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Despite many countries employing the use of national and large scale regional surveys to explore women’s experiences of their maternity care, with the results informing national maternity policy and practice, the concept itself is ambiguous and ill-defined having not been subject of a structured concept development endeavour.
Aim
The aim of this review is to report on an in-depth analysis conducted on the concept of ‘women’s experiences of their maternity care’.
Methods
Using the principle-based method of concept analysis by Penrod and Hupcey (2005), the concept of ‘women’s experiences of their maternity care’ was analysed under the epistemological, pragmatic, linguistic and logical principles. The final dataset included 87 items of literature published between 1990 and 2017 retrieved from a systematic search of the MEDLINE, CINAHL, EMBASE and PSYCinfo databases.
Findings
The epistemological principle identified that a theoretical definition of the concept is elusive with a variety of implicit meanings. The pragmatic principle supports the utility of the concept in scientific literature, however the lack of a theoretical definition has led to inconsistent use of the concept, as highlighted by the linguistic principle. Furthermore, the logical principle highlighted that as the concept lacks definition blurring is identifiable when theoretically positioned with related concepts.
Conclusion
The outcome of this concept analysis is a theoretical definition of a previously undefined concept. This definition highlights the subjective nature of the concept, its dependency upon a woman’s individual needs, expectations and circumstances and the influence of the organisation and delivery of maternity care.
The concept of ‘women’s experiences of their maternity care’ is ambiguous and has not been examined in the context of a structured concept analysis to date.
What is already known
Since the 1960s there has been a growing focus on the measurement of people’s experiences of health care to inform quality assurance and improvement. More recently, the measurement of women’s experiences of their maternity care has dominated the literature in relation to the measurement of maternity care quality. The value of this measurement has been recognised internationally with many countries using nationwide surveys to assess women’s experiences of their maternity care with the results informing national policy and practice.
What this paper adds
The concept of ‘women’s experiences of their maternity care’ was analysed under the epistemological, pragmatic, linguistic and logical principles as per the principle-based method of concept analysis by Penrod and Hupcey (2005). The outcome of this analysis is a theoretical definition of a previously undefined concept that serves as a foundation for future research.
Introduction
A paradox of modern healthcare is that as healthcare knowledge advances, bringing with it considerable benefits, the delivery of healthcare has become increasingly complex and fragmented. Since the 1960s, the growing focus on the measurement, recording, interpretation and analysis of people’s experiences of healthcare has been described as an attempt to “address the imbalance of knowledge, skills, and research effort with the aim of making care more patient- centred”,
This is evident within maternity services where the concept of women’s experiences of their maternity care dominates discussions on the measurement of maternity care quality.
The value of evaluating the quality of maternity care from the perspective of service users has been recognised by many countries including the UK,
who have employed the use of large scale regional surveys to explore women’s experiences of their maternity care with findings informing maternity policy and practice. However, despite the recognition of the significance of women’s experiences of their maternity care,
The ambiguity surrounding the meaning and use of the concept became apparent when preforming preliminary searches of the concept prior to embarking on a research project to develop a self- report survey instrument for use within the Republic of Ireland specifically to evaluate women’s experiences of their maternity care, namely, the National Maternity Experience Survey (see www.yourexperience.ie/maternity); the results of which will be used to influence national maternity policy and practice.
Following consideration and comparison of numerous methods of interrogating the literature, and given that “the primary utility of concept analysis is to determine the existing state of the science so that further work may be strategically and appropriately planned”,
The aim of this paper is to present the findings of a concept analysis of ‘women’s experiences of their maternity care’.
Methods
It is argued that in relation to concept analysis “the selection of methods must be based on sound philosophical rationale and appropriateness for the purpose of the study”,
has guided the analysis of this concept. This method provides a robust means to determine the state of the science surrounding the concept at a given point in time. Principle based concept analysis focuses exclusively on the use of empirical literature, rather than interpretations from media, art forms or other representations.
Retrieved literature is analysed in accordance with four principles that represent the philosophical perspectives of epistemology, pragmatics, linguistics and logic. The degree to which the criteria of each is met by the concept of ‘women’s experiences of their maternity care’ indicates the level of advancement, and maturity, of the concept. The outcome of the analysis is a theoretical definition of the concept as evident in the empirical literature, described as the “best estimate of probable truth”,
The citation databases MEDLINE, CINAHL, EMBASE and PSYCinfo were searched systematically within the time limit of 1990 to May 2017. Previous research has deemed the inclusion of data from 1990 onwards sufficient to capture the evolving recognition of the importance of women’s experiences to the woman and her family.
recommend the inclusion of scientific literature originating from disciples relevant to the concept being analysed. Based on the multidisciplinary nature of maternity care, and as such the potential of literature from these disciples for contributing to the analysis of the concept, literature was sought from within the disciplines of midwifery, obstetrics, nursing, medicine, psychology and sociology. However, the majority of literature retrieved originated from within the midwifery domain.
