Midwifery 30 (2014) e151–e156
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
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 Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden Faculty of Health Sciences, Vestfold University College, Norway d Midwifery 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 b c
art ic l e i nf o
a b s t r a c t
Article history: Received 17 April 2013 Received in revised form 31 October 2013 Accepted 4 November 2013
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 We excluded protocols for systematic reviews and systematic reviews that had been withdrawn.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 interventionbased research. We recommend the development of a core outcome data set of salutogenically-focused outcomes for intrapartum research. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Salutogenesis Salutogenically-focused outcomes Systematic review Intrapartum interventions
Contents Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aim of review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Criteria for considering reviews for inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search methods for identification of reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data collection and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n
Corresponding author. School of Nursing and Midwifery, University of Dublin, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland. E-mail address: [email protected] (V. Smith).
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Screening and selection of included reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Salutogenically focused reported outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Introduction Aim of review The concept of salutogenesis was first 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. easily find 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 individual'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 overextended to routine use in all childbearing women. The acceleration 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 maternity 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).
To identify salutogenically-focused outcomes reported in systematic 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 definition were certain attributes from the ‘salutogenesis umbrella’ (Fig. 1), including, for example, coping, locus of control, sense of coherence and attachment. We defined a salutogenicallyfocused 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 interventions 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 contractions, and there is some cervical change, including cervical effacement 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 group filter ‘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). Citations were exported to Endnote. Each citation was reviewed independently 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 Data were extracted from each included review independently by at least two review authors using a purposively developed data extraction form. Any disagreements were resolved through within pair discussions or deferral to the team for discussion and consensus (a consensus meeting was held with all team members in attendance to agree on the final list of salutogenicallyfocused outcome categories). Unique lists of salutogenicallyfocused and non-salutogenically-focused outcome categories were identified.
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Findings
Salutogenically focused reported outcomes
Screening and selection of included reviews
Fig. 3 details 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).
Fig. 2 provides a flow diagram detailing the process for and results of screening and selecting the systematic reviews for inclusion.
Fig. 1. Salutogenesis umbrella. (Reproduced with permission from Bengt Lindström (Lindström and Eriksson, 2010.)).
436 systematic reviews identified from Cochrane Pregnancy & Childbirth group (Sept 2011)
Random allocation of reviews for independent screening
Reviewer pair 1
Reviewer pair 2
Reviewer pair 3
n = 147
n = 143
n = 145
Included
Included
Included
n = 39
n = 36
n = 27
Total included n = 102
Fig. 2. Screening and selection of reviews for inclusion.
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Reviews included n = 102
Within pair independant data extraction and pooling of outcomes
Non-salutogenically
Salutogenically focused outcome categories n = 23
focused outcome categories n = 49
Consensus meeting outcome categories excluded n=7
Number of outcome categories n = 16
Fig. 3. Data extraction process.
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 interventions. Sixteen salutogenically-focused outcome categories (representing 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 salutogenicallyfocused 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 riskreduction continues to form the basis for policy and practice development (Royal College of Midwives, 2005) with little consideration for outcomes indicative of maternal and neonatal positive health or well-being. In maternity care, salutogenesis
V. Smith et al. / Midwifery 30 (2014) e151–e156
Table 1 Unique list of salutogenically focused reported outcomes. Salutogenically-focused outcome categories
Maternal satisfaction with care, experience, etc. Breast feedingn (e.g. initiation, duration, success) Controln(perceived/personal control) Spontaneous vaginal birth (or ‘normal vaginal birth’) Positive relationship with infant/bonding Well-being (mother/father, psychological/emotional) n Caregiver experience/satisfaction Viewsn (mother's and/or father's) Mobility during labour Pregnancy prolongation Spontaneous rupture of membranes Comfort Maternal perception of pain experiencedn Maternal parenting confidence Relaxation Intact perineum n
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Table 2 Unique list of non-salutogenically focused reported outcomes.
No. of times individual outcome was reported 51 32 12 6 6 5 5 4 3 3 2 2 2 1 1 1
Positive reference.
