A literature review on integrated perinatal care

Most individual-level studies examined interventions for patients with specific characteristics such as preterm birth, low birth weight, maternity-related deaths, or low-income mothers.

“Most of the investigations that fall into the individual practice level explore the effectiveness of health care interventions for patients who share a specific characteristic, such as pre-term births [11, 12], low-weight newborns [12], maternity-related deaths [13, 14], or low-income mothers [15, 16].”

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D'Amour et al. found that a regional initiative to integrate perinatal care had very modest success in accessibility, continuity, and relevance.

“This was the case in the study by D'Amour et al., in which the authors noted the very modest success of a regional perinatal care integrative initiative in terms of accessibility, continuity of care and relevance [18].”

• cites [18]Not matched

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The review found that research on integrated perinatal care has mainly examined continuity of care and clinical and professional integration by evaluating individual clinical practices and intervention programs.

“Researchers interested in integrated perinatal care have, by assessing the effectiveness of individual clinical practices and intervention programs, mainly addressed issues of continuity of care and clinical and professional integration.”

• AssumptionRests on an assumption: The conceptual framework is a powerful tool that supports meaningful answers and reveals useful strategies.

Earle's longitudinal study of women in first pregnancy identified aspects of the midwife-client relationship that help the expectant mother achieve the highest possible well-being during that pregnancy.

“Through a longitudinal study of mothers in their first pregnancy, Earle identifies the dimensions of the relationship between midwife and pregnant client that make it possible for the future mother to experience her first pregnancy with the greatest possible sense of well-being.”

• cites [17]Not matched

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Hemminki and Blondel's comparison of eastern and western European countries indicates no prenatal service model has a clear advantage in service use or perinatal mortality in Europe.

“Likewise, the comparison of eastern and western European countries conducted by Hemminki and Blondel indicates that no one prenatal service model displays a clear advantage in terms of service use or perinatal mortality in Europe [19].”

• cites [19]Not matched

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At the systemic level, results on the effectiveness of integrated perinatal care were rather disappointing.

“In the group of studies that explore integrated perinatal care at a systemic level, the results regarding its effectiveness appeared rather disappointing.”

For women whose pregnancies have no medical complications, biological outcomes for mother and child do not differ significantly between prenatal care led by obstetrician-gynaecologists and care led by general practitioners or midwives.

“those measuring biological results in the mother and the child suggested that, in women experiencing a pregnancy without medical complications, prenatal services led by obstetrician–gynaecologists and those provided by general practitioners or midwives do not differ significantly4.”

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Almost all of the 18 studies at the individual and systemic levels aimed solely to determine the effectiveness of the interventions examined.

“Further, the sole aim of almost all these 18 studies is to ascertain the effectiveness of the interventions under examination.”

The studies selected for the review were markedly heterogeneous in objectives, methods, duration, and contexts.

“the studies chosen were markedly heterogeneous in terms of objectives, methods, length of time being studied, and the contexts in which they were conducted.”

Women report more satisfaction when a midwife is the main perinatal care provider.

“By and large, these studies indicate that women express greater satisfaction when the principal perinatal caregiver is a midwife.”

Multidisciplinary team practices involving midwives and obstetricians are promising in terms of cost of service provision.

“Experiments in Australia [29–31] and the United States [38], in which a clinical team made up of midwives and obstetricians worked together in a community maternity clinic, show multidisciplinary team practices involving midwives and obstetricians are effective in safeguarding the health of the mother, and promising in terms of cost of service provision [38].”

• cites [38]Not matched

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Women who make up these specific clienteles value continuity of care.

“Quantitative and qualitative analyses clearly demonstrate that the women who make up these specific clienteles value continuity of care.”

When prenatal management services were provided by midwives, who received lower salaries than doctors within the same organization, operating cost economies were realized.

“Their study points out that when services were provided by professionals receiving lower salaries than doctors within the same organization (in the case being studied, prenatal management services provided by midwives), economies in operating costs were realized.”

• cites [28]Not matched

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The review identified three strategies that seem useful in adapting specific client services and making them more accessible.

“The review has allowed us to identify three strategies that seem to be useful in adapting specific client services and making them more accessible.”

The practice of midwifery, especially when carried out in isolation, is associated with an elevated perinatal mortality rate.

“Finally, in terms of clinical effectiveness, the practice of midwifery, especially when carried out in isolation [36], is associated with an elevated perinatal mortality rate.”

• cites [36]Not matched

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A UK economic evaluation using 1993-1994 data found no economic savings for the health system from reducing prenatal visit frequency.

“One evaluation of economic status in the United Kingdom, using data from 1993–1994, indicated that a decrease in the number of prenatal visits did not result in economic benefits to the health care system [22, 23].”

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A lower number of prenatal visits did not appear to change mother's or child's health measures significantly.

