The role of structured Antenatal Risk Management (sARM) on experiences with antenatal care by vulnerable clients

Abstract

Introduction

Vulnerable clients (i.e. clients reporting psychopathology, psychosocial problems, or substance use, and/or features of deprivation) represent a challenge in perinatal care, both in term of care process and outcome. Adhering to a structured care process (i.e. structured Antenatal Risk Management [sARM]) has shown to benefit professionals in supporting vulnerable clients, but its effect on client experiences is yet to be determined. As better processes are assumed to benefit outcome, we investigated the relationship between vulnerable clients’ experiences with antenatal care in perinatal units adhering to differing degrees of sARM.

Methods

We combined data from two sources: on the client level antenatal collected survey data from which vulnerability status (Mind2Care instrument) and client experiences (ReproQ questionnaire) were derived, and on the unit level interview data from healthcare providers from which the unit degree of sARM was ascertained.

Results

A total of N = 1.176 clients from N = 38 units were included in the study. Vulnerable clients with psychosocial problems reported more negative experiences than non-vulnerable clients. In high sARM units, vulnerable clients, regardless of type of problems, reported more negative experiences than non-vulnerable clients. In multiple regression analysis this effect disappeared and only vulnerability defined as psychosocial problems remained predictive for negative experiences.

Conclusions

Vulnerable clients, specifically those with psychosocial problems, present a challenge in perinatal healthcare. Negative appraisal of care might be an unavoidable drawback of adhering to sARM. It also stresses the need for improving caregiver-client expectations and system side improvements.

Introduction

Despite overall high standard of perinatal healthcare across high-income countries, major health inequalities exist in this domain (Mohangoo et al., 2011, Zeitlin et al., 2013, Zeitlin et al., 2016). Vulnerable clients consistently show higher adverse outcome rates, in particular in large metropoles (de Graaf et al., 2013). Explanation of these inequalities is not straightforward: we assume that vulnerability relates to a set of interacting negative health factors on the personal and environmental level, such as lack of social support, living in a deprived area, and health illiteracy (World Health Organization, 2008a).

The WHO sets the decrease of vulnerability as health policy priority for decreasing health inequalities (Sridhar et al., 2015, World Health Organization 2008b). In perinatal care, guidelines advocate screening for risk factors and helping women manage their stressors as part of comprehensive care (American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women 2006, National Institute for Health and Care Excellence (NICE) 2016).

In the Southwest region of the Netherlands, obstetrical providers joined forces and introduced structural Antenatal Risk Management (sARM) into routine care. For its clinical and organizational benefits, sARM is widely promoted (de Groot et al., 2016, Honest et al., 2009, Lagendijk et al., 2018, Vos et al., 2015a, Vos et al., 2015b, Quispel et al., 2014, Rayment-Jones et al., 2015, Requejo et al., 2013). sARM includes use of specific risk tools, which provide as output to both client and caregiver: what problems seem present, what treatment approach seems justified, and what options are locally available; sARM thus involves structural working relations with multiple caregivers outside the obstetric domain. The current tool is confined to psychiatric, psychosocial and substance use problems. Additionally, it measures specific deprivation factors (or, defined positively, ‘enabling’ factors; Quispel et al., 2012). sARM is designed to benefit both professional and client. A previous study on sARM consequences showed that, from the perspective of the perinatal caregiver or unit, sARM makes the vulnerability burden manageable for healthcare professionals (de Groot et al., 2016), in particular if prevalence of vulnerable clients was high. While the process benefits for professionals may be present, little is known about how clients experience this practice approach.

According to the World Health Organization (WHO) client experiences are the yardstick of quality of care process, referring to the ability of healthcare professionals and care setting to meet client values and expectations (Valentine et al., 2003). These experiences matter, as they are independent process goals apart from clinical outcome goals. Assumably, better processes benefits outcome (Lindquist et al., 2014). Client experiences are measured with so-called Patient Reported Experience Measures (PREMs); in the Netherlands a validated perinatal PREM questionnaire (ReproQ) is available. It covers domains like Respect, Autonomy, Dignity, Access, and Communication (Scheerhagen et al., 2015).

This paper reports on the impact of vulnerability on client experiences with the received antenatal care, specifically the role of process quality in general; and with a focus on the impact of sARM.

We expected vulnerable clients with manifest psychosocial problems and/or features of deprivation to more often report negative experiences with antenatal care compared to non-vulnerable clients. However, the added impact of a consequent and structured professional risk approach implying e.g. systematic psychosocial screening and intervention may go into two directions. The added professional attention and empowering approach may be welcomed, and the better caseload management (de Groot et al., 2016) may translate into better experiences; on the other hand, the inquiry into what may be felt as personal and pregnancy-unrelated affairs may be perceived as annoying, an infringement of autonomy and elicit a ‘paradoxical’ negative response in care evaluation.