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Salutogenically focused outcomes in systematic reviews of intrapartum

interventions: A systematic review of systematic reviews

Valerie Smith, RM, PhD (Lecturer in Midwifery)

a,n

, Deirdre Daly

RM, MSc (Lecturer in Midwifery)

a

, Ingela Lundgren, RM, PhD (Professor of Midwifery)

b

,

Tine Eri, RM, PhD (Lecturer in Midwifery)

c

, Carina Benstoem

RM, MSc (Research Associate)

d

, Declan Devane, RM, PhD (Professor of Midwifery)

e

a

School of Nursing & Midwifery, University of Dublin, Trinity College Dublin, Dublin, Ireland b

Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden c

Faculty of Health Sciences, Vestfold University College, Norway

dMidwifery Research and Education Institute, Department of Obstetrics, Gynaecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany

e

School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland

a r t i c l e i n f o

Article history: Received 17 April 2013 Received in revised form 31 October 2013

Accepted 4 November 2013

Keywords: Salutogenesis

Salutogenically-focused outcomes Systematic review

Intrapartum interventions

a b s t r a c t

Introduction: research on intrapartum interventions in maternity care has focused traditionally on the identification of risk factors' and on the reduction of adverse outcomes with less attention given to the measurement of factors that contribute to well-being and positive health outcomes. We conducted a systematic review of reviews to determine the type and number of salutogenically-focused reported outcomes in current maternity care intrapartum intervention-based research. For the conduct of this review, we interpreted salutogenic outcomes as those relating to optimum and/or positive maternal and neonatal health and well-being.

Objectives: to identify salutogenically-focused outcomes reported in systematic reviews of randomised trials of intrapartum interventions.

Review methods: we searched Issue 9 (September) 2011 of the Cochrane Database of Systematic Reviews for all reviews of intrapartum interventions published by the Cochrane Pregnancy and Childbirth Group using the group filter “hm-preg”. Systematic reviews of randomised trials of intrapartum interventions were eligible for inclusion. We excluded protocols for systematic reviews and systematic reviews that had been withdrawn. Outcome data were extracted independently from each included review by at least two review authors. Unique lists of salutogenically and non-salutogenically focused outcomes were established. Results: 16 salutogenically-focused outcome categories were identified in 102 included reviews. Maternal satisfaction and breast feeding were reported most frequently. 49 non-salutogenically-focused outcome categories were identified in the 102 included reviews. Measures of neonatal morbidity were reported most frequently.

Conclusion: there is an absence of salutogenically-focused outcomes reported in intrapartum intervention-based research. We recommend the development of a core outcome data set of salutogenically-focused outcomes for intrapartum research.

&2013 Elsevier Ltd. All rights reserved.

Contents

Introduction. . . e152 Aim of review . . . e152 Methods. . . e152 Criteria for considering reviews for inclusion . . . e152 Search methods for identification of reviews . . . e152 Data collection and management . . . e152

Contents lists available atScienceDirect

journal homepage:www.elsevier.com/midw

Midwifery

0266-6138/$ - see front matter&2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.midw.2013.11.002

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Findings . . . e153 Screening and selection of included reviews . . . e153 Salutogenically focused reported outcomes . . . e153 Discussion . . . e154 Conclusion . . . e156 Acknowledgements . . . e156 References . . . e156

Introduction

The concept of salutogenesis wasrst introduced by Aaron Antonovsky while he was studying the psychological impact of surviving concentration camps (Antonovsky, 1987). Antonovsky explored how some people who had experienced extremely stressful life events remained resilient and positive about their lives. Antonovsky asked ‘what creates health?’ and began to form a new theoretical framework for health, which he coined

‘salutogenesis’. A key component of salutogenesis is that of a

‘sense of coherence’, which postulates that an individual who can view the world as manageable (i.e. easilyfind resources for coping), comprehensible (perceived clarity, order and structure) and meaningful (has purpose) is more likely to view their life as coherent. In this sense, no matter how extreme an indivi-dual's experience might be, they will have the ability to cope positively with adverse events. Salutogenesis was the first theory of its kind to explore health systematically in terms of movement along the health continuum, thereby eliminating a distinct dichotomy of being in a state of health or being in a state of disease.