“Moreover, fewer prenatal visits did not seem to be associated with significant differences in the measures of the mother's and child's health [20].”

• cites [20]Not matched

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The main consensus around these articles is on the importance of prompt, regular, and adequate prenatal management to reduce health problems during the perinatal period.

“Overall, the main consensus crystallizing around these articles centers on the importance of prompt, regular and adequate prenatal management to reduce health problems during the perinatal period.”

The drop from 178 to 64 articles occurred largely because 'integration' was used for matters beyond care delivery.

“This significant reduction was mainly due to the term ‘integration’ being associated with issues other than care delivery.”

Assembled meta-analyses note a higher, although not statistically significant, rate of neonatal mortality in the group of women monitored by midwives.

“A higher, although not statistically significant, rate of neonatal mortality in the group of women monitored by midwives is noted in the assembled meta-analyses [27, 37];”

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Compared with routine or standard services, midwife teams improve continuity of care in both community and hospital settings.

“The results of the review also indicate that, in comparison with the routine or standard services in place, teams of midwives improve continuity of care, whether this involves midwife teams working in the community, as in the British experience, or midwife teams working in hospital maternity clinics, as in Australia.”

A small group of midwives who adopt a common approach to care, characterized by humanization and continuity throughout pregnancy, delivery, and postnatal period, is the model preferred by both mothers and midwives.

“In this context, a pattern emerges: a small group of midwives who adopt a common approach to care, characterized by humanization and continuity of care throughout the pregnancy, delivery and postnatal period, is the model preferred by both mothers and midwives.”

Ensuring continuity of care has positive effects, as underlined in virtually all the literature on this subject.

“The first strategy consists of ensuring continuity of care, and its positive effects are underlined in virtually all the literature on this subject [43–46].”

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A significant proportion of deaths in childbirth in the United States could be avoided by adequate pre- and postnatal management.

“Harper et al. provide a convincing illustration that a significant proportion of deaths in childbirth in the United States could be avoided by adequate pre- and postnatal management [42].”

• cites [42]Not matched

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Multidisciplinary team practices involving midwives and obstetricians are effective in safeguarding the health of the mother.

“Experiments in Australia [29–31] and the United States [38], in which a clinical team made up of midwives and obstetricians worked together in a community maternity clinic, show multidisciplinary team practices involving midwives and obstetricians are effective in safeguarding the health of the mother, and promising in terms of cost of service provision [38].”

• cites [29]Not matched

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Satisfaction is higher during the prenatal period regardless of study, country, or principal caregiver.

“The level of satisfaction is higher during the prenatal period, irrespective of the study, the country in question or the principal caregiver.”

Operating cost economies were not evident when the professionals worked in different organizations.

“Such economies were not evident when the professionals worked in different organizations [32].”

• cites [32]Not matched

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Women were more satisfied with care from family doctors and midwives than with care from obstetrician-gynaecologists.

“However, in all these cases, women expressed greater satisfaction with the services provided by family doctors and midwives than with those provided by their obstetrician–gynaecologists.”

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The profile of women who use Sweden's birthing houses resembles that of women who use birthing houses in other countries.

“This profile resembles that of women who use birthing houses in other countries [40].”

• cites [40]Not matched

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Continuity of care, in its informational and relational dimensions, was enhanced when perinatal services were provided by a small number of midwives working within the same team.

“In perinatality, continuity of care, understood in terms of its informational approach and relational dimensions [3], was enhanced when perinatal services were provided by a small number of midwives working within the same team.”

• cites [3]Not matched

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The scheduling and content of prenatal visits varied widely across countries.

“The scheduling as well as the content of prenatal visits varied widely from one country to another [20, 21].”

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Several studies identified improved exchange of clinical information between first-line general practitioners and hospitals as a way to make individual prenatal and postnatal care more effective.

“Better transmission of clinical information between first-line general practitioners and hospitals emerged in several studies as a way to enhance the effectiveness of individual clinical practice in the prenatal and postnatal periods [25].”

• cites [25]Not matched

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Higher mortality rates generally occur among women at low medical risk at the outset of their pregnancy.

“the higher mortality rates generally occur among women at low medical risk at the outset of their pregnancy.”

• cites [27]Not matched

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• cites [37]Not matched

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For certain problems, such as those associated with HIV, the interdisciplinary approach already seems to be predominant in Europe.

“For certain problems, such as those associated with HIV, the interdisciplinary approach already seems to be predominant in Europe [47].”

• cites [47]Not matched

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The third strategy emerging from the texts as having the potential to promote health and especially accessibility of care is to set up clientele-adapted services.

“Finally, the third strategy emerging from the texts as having the potential to promote health and especially accessibility of care is to set up clientele-adapted services.”

With regard to the majority of women who experience pregnancy without complications, and at the level of individual clinical practice, humanization and medical competence emerge as the most important dimensions.

