancy. Although evidence of the impact of individual components of antenatal care is limited, as a whole it is widely acknowledged as contributing to improved pregnancy outcomes. Chapter one considers how late booking for antenatal care is associated with poorer outcomes for both mother and baby, though this is complicated by socio-demographic risk factors amongst many late booking women. Many authors have identified the value of examining the attitudes and beliefs of late booking women, in an attempt to improve understanding, access to care and, ultimately, health outcomes. My own perspective on late booking, as a midwife, is also considered. Few UK based studies have been undertaken to examine the perceptions and beliefs of women in relation to barriers to the initiation of antenatal care. This is reflected in the findings of the literature review and Critical Interpretive Synthesis (CIS) presented in chapter two. CIS is a method which aims to bring together a large and diverse body of evidence, in terms of methodologies, settings and participants. Originally used to synthesise evidence relating to access to healthcare by vulnerable groups, it has not been used to examine antenatal access before. The findings demonstrate a broad range of interacting influences, including personal and practical barriers to care. The synthesis has created a fresh perspective on late booking for antenatal care, one which identifies acceptance of personal and public pregnancies as the core concept. Acceptance of the ‘personal’ pregnancy considers the influence of mindset in the recognition and acceptance of pregnancy. This acceptance is influenced by knowledge of pregnancy symptoms, pregnancy planning and desire, psychological factors associated with the recognition of pregnancy and the support of a woman’s immediate social network. Second, acceptance of the ‘public’ pregnancy considers women’s assessment of the social consequences of pregnancy, and the relevance and priority of antenatal care. This acceptance is influenced, amongst other things, by past experience, both positive and negative, beliefs about pregnancy and a consideration of life priorities. Late booking may result from the non-acceptance of either or both of these. Recognition of the risks associated with late booking and a gap in the evidence base, both in terms of UK-based but also qualitative research, led to the development of a study undertaken in Sheffield. The study’s aim was to try to understand women’s reasons for late booking and to explore barriers to antenatal attendance. It was part of a larger project which also included health and social care practitioner perspectives on late booking. The research question for the Sheffield study developed to become “what perceptions and beliefs do late booking women express about the delayed initiation of antenatal care?” Chapters three and four consider in detail the qualitative methodology and research methods chosen for the study, and the theoretical background to these. The ontological and epistemological influences behind the methodology are presented and discussed in chapter three, in relation to the conduct of the research, including sampling, data collection and data analysis. There is also a consideration of bias and quality in relation to the conduct of qualitative research, and the ways in which these were addressed in the study. Chapter four details the conduct of the research. It considers the background to the study, the processes of sampling and recruitment, and the procedure for the 27 individual interviews that were undertaken with late booking women. Ethical issues in relation to the participants are discussed, particularly in relation to consent and confidentiality. A thematic analysis of the data was undertaken and its stages are detailed. In each section the practical decisions made at all stages of the study are presented, alongside the rationale for these choices. The detailed themes and sub-themes emerging from the analysis of individual interviews with 27 late booking women are presented in chapter five. The diverse demographic characteristics of the women are presented briefly. A taxonomy of themes relating to late booking was developed and is presented in detail, illustrated with quotes from the women. Three original explanatory themes developed from the women’s interviews: women not realising or believing they were pregnant and therefore not accessing care (not knowing), women knowing they were pregnant and avoiding or postponing antenatal care (knowing) and women being prevented from accessing care by others (delayed). The chapter also considers additional emergent themes relating to triggers for accessing care, and the range of attitudes towards their late booking demonstrated by the women interviewed. Chapter six considers the three themes identified from the qualitative analysis of the individual interviews with the late booking women, and the similarities and differences with previous research. Not knowing examines the influences on women’s initial recognition of their pregnancies (the personal pregnancy identified in chapter 2) and the influence of a pregnancy ‘mindset’, related to women’s expectation of becoming pregnant. The study suggests that for some women ‘not knowing’ that they are pregnant is a combination of lack of recognition, acknowledgement and acceptance of the signs, symptoms and consequences of pregnancy, in part related to the absence of pregnancy planning. Knowing appraises the public or social aspects to a woman’s pregnancy and the formation of her pregnancy identity. Women’s perceptions of the relevance and priority of antenatal care are considered, as is the importance of familiarity, particularly in relation to a woman’s previous pregnancy experience and her home situation. Delayed considers organisational barriers to accessing care, as a result of professional and system failures, but also women’s acceptance of such delays. Whilst many of the findings from the Sheffield study concur with existing research around antenatal access, it has also generated different perspectives, reflecting in part the diverse sample of women interviewed. This contributes to a new understanding of late booking. The findings suggest that antenatal care initiation behaviour is complex, with cognitive, emotional, personal and environmental factors all interacting influences. Chaotic lifestyles and economic deprivation do influence women’s perceptions of their healthcare needs and priorities. However the themes from this study suggest a different emphasis, across the social spectrum. Whilst vulnerable groups are strongly represented in this cohort, women do not always fit a socio-cultural stereotype of a ‘late booker’. Rather, the women illustrate a different set of priorities regarding antenatal care, relating to its relevance, convenience and familiarity, using their previous pregnancy experience and embodied knowledge, and good health. Many take an active rather than passive role in their pregnancies to ensure wellbeing. There is also greater emphasis on the lack of a pregnancy mindset, relating to women’s expectation of becoming pregnant, and the creation of her pregnancy identity, as part of her ‘social’ pregnancy’. The chapter concludes with a consideration of the strengths and limitations of the qualitative methods used in the study. The purpose of the Sheffield study was to try to understand late booking from the women’s perspective, and ultimately to try to inform changes in policy and practice to improve outcomes. Whilst considering the findings of the Sheffield study, and diverse research into antenatal access and attitudes to care, chapter seven makes three recommendations to try to reduce late booking for antenatal care. These are based around the three overlapping themes from the study, and the concept of pregnancy as having both personal and public (social) aspects. The recommendations include strategies for addressing unintended pregnancies by improving reproductive health literacy, facilitating early access to antenatal care and improving the quality of antenatal care women receive, thus influencing women’s perceptions of its relevance and value. The role midwives play in such strategies is considered, as is the potential role for financial incentives in encouraging early attendance. It is recommended that women, their friends and families, are better informed about all aspects of reproductive health. However, if women are to value and prioritise antenatal care, it also needs to be readily accessible and perceived as relevant to their lives and pregnancies: flexible and focused on the individual, with more emphasis on choice and psychological support and less emphasis on physical aspects of care. Suggestions are made for future research, considering the impact of different models of care and antenatal or postnatal interventions, whilst also examining further the characteristics, outcomes and perceptions of women who book both early and late for antenatal care. It is suggested that multiple methodologies are required to contribute to a greater understanding of the multi-faceted nature of late booking, in order to promote the provision of timely antenatal care for all women. Yüklə 0,62 Mb. Dostları ilə paylaş:
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