Keywords and phrases used to guide the search were ‘women* experience*’, ‘(women*) N5 (opinion* OR perspective* OR perception* OR attitude* OR perceiv*)’,’antenatal care’, ‘prenatal care’, ‘intrapartum care’, ‘postnatal care’, ‘obstetric care’, ‘maternity care’, ‘childbirth’. N5 represents the number of words that could appear between keywords/phrase. Truncation, wildcard and proximity functions were used in accordance with the guidelines of each individual database. Boolean logic was used to combine search strings.
Papers were eligible for inclusion if they were primary research, in English, and focused upon either women’s experiences of their maternity care or terms that are often used interchangeably with ‘experiences’ including women’s opinions on, perspective on or perception of their maternity care. Papers that focused on women’s experiences of their maternity care in general, as opposed to a focus on care received from a specific profession, e.g. midwives were also included. Furthermore, papers that focus on multiple experiences of maternity care, as opposed to just one were included. For example, ‘women’s experiences of care during labour and birth’ would be included, but ‘women’s experience of care during caesarean section’ would not be included. This criterion has been influenced by the work of Kalmakis and Chandler
and has been included to maintain the intent of analysing the concept of women’s experiences of maternity care as a plural term.
Conversely, papers were excluded if they were deemed as being non- empirical data, if they focused solely on women’s satisfaction with their maternity care, rather than their experience of that care or if they focused on a woman’s maternity experience, rather than their experiences of their maternity care during that period. Finally, papers that addressed childbirth experiences that merit specific consideration, for example stillbirths, were excluded as, while important, these experiences require approaches focused on the particular needs and experiences of women in these groups.
Findings
Searches yielded 2184 citations after the removal of duplicates. Following title and abstract screening by two authors (CB and MD), 2053 citations were excluded based on the predetermined exclusion and inclusion criteria.
A full text review (CB) of the remaining 131 papers resulted in a further 44 exclusions. These results are documented within the PRISMA flow diagram (Fig. 1).
The final dataset comprised of 87 papers addressing the concept of ‘women’s experiences of maternity care’. Key aspects of each paper (complete citation, important quotes, etc.) were exported to a spreadsheet developed specifically to facilitate the analysis of this concept. The individual analysis of each paper was also added to this file allowing for easy access to, and comparison of, a relatively large dataset.
Each paper within the final dataset was analysed (by CB and confirmed by MD) using the epistemological, pragmatic, linguistic and logical principles outlined by Penrod and Hupcey.
Please see Table 1 for definitions of each of the four guiding principles and a description of their application to the concept. The findings of these four principles are presented in the following section. The conceptual components attributed to the concept, as revealed through this analysis, are then discussed and finally all findings are summated in a theoretical definition.
Table 1Definitions of the guiding principles and their application to the concept.
Principle
Definition of principle provided by Penrod and Hupcey
Description of the application of principle to the concept ‘women’s experiences of their maternity care’
Epistemological principle
“Epistemology refers to the nature of knowledge. The related analytic criterion is rooted the rationalists’ reliance on reason as a source of knowledge. When applied to concept analysis, the epistemological principle focuses on the discipline’s distinction of a concept within the knowledge base”
The epistemological maturity of ‘women’s experiences of their maternity care’ guided an examination of how clearly the concept has been defined in the scientific literature and how well it has been differentiated from other concepts.
Pragmatic principle
“Focusing on pragmatics, that is, on the concept’s applicability in explaining or describing phenomena encountered within the discipline, the data are analysed from the perspective of usefulness. For a concept to be pragmatically mature, members of the discipline should be able to recognize manifestations of the concept; it should ring true with experience”
The pragmatic principle was used to describe ‘women’s experiences of their maternity care’ as encountered in the scientific literature and its usefulness to midwifery.
