Research proposal
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psy_610_individual_programmatic_assessment.docxINDIVIDUAL PROGRAMMATIC ASSESSMENT 11
Individual Programmatic Assessment: Research Proposal
March 27, 2017
PSY 610
Introduction
Pregnancy and motherhood can trigger quite of a few controversial conversations. Like that of having the support and knowledge of a care provider like an obstetrician, family physician, or midwife of a birthing plan that includes the birthing environments such as home birth and the maternity care associated. This controversy can trigger an array of emotions from expecting mothers and especially professionals that may have another view point in the management of labor and birth. Even though, it ultimately boils down to personal preference and the unique factors surrounding labor and birth from the woman like a planned home birth. Maternity professionals do not share a unified approach to the management of labor and birth.
Actually, a significant polarity in attitudes towards common maternity care practices, with obstetricians and family physicians favoring hospital deliveries and obstetric interventions (Davis -Floyd,1994), and midwives favoring a low-intervention approach to labor and birth, either at home or the hospital is a conflict. In this paper, the development of a scale that measures attitudes of multidisciplinary care providers towards home birth will be described. To examine the sources of potential conflict among maternity providers around women’s choice of birth setting, the Canadian Birth Place Study was set up to evaluate the many factors and personal, educational and practice experiences, that are associated with attitudes towards home birth among family physicians, obstetricians, and midwives.
Background
Currently, across the United States, pregnant women can opt to choose an obstetrician or a midwife as a primary maternity provider, and their comprehensive pregnancy and birth care is funded either out of pocket or through insurance. All obstetricians that provide intra-partum care deliver exclusively in hospitals. Midwives on the other hand can offer choices of birth place like that the home, hospital, or birthing center. The national rate of planned home birth as of 2012 is at 1.36% with a midwife or free birth which is labor and delivery without professional assistance while, delivery at a hospital or birthing center is with an obstetrician or a certified midwife (Bovbjerg, Cheyney, Everson, Gordon, Hannibal, Vedam, 2014). Hence, many different factors and professionals can be involved in the women’s decision making as to where they choose to give birth.
Review of Literature
The Canadian Birth Place study was designed to evaluate the opinions and experiences with planned home births among all types of maternity providers, and the potential impact of these attitudes on inter-professional collaboration across birth settings. Few studies have explored and measured attitudes towards home birth across the maternity professions. In 2007, Vedam developed and evaluated a 20 item ‘Provider Attitudes towards Planned Home Birth scale' (PAPHB) and applied it to Certified Nurse-Midwives, in the United States. Educational and practice exposure to planned home birth, age, inter-professional relationships, and financial concerns emerged as significant covariates of attitudes. This study was conducted using survey research and fieldwork research. This study took place in the United States and Canada. The participants were chosen by their profession. In Canada, the participants were Registered Midwives. In the United States, the participants were Certified Nurse- Midwives. The study was conducted by asking each participant 20 survey questions about their experience with home births as well as the experience of the mother and newborn. In regards, to the validity of the information provided in the survey, the researchers used a comparative approach when collecting the information regarding education, experience, certifications, as well as their feelings towards planed home-births. It was found that Certified Nurse-Midwives lack of confidence in their own ability to manage complications in the home associated with less favorable attitudes and are less willing to provide care in the home setting. This previous research informed the survey and scale development for the Canadian Birth Place Study.
Purpose of the Study
The purpose of this study is to get an in-depth look at the experience that a homebirth can provide to both the mother and the child, when monitored by a trained professional. We aew looking at provider beliefs about the normalcy of birth, the ability to provide skilled emergency care, and risks of loss or liability from home birth are some of the assumptions that have an unfavorable point of view. While, favor from midwives believe that home birth is safe and can enhance maternal-newborn benefits of individualized care, facilitates bonding, and empowerment (Janssen, Saxell, Page, Klein, Liston, Lee, 2009).
Research Methods and Procedures
Study design
A comprehensive survey of attitudes towards planned home birth among physicians and midwives were assessed. The survey measured the construct of “attitudes to home birth” in four subdomains: the safety of planned home birth, maternal/newborn outcomes from planned home births, maternal/newborn benefits from home births, and inter-professional experiences and engagement with home birth practice.
Random obstetricians (n=835), registered midwives (n=759), and a random sample of family physicians (n=3000) were invited during the quantitative phase to complete this comprehensive survey that included information about their demographic profile, education and practice experiences with home birth (39 items), and 48 attitude items. Response options for each attitude item ranged from 1 (strongly disagree) to 5 (strongly agree). To participate in the survey registered midwives, obstetricians, and family physicians were contacted via multiple avenues such as e-mail, direct postcards, posters, and fax, and reminders at 2–3 week intervals.
Scale Construction
Results for each provider type were analyzed to select items for an attitude scale that could be used as an outcome measure. The correlation between each item score and the total score of the 48 attitude items was first examined. The 17 items that had Pearson correlational coefficients exceeding 0.3 for each care provider group (obstetricians, midwives, family physicians) were retained for inclusion in the scale. Next, a calculation of internal consistency for the 17 items was measured. The overall scale alpha was excellent for the full sample (Cronbach’s alpha = 0.974), and good for each care provider group (MW alpha = 0.795; GP alpha = 0.922; OB alpha = 0.839). This meant that together the 17 items measured a single construct and should not be split into subscales. Factor loadings for the 17 items ranged from 0.326 to 0.759 for obstetricians, to 0.347 to 0.832 for GPs, and 0.269 to 0.628 for midwives. Higher scores indicate more favorable attitudes towards planned home birth.