“With regard to the majority of women who experience pregnancy without complications, and at the level of individual clinical practice, it is humanization and “medical” competence that emerge as the most important dimensions.”

For immigrant women, adapted services aim primarily at reducing linguistic and cultural barriers that block access to care and services.

“For immigrant women, adapted services aim primarily at reducing linguistic and cultural barriers, which block access to care and services [49].”

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Contemporary women want customized management involving a relational process with the provider or providers of perinatal services.

“In other words, contemporary women want “customized” management involving a relational process with the provider (or providers) of perinatal services [17].”

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With regard to management of general clienteles experiencing pregnancies without complications, no optimal model of task coordination and inter-organizational collaboration emerges from the studies reviewed.

“To sum up, with regard to management of general clienteles experiencing pregnancies without complications, no “optimal” model of task coordination and inter-organizational collaboration emerges from the studies reviewed, apart from the observation that perinatal services do not appear to require a tightly integrated service system to ensure better health outcomes.”

Modalities of coordination established between teams of midwives and medical personnel appear to vary widely from one country to another.

“Modalities of coordination established between teams of midwives and medical personnel appear to vary widely from one country to another.”

Care coordinating services, offering both psychosocial support and personalized assistance in accessing various organizations and services, appear to have shown effectiveness in North Carolina.

“Care coordinating services, offering both psychosocial support and personalized assistance in accessing various organizations and services, appear to have shown effectiveness in North Carolina [48].”

• cites [48]Not matched

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Articles concerning teenaged mothers seem to highlight the appeal of interdisciplinarity for this clientele.

“The articles concerning teenaged mothers also seem to highlight the appeal of interdisciplinarity for this clientele [43].”

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The review concludes that improvements in perinatal care delivery are linked not to structurally integrated delivery systems but to organizing approaches that support woman-centred care and cooperative clinical practice.

“Improvements in perinatal health care delivery appear related not to structurally integrated health care delivery systems, but to organizing modalities that aim to support woman-centred care and cooperative clinical practice.”

• AssumptionRests on an assumption: The conceptual framework is a powerful tool that supports meaningful answers and reveals useful strategies.

In perinatality, poverty and health problems are so closely intertwined that it is difficult or impossible to distinguish the physiological and socio-economic components of risk.

“In the area of perinatality, as elsewhere, problems of poverty and health are so closely intertwined that it is difficult, often impossible, to distinguish the physiological and socio-economic components of risk [41].”

• cites [41]Not matched

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Such specialized programs may mitigate disparities in health status.

“Such specialized programs may mitigate disparities in health status.”

It cannot be determined whether the greater satisfaction with midwife care comes from greater continuity of care or from the clinical practice of midwifery itself.

“However, because the services of midwives have been compared to services provided by other professionals operating within diverse models of organizing care, it is difficult to determine if this greater satisfaction is due to greater continuity of care or to the clinical practice of midwifery itself [27].”

• cites [27]Not matched

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In industrialized countries, reducing prenatal visits would likely be associated with greater dissatisfaction with services received.

“Finally, such a reduction would, in industrialized countries, likely be associated with greater dissatisfaction with services received [23].”

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An intervention can work well for individual patients yet be inefficient system-wide if made universally available.

“An intervention or procedure may prove highly effective at the individual level but be inefficient at the system level should it become universally available.”

A single intervention type seldom achieves every objective at every system level at once.

“the same type of intervention rarely enables the simultaneous achievement of all objectives at all levels of the system.”

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Health care systems in industrialized countries are developed around acute health problems.

“Health care systems in industrialized countries are developed around acute health problems [51].”

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The reviewed articles tend to demonstrate that the popularity of the multidisciplinary approach is justified.

“The multidisciplinary approach is currently very much in fashion, in research as well as in intervention, and the reviewed articles tend to demonstrate that this popularity is justified.”

A small number of caregivers working together seems the most satisfactory formula for both mothers and professional team members.

“A small number of caregivers working together thus seems the most satisfactory formula for both mothers and professional team members.”

Putting the proposed strategies in place will have a positive, if limited, effect on health and the reduction of inequalities.

“Putting the proposed strategies in place will, we believe, have a positive, if limited, effect on health and the reduction of inequalities.”

Perinatal services do not appear to require a tightly integrated service system to ensure better health outcomes.

“To sum up, with regard to management of general clienteles experiencing pregnancies without complications, no “optimal” model of task coordination and inter-organizational collaboration emerges from the studies reviewed, apart from the observation that perinatal services do not appear to require a tightly integrated service system to ensure better health outcomes.”

Continuity of care in its informational, approach, and relational dimensions would not necessarily require that services be provided entirely by the same care-provider but could be achieved by a small group of professionals, all of whom are known to the woman.

“Continuity of care (informational, approach and relational) would not necessarily require that services be provided entirely by the same care-provider but could be achieved by a small group of professionals, all of whom are known to the woman.”