Linguistic principle
“Linguistics refers to human speech and language and, when applied to concept analysis, this principle evaluates the appropriate use of the concept. In this assessment, consistency in use and meaning are considered. There is also a more oblique consideration of context, examining the fit of the concept within context (Penrod 2001b). Concepts should be appropriate to their use in context; however, in this sense, context is a more complicated issue than merely the setting. Concepts may be context-bound (that is, limited to a pre- scribed setting or theoretical use) or stripped of context (stripped of contextual ties, of broader scope, more abstract)”
The linguistic principle was used to evaluate whether the consistency of use and meaning of the concept of ‘women’s experiences of their maternity care’ was maintained in the scientific literature.
Logical principle
“Derived through the philosophical perspectives of logic, that is, focused on correct and incorrect reasoning, this principle refers to the integration of the concept with related concepts. Focusing on conceptual boundaries, the data are analysed to determine if the concept becomes blurred when positioned theoretically with other concepts”
The logical maturity of ‘women’s experiences of their maternity care’ was evaluated based on the how well the concept held its boundaries when theoretically integrated with related concepts.
The epistemological principle guided an exploration of how well defined the concept of ‘women’s experiences of their maternity care’ is within the empirical literature and how well differentiated it is from other concepts. Despite the recognition of the significance of the concept, no explicit definition of the concept was evident within the literature retrieved. However, implicit meaning contributes to the identification of the key aspects defining this evidently complex concept.
have highlighted that concepts within the realm of healthcare may manifest differently at various stages of the health trajectory. This is especially true for the concept analysed here as women’s experiences of their maternity care encapsulates the antenatal, intranatal and postnatal periods during which numerous models of care and services can be encountered with several professions and professionals at various timepoints.
The concept of women’s experiences of their maternity care is referred to consistently, and at times interchangeably, throughout the literature with ‘women’s perceptions of their maternity care’
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Perceived discrimination during prenatal care, labor, and delivery: an Examination of Data from the Oregon Pregnancy Risk Assessment monitoring System, 1998-1999, 2000, and 2001.
Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi.
Given this ambiguity, it is unsurprising that the majority of the literature retrieved focused on the measurement of women’s individual experiences of the maternity care they received.
Measuring experiences of care can be accomplished using mixed methods, quantitative or qualitative approaches. The literature retrieved included 44 qualitative, 30 quantitative and 13 multi or mixed method studies.
have stated that a concept is epistemologically mature when well defined and well differentiated from other concepts. We believe the concept of ‘women’s experiences of their maternity care’ is epistemologically immature with differentiation from similar concepts often unclear.
Pragmatic principle
The pragmatic principle focused on exploring the applicability of the concept of ‘women’s experiences of their maternity care’ in explaining or describing the phenomenon from the perspective of how it is used.
Considering the range, depth and frequency of the application of the concept of ‘women’s experiences of their maternity care’, the utility of the concept appears high.
Throughout the literature, the ‘use’ of the concept is related to the subjective measurement of women’s experiences, perception or views of various aspects of the maternity care that has been delivered to them. The concept has, for example, been measured in terms of organisational factors including access and referral to maternity services,
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Survey of women’s experiences of care in a new freestanding midwifery unit in an inner city area of London, England – 1: methods and women’s overall ratings of care.
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi.
Interpersonal aspects of the concept that have been measured throughout the literature include cognitive support (information sharing, informed choice, consent),
“is the doctor God to punish me?!” An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia.
Furthermore, the concept has been used to describe the measurement of physical interventions throughout maternity care for example induction and augmentation of labour,
There is robust evidence of a high utility of the concept of ‘women’s experiences of their maternity care’ throughout the empirical literature, suggesting that women’s experience is influenced by organisational, interprofessional and birth intervention elements. Even in the absence of a precise definition, these elements suggest development in the concept’s pragmatic maturity.
Linguistic principle
The appropriate and consistent use of the concept of ‘women’s experiences of their maternity care’ is explored through the linguistic principle along with the fit of the concept in context.
The concept of women’s experiences of their maternity care is dependent on the individual woman who is a consumer of the care, and the actual care delivered. This is evident throughout the empirical literature with a wide variation of factors attributed to the interpretation of the concept across the continuum of maternity care.
Women’s individual circumstances play a significant role in their experience of their maternity care.
It is evident that although women may experience the same maternity care within the same maternity service, their interpretation of this can vary widely.
Perceived discrimination during prenatal care, labor, and delivery: an Examination of Data from the Oregon Pregnancy Risk Assessment monitoring System, 1998-1999, 2000, and 2001.
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Linguistic analysis of consistency in meaning has identified that culture makes a significant contribution to the complexity of this concept and the way in which it is interpreted.