Data analysis
The care provider variable was entered into a linear regression model, with the 17 item PAPHB-m scale score as the outcome variable, to determine how much variance in attitudes towards planned home birth could be accounted for by type of care provider alone. A negative coefficient indicates that the item is correlated with more unfavorable attitudes; a positive coefficient means that the item is associated with more favorable attitudes towards home birth.
Results
950 care providers responded to the survey. The final sample size was comprised of 825 care providers: 451 midwives, 235 obstetricians and 139 family physicians. The response rate was 18.1% (of invited care providers). Response rates were highest for midwives (59.4%) and lowest for family physicians (4.6%). Midwives were the youngest group of providers (mean age = 41.3) followed by obstetricians (mean age = 46.5) and family physicians (mean age = 48.1). Most midwives who responded to the survey were female (99.3%), compared to 55.6% of obstetricians and 54.0% of family physicians. The results showed that 2.2% of family physicians had very little exposure to home birth during medical school and practice, 1% of obstetricians learned about planned home birth as part of their core curriculum, whereas 82.7% of midwives reported that their curriculum included coursework about planned home birth. 99.1% of midwives reported providing intra-partum care in the home, only 5% of family physicians, and 1% of obstetricians had this experience.
Scale Scores
The Provider attitudes to planned home birth Scale – m has a hypothetical range of 17–85, with scores below 51 indicate unfavorable attitudes towards home birth and scores exceeding 68 indicate favorable attitudes. Scores between 51 and 67 represent neutral attitudes. These categories were derived as follows: A score of 3 on an individual item indicated a neutral attitude towards that item, scores of 1 and 2 denoted disagreements with the item and scores of 4 and 5 indicated agreement. By multiplying these response options by the number of scale items, cut off scores were created to allow better interpretation where each care provider group falls on the scale.
Midwives (n = 451) scored an average of 78.65, with less dispersion around the mean (SD = 6.28) compared to the other two care provider groups. The median score of midwives was 80 (5th, 95th percentiles: 68, 85). Almost all midwives fell into the favorable range of the scale.
Obstetricians (n=239) had a mean score of 34.43 on the scale (SD = 9.75) and a median score of 33 (5th, 95th percentiles: 21, 51). Most obstetricians fell into the unfavorable range; obstetricians who scored in the 95th percentile on the scale held neutral attitudes towards home birth, on average.
Family physicians (n=139) scored an average of 41.58 points with the most dispersion around the mean (SD = 14.25). The median score of family physicians was 38 (5th, 95th percentiles: 22, 71). Family physicians, on average, scored in the unfavorable range; however the 95th percentile of family physicians scored in the favorable range.
Implications
The barriers to maternity care include differences in provider models that are noted in the different scopes of practice and curriculum. Curriculum for physicians and midwives differ significantly because of differences in the scopes and sites of practice of these health professionals. Less favorable attitudes among both physicians and internationally educated midwives may indicate a need for additional education and/or resources to assist them to become comfortable with the model of midwifery care, including requirements for home birth practice.
Midwives are required by regulation to provide care in all settings while, physicians are restricted to hospital births by many professional policies and home birth is not easily integrated into office practice. Also insurance and monetary reimbursement for services by different types of professionals may also raise obstacles when providing maternity care. All of these factors may contribute to differences in attitudes and philosophy of care.
Maternity care providers and the woman’s environmental choice of where to have a baby can be reviewed in a research article from the Canadian Birth Place Study in 2009 on how a woman’s choice can be influenced. The College of Physicians and Surgeons of BC reversed its previous stance, prohibiting physicians from attending home birth and published new Guidelines on Planned Home Birth which state, “When a woman is considering planned home birth, physicians play an important role in providing advice and information so that it is an informed choice, considering all the benefits and potential adverse outcomes …Physicians involved in planned home births need to ensure that they have appropriate knowledge, training, equipment and understanding of the assessments necessary in planned home delivery.”
The development of systems that can deliver high-quality, cost-effective, and equitable maternity care to all populations, must consider both roles and interactions among different types of health professionals, even when women have access to highly-resourced care.
Even when physicians and midwives practice in different settings, and the course of pregnancy is normal, the nature of perinatal care requires effective communication among all types of maternity providers. The significant differences in attitudes to planned home birth and the covariates of these attitudes suggest that an increased emphasis in health professional education on preparation for practice in all birth places is important for family physicians, and obstetricians, as well as midwives. The data suggest that developing inter-professional competencies for the best care and communication when collaborating for women across several birth settings may increase favorability among physicians and midwives. Ultimately, understanding the perceptions and actual obstacles to inter-professional practice may inform the design of effective evidence-based models for delivery of maternity care across many birth environments.
References
Bovbjerg, M., Cheyney, M., Everson, C., Gordon, W., Hannibal, D., Vedam, S. (2014). The MANAStats 2.0 Dataset: Key outcomes from planned home and birth center births in the United States. Journal of Midwifery and Women’s Health
Davis -Floyd, R. (1994). The Rituals of American Hospital Birth. In Conformity and Conflict: Readings in Cultural Anthropology. David McCurdy, ed. 8th ed. Pp. 323-340. New York: HarperCollins.
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Janssen, P.A., Saxell, L., Page, L.A., Klein, M.C., Liston, R.M., Lee, S.K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Medical Association. 181:377-83.
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Vedam, S., Klein, M.C., Stoll, K., Dharamsi, S. (2013) The Canadian Birth Place Study Team: Midwives and Physicians: Explaining Conflict and Controversy Around Home Birth.