Antonovsky's question of ‘what creates health’is relevant to pregnancy and childbirth, which has long been considered on two parallel views: one views pregnancy and childbirth as a normal physiological event in line with health and salutogenesis whereas the second views pregnancy and childbirth as a pathology, which only becomes normal in retrospect. Research in maternity care has focused traditionally on the reduction of adverse outcomes with little consideration for what is optimum, for whom and in what context. In this sense, much research in maternity care has focused on the prevention of adversity rather than on the promotion of health. The problem with only focusing on adversity is linked with a critique of the so-called ‘risk society’(Beck, 1992) in which a super-valuing of risk leads to a paradoxical decrease in well-being. The consequences of risk aversion in maternity care, contrary to evidence suggesting that risk in maternity care is ambiguous and ill-defined (Smith et al., 2012), are that interventions designed to manage high-risk pregnancy and labour have become over-extended to routine use in all childbearing women. The accelera-tion of this way of managing birth has resulted in increased intervention in childbirth; for example, rates of caesarean birth are over 80% in some maternity units in Europe and as high as 38% in one EU country (EURO-PERISTAT, 2008). Such an interventionist approach suggests that there is little understanding of what contributes to/enhances the health and the well-being of women and what constitutes salutogenically focused outcomes in mater-nity care. As a first step, we evaluate current maternity care intrapartum intervention-based research to determine the type and number of salutogenically-focused reported outcomes and to do so by means of a systematic review of reviews. This systematic review of reviews constitutes one element of an initiative aimed at developing a minimum core data set of salutogenically-focused outcomes for reporting in maternity care research. The conduct and reporting of this review adheres to, in as far as is possible, the PRISMA checklist of reporting of systematic reviews (Moher et al.,

2009).

Aim of review

To identify salutogenically-focused outcomes reported in sys-tematic reviews of intrapartum interventions.

For the purposes of this review, we used a broad definition of the term‘salutogenesis’as it relates to optimum (and/or positive) maternal and neonatal health and well-being. Guiding our defi ni-tion were certain attributes from the ‘salutogenesis umbrella’

(Fig. 1), including, for example, coping, locus of control, sense

of coherence and attachment. We defined a salutogenically-focused outcome as an outcome reflecting positive health and well-being rather than illness or adverse event prevention or avoidance.

Methods

Criteria for considering reviews for inclusion

Systematic reviews of randomsied trials of intrapartum interven-tions were eligible for inclusion. An intrapartum intervention was defined as any intervention that occurred from the latent phase of labour (i.e. a period of time when there are painful uterine contrac-tions, and there is some cervical change, including cervical efface-ment and dilatation up to 4 cm;National Institute of Health and

Clinical Excellence, 2007) up to, and including, the time of birth of

the placenta and membranes. We excluded protocols for systematic reviews and systematic reviews that had been withdrawn.

Search methods for identification of reviews

We searched Issue 9 (September) 2011 of the Cochrane Database of Systematic Reviews for all reviews published by the Cochrane Pregnancy and Childbirth Group using the groupfilter ‘hm-preg’

(a tag used to identify reviews registered with the Cochrane Pregnancy and Childbirth Group where‘hm’stands for‘home’code and‘preg’is the Group's suffix) and restricting retrieved citations to completed reviews only (i.e. excluding protocols for reviews). Cita-tions were exported to Endnote. Each citation was reviewed inde-pendently by at least two members of the team against the inclusion criteria in two stages as follows: (1) title and abstract screening and (2) full text screening of citations judged relevant or potentially relevant for inclusion from stage 1.

Data collection and management

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Findings

Screening and selection of included reviews

Fig. 2provides aflow diagram detailing the process for and

results of screening and selecting the systematic reviews for inclusion.

