Determining the most adequate content for antenatal care programmes has been a topic of discussion over the last decades in Europe ( Hall et al. 1985, Heringa 1998). Antenatal care was institutionalised in Western Europe at the beginning of the 20th century with the aim of reducing maternal and infant mortality. Although originally the emphasis was on educating mothers to take care of themselves and their babies a shift was noticed shortly after World War I to an emphasis on professional supervision of expectant mothers. A reduction in the infant mortality rate seemed to confirm the effectiveness of the antenatal care programmes, although changing environmental factors were neither taken into account, nor did a proper evaluation take place ( Hall et al. 1985, Heringa 1998).
Influenced by the consumer movement a call for evaluating maternity services arose during the 1970s and 1980s. Several studies addressing the subject of antenatal care were undertaken ( Chalmers et al. 1989). The WHO ( 1987) undertook a descriptive survey from 1979 to 1984 addressing antenatal care programmes in 22 countries in Europe. The survey showed that there were big differences between the programmes, which were mainly focused on risk assessment. The authors emphasised the need for a proper evaluation of the contents’ quality and quantity, a growing connection between the medical and the social content and the empowerment of the women using these services.
A new template of antenatal care with a reduced number of visits and a reduced content was tested in Aberdeen between 1980 and 1982. The research using a before-and- after design showed similar results in pregnancy outcome after the introduction of the new template ( Hall et al. 1985). Sociological research in the United Kingdom addressing the transition to motherhood also studied the experience of women and their satisfaction with antenatal care by interviews or questionnaires. Women were mainly less satisfied with organisational aspects, the information they were receiving, discontinuity of care and the impersonal treatment at the antenatal care clinics ( Hall et al 1985, Reid & Garcia 1989).
During the 1990s research in antenatal care addressed the number of antenatal care visits, the person of the care provider, organisational aspects and screening procedures ( Heringa 1998, Bigirimani & Fraser 1999, Villar & Khan- Neelofur 2001). Women’s views were studied on the subject of antenatal classes and prenatal diagnostics ( Gregg 1995).
Evaluation studies on antenatal care have still not assessed the effectiveness of the routine antenatal care programmes ( Fink et al. 1992, Fiscella 1995). A study of routine antenatal care in nine departments of obstetrics in eight different countries in Europe using a questionnaire revealed the consistent differences between the antenatal care programmes ( Langer 1999). Not only did good scientific evidence seem to be lacking for some recommendations; the question arose whether the actual content of the antenatal care programmes was of any importance in reaching its aims of health gain for women and their babies ( Heringa 1998).
Despite such lack of evidence new procedures have been added to antenatal care programmes throughout Europe through national or professional guidelines and the actual content was not reduced. Maternal and perinatal morbidity were added as indicators of effective care as mortality rates were very low and stable ( Heringa 1998).
Although antenatal care is a service focused on women, a search in Medline for “ experience”, “ expectations” and “ antenatal care” revealed no results for routine antenatal care programmes from 1996 to 2001. This research will address the actual needs and expectations of the women using antenatal care in order to evaluate the content of the programmes in Europe and its effectiveness.
To analyse routine antenatal care in Europe
To construct a conceptual model of antenatal care based on women’s views
1. To determine important aspects of antenatal care from the women’s point of view
2. To develop a woman- constructed conceptual model of antenatal care
The objectives of this study will be attained by a grounded theory approach, because it uses a bottom up approach through inductively developing a theory grounded in everyday reality. In this way it would take into account the many factors possibly influencing the model. This research approach includes all aspects of research from sampling to data collection and analysis
( Strauss & Corbin 1990).
Participants will be recruited in 3 countries in Europe: the United Kingdom, the Netherlands and Switzerland. Initial access to participants will be gained through their main care provider, once relevant permission has been obtained. The participants will be pregnant women at different stages of pregnancy or mothers within 6 months after giving birth to get a wide sample. As data saturation is the aim of the approach the number of participants can not be determined beforehand. Initially the sampling will be open to provide the greatest opportunity to gather the most relevant data. The emerging categories during this stage will determine further selective sampling.
