TY - JOUR
T1 - Project20
T2 - Maternity care mechanisms that improve access and engagement for women with social risk factors in the UK - A mixed-methods, realist evaluation
AU - Rayment-Jones, Hannah
AU - Dalrymple, Kathryn
AU - Harris, James M.
AU - Harden, Angela
AU - Parslow, Elidh
AU - Georgi, Thomas
AU - Sandall, Jane
N1 - Funding Information:
This report is an independent research supported by the National Institute for Health Research (NIHR Doctoral Research Fellowship, HR-J, award no DRF-2017-10-033). AH is supported by the NIHR Applied Research Collaboration North Thames. JS (King’s College London) is supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London). JS is also an NIHR Senior Investigator. JMH is supported by a Post-doctoral Fellowship from Wellbeing of Women (Award Ref PRF006). KD is funded by the Medical Research Council (MRC) (grant number: MR/V005839/1). The views expressed in this article are those of the author(s) and not necessarily those of the National Health Service, the NIHR, the MRC or the Department of Health and Social Care.
Publisher Copyright:
© 2023 BMJ Publishing Group. All rights reserved.
PY - 2023/2/7
Y1 - 2023/2/7
N2 - Objectives To evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how? Design Realist evaluation. Setting Two UK maternity service providers. Participants Women accessing maternity services in 2019 (n=1020). Methods Prospective observational cohort with multinomial regression analysis to compare measures of access and engagement between models and place of antenatal care. Realist informed, longitudinal interviews with women accessing specialist models of care were analysed to identify mechanisms. Main outcome measures Measures of access and engagement, healthcare-seeking experiences. Results The number of social risk factors women were experiencing increased with deprivation score, with the most deprived more likely to receive a specialist model that provided continuity of care. Women attending hospital-based antenatal care were more likely to access maternity care late (risk ratio (RR) 2.51, 95% CI 1.33 to 4.70), less likely to have the recommended number of antenatal appointments (RR 0.61, 95% CI 0.38 to 0.99) and more likely to have over 15 appointments (RR 4.90, 95% CI 2.50 to 9.61) compared with community-based care. Women accessing standard care (RR 0.02, 95% CI 0.00 to 0.11) and black women (RR 0.02, 95% CI 0.00 to 0.11) were less likely to have appointments with a known healthcare professional compared with the specialist model. Qualitative data revealed mechanisms for improved access and engagement including self-referral, relational continuity with a small team of midwives, flexibility and situating services within deprived community settings. Conclusion Inequalities in access and engagement with maternity care appears to have been mitigated by the community-based specialist model that provided continuity of care. The findings enabled the refinement of a realist programme theory to inform those developing maternity services in line with current policy.
AB - Objectives To evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how? Design Realist evaluation. Setting Two UK maternity service providers. Participants Women accessing maternity services in 2019 (n=1020). Methods Prospective observational cohort with multinomial regression analysis to compare measures of access and engagement between models and place of antenatal care. Realist informed, longitudinal interviews with women accessing specialist models of care were analysed to identify mechanisms. Main outcome measures Measures of access and engagement, healthcare-seeking experiences. Results The number of social risk factors women were experiencing increased with deprivation score, with the most deprived more likely to receive a specialist model that provided continuity of care. Women attending hospital-based antenatal care were more likely to access maternity care late (risk ratio (RR) 2.51, 95% CI 1.33 to 4.70), less likely to have the recommended number of antenatal appointments (RR 0.61, 95% CI 0.38 to 0.99) and more likely to have over 15 appointments (RR 4.90, 95% CI 2.50 to 9.61) compared with community-based care. Women accessing standard care (RR 0.02, 95% CI 0.00 to 0.11) and black women (RR 0.02, 95% CI 0.00 to 0.11) were less likely to have appointments with a known healthcare professional compared with the specialist model. Qualitative data revealed mechanisms for improved access and engagement including self-referral, relational continuity with a small team of midwives, flexibility and situating services within deprived community settings. Conclusion Inequalities in access and engagement with maternity care appears to have been mitigated by the community-based specialist model that provided continuity of care. The findings enabled the refinement of a realist programme theory to inform those developing maternity services in line with current policy.
KW - Organisation of health services
KW - PRIMARY CARE
KW - PUBLIC HEALTH
KW - SOCIAL MEDICINE
UR - http://www.scopus.com/inward/record.url?scp=85147611061&partnerID=8YFLogxK
U2 - 10.1136/bmjopen-2022-064291
DO - 10.1136/bmjopen-2022-064291
M3 - Article
C2 - 36750277
AN - SCOPUS:85147611061
SN - 2044-6055
VL - 13
JO - BMJ Open
JF - BMJ Open
IS - 2
M1 - e064291
ER -