Salutogenically focused reported outcomes

Fig. 3details the results of the data extraction process.

Following the data extraction process, a list of 135 salutogenically-focused outcomes were identified and collapsed into 16 outcome categories (for example, any positive reference to breast feeding) (Table 1).

436 systematic reviews identified from Cochrane Pregnancy & Childbirth group (Sept 2011)

Reviewer pair 1

n = 147

Included n = 39

Reviewer pair 2 n = 143

Included n = 36

Reviewer pair 3 n = 145

Included n = 27

Total included

n = 102 Random allocation of reviews for

[image:3.595.141.464.154.393.2]

independent screening

Fig. 2.Screening and selection of reviews for inclusion.

[image:3.595.140.469.441.733.2]
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The list of the 1632 unique non-salutogenically-focused reported outcomes in the 102 included reviews collapsed into 49 outcome categories (for example, Apgar score) are provided in Table 2. The number of times the outcome was reported is also provided.

Discussion

The aim of this review was to identify salutogenically-focused reported outcomes in systematic reviews of intrapartum interven-tions. Sixteen salutogenically-focused outcome categories (represent-ing 135 individual reported outcomes across all reviews) were identified in the 102 reviews. Measures of maternal satisfaction and breast feeding were the most frequently reported salutogenically-focused outcomes. This compares unfavourably to a unique list of 49 non-salutogenically-focused outcome categories (representing 1632

individually reported outcomes across all reviews) reported in the included reviews, with certain outcomes (e.g. neonatal morbidity and bleeding/blood loss outcomes) reported more frequently than other outcomes.

The findings of our review support the hypothesis that the effectiveness of intrapartum interventions is measured against adverse outcomes rather than increases in measures of health and well-being and/or elements of salutogenesis (e.g. a ‘sense of coherence’(SOC)). Avoidance of adversities are crucial elements when considering maternity care provision and this is not to say that they should not be included when measuring the effects of interventions. However, the consistent, dominant focus on risk-reduction continues to form the basis for policy and practice development (Royal College of Midwives, 2005) with little con-sideration for outcomes indicative of maternal and neonatal positive health or well-being. In maternity care, salutogenesis

Reviews included

n = 102

Salutogenically focused

outcome categories

n = 23

Consensus meeting

outcome categories

excluded

n = 7

Number of outcome

categories

n = 16

Non-salutogenically

focused outcome

categories

n = 49

Within pair independant

[image:4.595.130.459.58.560.2]

data extraction and

pooling of outcomes

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has been described as both a descriptor of the birth process and as an outcome of that process (Downe, 2001). Positive views of birth and the birth experience, even for women undergoing medically managed and technological birth or for women who experience birth contrary to their preconceived expectations or desires, are strongly related to salutogenesis and the elements of manage-ability, comprehensibility and meaningfulness (Downe, 2001). In this sense, irrespective of the type of birth experienced, women who can easilyfind resources for coping, achieve perceived clarity, order and structure and emotionally reconcile with a sense of purpose, will undergo a salutogenic birth. The baseline argument here, in promoting a salutogenically orientated approach to maternity care, is a dedicated move away from a mono-focus on

‘risk factors’and an alternative move towards a ‘health factors’

focused approach (Day-Stirk and Palmer, 2003).

[image:5.595.309.554.79.742.2]