Data will be collected by one- to- one interviews. The leading question will address the issue of what are the important aspects of care during pregnancy. The researcher, who speaks English, Dutch and German, will personally carry out these interviews. The interviews will preferably take place outside the setting of professional antenatal care.
The analysis of the data obtained will be transcription of the interviews followed by open, axial and selective coding for defining categories as described for the grounded theory approach by Strauss and Corbin ( Strauss & Corbin 1990). With these categories a concept will be developed.
Development from MPhil to PhD stage
Once the above conceptual model has been generated it will be compared with the national guidelines of countries in Europe. This will be the transition from the MPhil to the PhD stage.
To test this model against current European guidelines on antenatal care
- To analyse national maternity guidelines in Europe concerning the content of the antenatal care programmes in obstetrical practice and determine similarities and differences
- To search for research evidence in supporting the recommendations in these guidelines
- To compare and contrast these results with the woman- constructed concept delivered
- To revise and refine the model accordingly
Major issues in this study are informed consent, anonymity and confidentiality. Research in the several countries which are included in this study do not only have to adhere to the Data Protection Act (1998), but also the specific local ethical guidelines of the country involved. Therefore I will currently be seeking the approval of the Ethics Committee of the Glasgow Caledonian University. After getting this approval access will be sought through the appropriate channel of each locality.
- Bigirimani P, Fraser WD ( 1999). Midwifery- led versus medical-led for low- risk women during pregnancy and childbirth ( Protocol for a Cochrane Review). In: The Cochrane Library, Issue 4. Update Software, Oxford.
- Chalmers I, Enkin M, Keirse MJNC ( ed) ( 1989). Effective care in pregnancy and childbirth. Oxford University Press, Oxford
- Fink A, Yano EM, Goya D ( 1992). Prenatal programs: what the literature reveals. Obstet. Gynecol. 80; 5: 867- 872
- Fiscella K ( 1995). Does prenatal care improve birth outcomes ? A critical review. Obstet. Gynecol. 85; 3: 468- 479.
- Gregg R ( 1995). Pregnancy in a high- tech age. Paradoxes of choice. New York Univerity Press, New York.
- Hall M, Macintyre S, Porter M (1985). Antenatal care assessed: a case study of an innovation in Aberdeen. The University Press, Aberdeen
- Heringa M ( 1998). Computerondersteunde screening in de prenatale zorg (Computer- aided screening in antenatal care). Dijkhuizen Van Zanten bv , Groningen.
- Langer B, Caneva MP, Schlaeder G ( 1999). Routine prenatal care in Europe: the comparative experience of nine departments of gynaecology and obstetrics in eight different countries. Eur J Obstet Gynecol Reprod Biol 85; 2: 191- 198.
- Reid M, Garcia J ( 1989). Women’s views of care during pregnancy and childbirth. In: Chalmers I, Enkin E, Keirse MJNC (ed). Effective care in pregnancy and childbirth. Oxford University Press, Oxford.
- Strauss A, Corbin J ( 1990). Basics of qualitative research. Grounded theory procedures and techniques. SAGE Publications, Newbury Park.
- Villar J, Khan- Neelofur D ( 2001). Patterns of routine antenatal care for low-risk pregnancy. In: The Cochrane Library, Issue 2.Update Software, Oxford.
- WHO (ed). ( 1987). Wenn ein Kind unterwegs ist… Öffentliches Gesundheitswesen in Europa 26. WHO, Kopenhagen.
De voorlopige resultaten van dit promotie-onderzoek zijn te lezen in het artikel in de bijlage. Hoofdelementen waren confidence, autonomy en responsibility. Momenteel wordt uit de data de core category ontwikkeld ( volgens de onderzoeksmethode).
De conclusies zullen te lezen zijn in het proefschrift, dat naar verwachting in de herfst van 2007 zal verschijnen.