Cultural norms lead to variation in the standard of care provided to women with studies from India, Cambodia and Zambia each reporting the lack of availability of medicines, equipment, water, electricity and skilled staff as normal experiences for women as part of their maternity care experiences.
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Survey of women’s experiences of care in a new freestanding midwifery unit in an inner city area of London, England – 1: methods and women’s overall ratings of care.
Inconsistency is also apparent in relation to the timing of data collection across studies. Whilst it has been acknowledged that a woman’s reported experience of her maternity care is influenced by when she is asked,
Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi.
an optimal timing has not been recommended within the retrieved literature. Considering the complex trajectory of maternity care and the various aspects of women’s experiences of their care that are evaluated, this absence may be attributed to the inappropriateness of having a single optimum timing for data collection. Consequently, dependant on the aspect of care being evaluated data collection timings varied from antenatally,
Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi.
The implied meaning of the concept of ‘women’s experiences of their maternity care’ within the retrieved literature is inconsistent. The concept is complex and may be interpreted differently depending on numerous factors which ultimately limits generalisability, therefore we are suggesting that it is linguistically underdeveloped.
Logical principle
The logical principle explores the theoretical integration of the concept of ‘women’s experiences of their maternity care’ with related concepts.
Given that the concept has been found to be epistemologically immature, it is unsurprising that at times the boundaries between it and other related concepts appear blurred.
The blurring between, and interchangeable use of the concept with, concepts such as ‘women’s perceptions of their maternity care’
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Perceived discrimination during prenatal care, labor, and delivery: an Examination of Data from the Oregon Pregnancy Risk Assessment monitoring System, 1998-1999, 2000, and 2001.
Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi.
has been identified previously. It is also evident that the concept is bound tightly with the concepts of ‘women’s satisfaction with their maternity care’
The quality of maternity care can be measured from a number of perspectives including clinical outcomes such as morbidity and mortality, cost and efficiency of the service and service user feedback.
The measurement of ‘women’s experiences of their maternity care’ and ‘women’s satisfaction with their maternity care’ are two methods regularly utilised to evaluate service user feedback.
Despite the concepts of both ‘women’s experiences of their maternity care’ and ‘women’s satisfaction with their maternity care’ being considered widely as a marker for quality care
there are significant differences in the underlying approaches to the measurement of each. The measurement of ‘women’s satisfaction with their maternity care’ has been criticised in the retrieved literature as being limited in its usefulness to understanding and improving quality care.
As satisfaction with care has generally been found to be reported as high, regardless of the actual quality of care that was being provided, focus has shifted from the measurement of ‘women’s satisfaction with their maternity care’ to ‘women’s experiences of their maternity care’ as a means to elicit more specific and relevant reports on the quality of maternity care received.
It is clear that the concept of ‘women’s experiences of their maternity care’ is closely related to, yet a separate entity from, the concepts of ‘women’s satisfaction with their maternity care’ and ‘quality of care’. However, the apparent blurring between the concept being analysed and ‘women’s perception of their maternity care’ and ‘women’s views of their maternity care’ highlights that clear conceptual boundaries between each of these latter concepts do not exist. Consequently, we propose that the concept of ‘women’s experiences of their maternity care’ is judged logically immature.
Summary of principle-based analysis
The evidence reviewed supports the utility of the concept of ‘women’s experiences of their maternity care’ (pragmatic principle) yet the lack of a precise definition of the concept, and as such the reliance on implied meaning (epistemological principle), had led to inconsistent use of a concept (linguistic principle) that blurs when theoretically positioned with other concepts (logical principle).
Conceptual components of ‘women’s experiences of their maternity care’
Through the analysis of ‘women’s experiences of their maternity care’, conceptual components attributed to the concept are identified. These are categorised as antecedents (preconditions that influence the concept) and consequences (effects of the concept).
Antecedents
The physical antecedent to women’s experiences of maternity care is pregnancy. Once pregnant, a woman accesses and experiences maternity care. There are, however, barriers to this care. These may be practical such as being unaware of why, where and how to access services,
and culturally inappropriate care, for example the unavailability of female staff for women who did not want to be treated by male staff due to their cultural beliefs.
Affective antecedents to women’s experiences of their maternity care are a woman’s needs and expectations of their maternity care. Each has a significant effect on a woman’s individual interpretation of their experiences of care. Akin to Maslow’s hierarchy of needs,
women’s maternity care needs, based on their personal and cultural circumstances, vary widely from basic needs such as food, water, medicines and electricity
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Similarly, women’s expectations of their maternity care are affected by their personal and cultural circumstances including their previous experience of maternity care,
Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi.