This work comprises one element of an initiative exploring the concept of salutogeneis in maternity care provision. Focusing solely on intrapartum intervention-based research limits our review to a select group of maternity service users (i.e. women undergoing labour and birth only) and to measurements of effectiveness against outcomes specific to the intrapartum period. However, our review was intentionally focused neither on specific populations nor on any particular intervention per se, rather on reported outcomes and whether they were salutogenic or not. We identified a paucity of salutogenically-focused outcomes when compared to non-salutogenically focused outcomes. This has implications for maternity care research in that the avoidance of ill-health or adversity remains the key driver for measuring the effectiveness of interventions. Adopting a more salutogenically-focused approach to maternity care research by incorporating salutogenically-focused outcome measures, such as the ones identified here, has the potential to provide evidence on women's (or other research participants') levels of well-being and on their sense of coherence (i.e. by collecting data on measures of coping, satisfaction, mother–infant interactions, etc.). It will allow for positive measures of maternal health to be identified and perhaps clarify more easily, in the context of the comparative effects of maternity care interventions, which interventions are promotional of positive health and well-being. For example, measuring mater-nal satisfaction as a core outcome measure will provide evidence on the effectiveness of interventions from a SOC perspective. Incorporating salutogenically-focused outcome measures in mater-nity care research will encourage health care providers, policy-makers and maternity service users to consider maternity care from a health-orientated client-based perspective rather than from a

Table 2

Unique list of non-salutogenically focused reported outcomes.

Non-salutogenically-focused outcomes No. of times individual outcome was reported

Composite of infant morbidity outcomes (short-/long-term; including any disability, HIE, asphyxia, seizures, RDS, PVL, cerebral palsy, etc.)

141

Bleeding/blood loss (of any type and variously defined)

129

Maternal infection (fever/temperature/sepsis, etc.)

74

Apgar score (at 1, 5 or 10 minutes oro7 or

‘low’atr5 minutes)

76

Fetal death, neonatal loss or stillbirth 65 Hospitalisation (length of stay, admission,

readmission, etc.)

60

‘Pain’of any type including assessment 56 Caesarean birth (for any reason) 55 Analgesia (request for/any type, epidural,

narcotics, GA, etc.)

52

‘Drugs’other than analgesics (administration/ side effects, etc.)

50

Neonatal admission to NICU/SCBU 49 Maternal mortality or serious morbidity (not

specified)

48

Labour length/duration (length of any stage, prolonged labour, etc.)

47

Neonatal infection (fever/sepsis including specific types of infections)

43

Any instrumental/assisted vaginal birth 41 Perineal/vaginal trauma (of any type including

episiotomy)

38

Preterm (birth, retinopathy of prematurity, gestational age at birth)

37

Nausea/vomiting/dehydration 35

Adverse event/outcome, serious complication–

maternal

33

Maternal negative related-expression (anxiety, dissatisfaction, fatigue, depression, low self-esteem, PTSD, etc.)

32

Labour and/or birth trauma 32

Resuscitation measures, arrest or LOC (maternal or infant)

31

Miscellaneous/other (fetal-maternal haemorrhage, zavanelli procedure, pulmonary oedema, additional tests, cord prolapse, etc.)

30

Induction and/or labour augmentation (ARM/ oxytocin)

29

Any pH levelso7.20 and BD412.0 25

Blood transfusion 25

Cost/economic outcomes 22

Blood pressure (hyper-/hypotension) 22 Uterine (expulsive effort, hyperstimulation,

rupture, etc.)

22

Fetal heart rate monitoring 20

Placenta (retained, manual removal, etc.) 20 Wound (haematoma, wound healing,fistula of

any type, etc.)

19

Fetal blood sampling (umbilical cord blood, FBS, lactate)

17

Mode of birth (unspecified) 16 Anaemia (or any reference to Hb levels/iron

administration)

16

Incontinence (any type) 16

Jaundice 16

Meconium stained liquor/meconium aspiration syndrome

13

Negative expression of breast feeding (failure, not established, etc.)

12

Anaesthesia with gastric reference (Mendelson's syndrome, etc.)

11

Negative expression of mother–infant interaction (detachment, difficulty with infant, prolonged crying, etc.)

10

Maternal admission to ICU 8

[image:5.595.44.293.80.252.2]

Birth weight 8

Table 1

Unique list of salutogenically focused reported outcomes.

Salutogenically-focused outcome categories No. of times individual outcome was reported

Maternal satisfaction with care, experience, etc. 51 Breast feedingn(e.g. initiation, duration, success) 32 Controln(perceived/personal control) 12 Spontaneous vaginal birth (or‘normal vaginal birth’) 6 Positive relationship with infant/bonding 6 Well-being (mother/father, psychological/emotional) 5

nCaregiver experience/satisfaction 5

Viewsn(mother's and/or father's) 4

Mobility during labour 3

Pregnancy prolongation 3

Spontaneous rupture of membranes 2

Comfort 2

Maternal perception of pain experiencedn 2

Maternal parenting confidence 1

Relaxation 1

Intact perineum 1

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perspective typified by morbidity and mortality, the latter of which is, at times and despite best health care treatment efforts, uncontrol-lable and uncertain in any event.

Given the relative absence of salutogenically-focused reported outcomes identified in our systematic review of reviews, we recom-mend the development of a core data set of salutogenic outcomes for reporting in maternity care research. Development of a data set such as this has the potential to incorporate measures of effect based on health and well-being outcomes rather than solely on adversity and/or ill-health. Data set development needs to consider involvement of clinically-based health care professionals, maternity health care researchers and users of maternal health services. Ideally, it is hoped that a database such as this would inform choice and selection of outcomes for reporting in studies and in systematic reviews of such studies in an effort to move towards a more salutogenically-focused approach to maternity care provision.

Conclusion

This systematic review of reviews represents afirst step in a broader research-based initiative aimed at exploring the concept

of salutogenesis in maternity care research which ultimately aims to develop a minimum core data set of salutogenically-focused outcomes for reporting in maternity care research. Further research is needed to identify salutogenically-focused outcomes that span the pregnancy, childbirth and postpartum continuum. Methods for conducting this research are currently being proposed.

Acknowledgements

This work was performed as part of the COST Action IS0907

‘Childbirth Cultures, Concerns, and Consequences: Creating a Dynamic EU Framework for Optimal Maternity Care’ which is funded by the EU 7th Framework Programme.

References

Antonovsky, A., 1987. Unravelling the Mystery of Health: How People Manage Stress and Stay Well. Jossy-Bass, California.

Beck, U., 1992. Risk Society. Towards a New Modernity. Sage, London.

Day-Stirk, F., Palmer, L., 2003. The RCM virtual institute for birth: promoting

normality. Midwives 6, 64–65.

Downe, S., 2001. Defining normal birth. MIDIRS Midwifery Digest 11, s31–s33.

EURO-PERISTAT Project, 2008. European Perinatal Health Report.〈http://www. europeristat.com〉.

Lindström, B., Eriksson, M., 2010. The Hitchhiker’s Guide to Salutogenesis:

Saluto-genic Pathways to Health Promotion. Helsinki, Folkhälsan Research Center.

Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., 2009. The PRISMA Group Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6 (7), e1000097, http://dx.doi.org/10.1371/journal.

pmed.1000097.

National Institute of Health and Clinical Excellence, 2007. Intrapartum Care. Care of Healthy Women and Their Babies During Childbirth. National Institute of Health and Clinical Excellence, London.

Royal College of Midwives, 2005. Midwives rebirthing midwivery,〈http://www.

rcm.org.uk/midwives/features/rebirthing-midwifery〉 (accessed 10 January

2013).

Smith, V., Devane, D., Murphy-Lawless, J., 2012. Risk in maternity care: a concept

[image:6.595.35.281.74.168.2]

analysis. International Journal of Childbirth 2, 126–135.

Table 2(continued)

Non-salutogenically-focused outcomes No. of times individual outcome was reported

Headache 7

Surgical reference (type of surgery, duration of surgery, etc.)

7

Thromboembolic event (DVT, PE) 6 Fetal position (mal-presentation, change, etc.) 5 Transition to extra-uterine life 4

Figure

Fig. 2. Screening and selection of reviews for inclusion.
Fig. 3. Data extraction process.
Table 2
Table 2 (continued )

References

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