Consequences of women’s experiences of their maternity care are based upon each woman’s interpretation of that care. The perception of either negative and positive experiences of maternity care carry the potential to influence a woman’s future development as a woman and mother.
“is the doctor God to punish me?!” An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia.
The concept of ‘women’s experiences of their maternity care’ is ambiguous. Through the integration of theoretical insights from the literature, this concept analysis has revealed a greater understanding of the complex and multi-dimensional nature of, and the interaction between, the concept, its antecedents and subsequent consequences. This understanding has facilitated the development of the following theoretical definition;‘Women’s experiences of their maternity care’ is a complex concept referring to women’s interpretation of their care encounters within the maternity services. It is subjective in nature and evolves throughout the course of pregnancy, childbirth and the postpartum period. It is dependent upon a woman’s individual needs and expectations, shaped by their personal circumstances and influenced by how their care is organised and delivered.’
Discussion
The purpose of the analysis of ‘women’s experiences of their maternity care’ using the principle based method by Penrod and Hupcey
was to reveal the current state of empirical knowledge surrounding this concept in order to facilitate its advancement. Although it is evident that much work has taken place on defining people’s experiences of healthcare in general,
these definitions are not applicable directly to the area of maternity care as the spectrum of care varies significantly.
Despite the utility of the concept being high, and the recognition of the importance of women’s experiences of their maternity care evident from a recent policy guideline published by the World Health Organization,
a conceptually derived definition of the concept was absent from the literature and implicit meaning abounds. This affects the epistemological maturity of the concept directly and the differentiation between it and related concepts such as ‘women’s perception of their maternity care’ and ‘women’s views of their maternity care’, emphasising the need for the development of a universally accepted definition.
Through analysis of the concept under the epistemological and pragmatic principles, its multifaceted nature is highlighted with the concept encompassing organisational and interpersonal aspects of care as well as physical interventions throughout the continuum of maternity care. Through an examination of the linguistic principle and the identification of the concept’s antecedents and consequences, it is evident that these aspects of care are context dependant with interpretations of the concept reliant on a woman’s needs and expectations of care, as influenced by individual circumstances. This clearly accentuates the impact that individualised maternity care has upon each woman’s perceived experience of that care.
The frequent measurement of ‘women’s experience of their maternity care’ has been identified throughout this analysis as a means for assessing quality care. Furthermore, within the logical principle the contrast between this measurement (report of actual care) and that of the concept of ‘women’s satisfaction with their maternity care’ (contentment with care) has been highlighted.
Conclusion
Despite the international focus on the concept of ‘women’s experiences of their maternity care’, as evidenced from the inclusion in this analysis of literature from 25 different countries, it is apparent that this concept is philosophically immature. This immaturity stems from the lack of a definitive agreed definition of the concept, ultimately hindering its effective utility. Further advancement of the concept of ‘women’s experiences of their maternity care’ has the potential to facilitate greater utility for research application. This concept analysis, and theoretical definition, serve as a foundation for future research, particularly in defining this evidently complex concept.
Conflict of interest
I confirm that there are no potential conflicts of interest arising from the authors (CB, DD, MW, RG & MD) of this manuscript.
Sources of outside support for research- funding
Claire Beecher (corresponding author) is being funded by the Programme for Health Service Improvement, Health Service Executive. Dr. Mark White, Programme Integration Manager, of this programme has contributed as a co- author on this manuscript. No other contribution by this funding body was made to this manuscript.
Ethical statement
Not applicable/required.
Acknowledgements
The corresponding author is being funded by the Programme for Health Service Improvement, Health Service Executive. The Programme Integration Manager of this programme has contributed as a co- author on this manuscript. No other contribution by this funding body was made to this manuscript.
References
Coulter C.
Understanding the experience of illness and treatment.
in: Ziebland S. Coulter C. Calabrese J.D. Locock L. Understanding and Using Health Experiences. Oxford University Press,
Oxford2013: 6-16
“Neither we are satisfied nor they”-users and provider’s perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.
Perceived discrimination during prenatal care, labor, and delivery: an Examination of Data from the Oregon Pregnancy Risk Assessment monitoring System, 1998-1999, 2000, and 2001.
Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi.
Survey of women’s experiences of care in a new freestanding midwifery unit in an inner city area of London, England – 1: methods and women’s overall ratings of care.
“is the doctor God to punish me?!” An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia.
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