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 manageability, comprehensibility and meaningfulness (Downe, 2001). In this sense, irrespective of the type of birth experienced, women who can easily find 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). 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 salutogenicallyfocused 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 maternal satisfaction as a core outcome measure will provide evidence on the effectiveness of interventions from a SOC perspective. Incorporating salutogenically-focused outcome measures in maternity care research will encourage health care providers, policymakers and maternity service users to consider maternity care from a health-orientated client-based perspective rather than from a
Non-salutogenically-focused outcomes
Composite of infant morbidity outcomes (short-/long-term; including any disability, HIE, asphyxia, seizures, RDS, PVL, cerebral palsy, etc.) Bleeding/blood loss (of any type and variously defined) Maternal infection (fever/temperature/sepsis, etc.) Apgar score (at 1, 5 or 10 minutes or o7 or ‘low’ at r 5 minutes) Fetal death, neonatal loss or stillbirth Hospitalisation (length of stay, admission, readmission, etc.) ‘Pain’ of any type including assessment Caesarean birth (for any reason) Analgesia (request for/any type, epidural, narcotics, GA, etc.) ‘Drugs’ other than analgesics (administration/ side effects, etc.) Neonatal admission to NICU/SCBU Maternal mortality or serious morbidity (not specified) Labour length/duration (length of any stage, prolonged labour, etc.) Neonatal infection (fever/sepsis including specific types of infections) Any instrumental/assisted vaginal birth Perineal/vaginal trauma (of any type including episiotomy) Preterm (birth, retinopathy of prematurity, gestational age at birth) Nausea/vomiting/dehydration Adverse event/outcome, serious complication – maternal Maternal negative related-expression (anxiety, dissatisfaction, fatigue, depression, low selfesteem, PTSD, etc.) Labour and/or birth trauma Resuscitation measures, arrest or LOC (maternal or infant) Miscellaneous/other (fetal-maternal haemorrhage, zavanelli procedure, pulmonary oedema, additional tests, cord prolapse, etc.) Induction and/or labour augmentation (ARM/ oxytocin) Any pH levels o 7.20 and BD 412.0 Blood transfusion Cost/economic outcomes Blood pressure (hyper-/hypotension) Uterine (expulsive effort, hyperstimulation, rupture, etc.) Fetal heart rate monitoring Placenta (retained, manual removal, etc.) Wound (haematoma, wound healing, fistula of any type, etc.) Fetal blood sampling (umbilical cord blood, FBS, lactate) Mode of birth (unspecified) Anaemia (or any reference to Hb levels/iron administration) Incontinence (any type) Jaundice Meconium stained liquor/meconium aspiration syndrome Negative expression of breast feeding (failure, not established, etc.) Anaesthesia with gastric reference (Mendelson's syndrome, etc.) Negative expression of mother–infant interaction (detachment, difficulty with infant, prolonged crying, etc.) Maternal admission to ICU Birth weight
No. of times individual outcome was reported 141
129 74 76 65 60 56 55 52 50 49 48 47 43 41 38 37 35 33 32
32 31 30
29 25 25 22 22 22 20 20 19 17 16 16 16 16 13 12 11 10
8 8
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Table 2 (continued ) Non-salutogenically-focused outcomes
Headache Surgical reference (type of surgery, duration of surgery, etc.) Thromboembolic event (DVT, PE) Fetal position (mal-presentation, change, etc.) Transition to extra-uterine life Symphysiotomy
No. of times individual outcome was reported 7 7 6 5 4 2
perspective typified by morbidity and mortality, the latter of which is, at times and despite best health care treatment efforts, uncontrollable and uncertain in any event. Given the relative absence of salutogenically-focused reported outcomes identified in our systematic review of reviews, we recommend 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 a first 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: Salutogenic 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 analysis. International Journal of Childbirth 2, 126–135.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
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 Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden Faculty of Health Sciences, Vestfold University College, Norway d Midwifery 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 b c
art ic l e i nf o
a b s t r a c t
Article history: Received 17 April 2013 Received in revised form 31 October 2013 Accepted 4 November 2013
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 interventionbased research. We recommend the development of a core outcome data set of salutogenically-focused outcomes for intrapartum research. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Salutogenesis Salutogenically-focused outcomes Systematic review Intrapartum interventions
Contents Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aim of review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Criteria for considering reviews for inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search methods for identification of reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data collection and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n
Corresponding author. School of Nursing and Midwifery, University of Dublin, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland. E-mail address: [email protected] (V. Smith).
0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.11.002
e152 e152 e152 e152 e152 e152
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Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Screening and selection of included reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Salutogenically focused reported outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Introduction Aim of review The concept of salutogenesis was first 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. easily find 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 individual'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 overextended to routine use in all childbearing women. The acceleration 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 maternity 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).
To identify salutogenically-focused outcomes reported in systematic 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 definition were certain attributes from the ‘salutogenesis umbrella’ (Fig. 1), including, for example, coping, locus of control, sense of coherence and attachment. We defined a salutogenicallyfocused 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 interventions 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 contractions, and there is some cervical change, including cervical effacement 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 group filter ‘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). Citations were exported to Endnote. Each citation was reviewed independently 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 Data were extracted from each included review independently by at least two review authors using a purposively developed data extraction form. Any disagreements were resolved through within pair discussions or deferral to the team for discussion and consensus (a consensus meeting was held with all team members in attendance to agree on the final list of salutogenicallyfocused outcome categories). Unique lists of salutogenicallyfocused and non-salutogenically-focused outcome categories were identified.
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Findings
Salutogenically focused reported outcomes
Screening and selection of included reviews
Fig. 3 details 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).
Fig. 2 provides a flow diagram detailing the process for and results of screening and selecting the systematic reviews for inclusion.
Fig. 1. Salutogenesis umbrella. (Reproduced with permission from Bengt Lindström (Lindström and Eriksson, 2010.)).
436 systematic reviews identified from Cochrane Pregnancy & Childbirth group (Sept 2011)
Random allocation of reviews for independent screening
Reviewer pair 1
Reviewer pair 2
Reviewer pair 3
n = 147
n = 143
n = 145
Included
Included
Included
n = 39
n = 36
n = 27
Total included n = 102
Fig. 2. Screening and selection of reviews for inclusion.
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Reviews included n = 102
Within pair independant data extraction and pooling of outcomes
Non-salutogenically
Salutogenically focused outcome categories n = 23
focused outcome categories n = 49
Consensus meeting outcome categories excluded n=7
Number of outcome categories n = 16
Fig. 3. Data extraction process.
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 interventions. Sixteen salutogenically-focused outcome categories (representing 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 salutogenicallyfocused 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 riskreduction continues to form the basis for policy and practice development (Royal College of Midwives, 2005) with little consideration for outcomes indicative of maternal and neonatal positive health or well-being. In maternity care, salutogenesis
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Table 1 Unique list of salutogenically focused reported outcomes. Salutogenically-focused outcome categories
Maternal satisfaction with care, experience, etc. Breast feedingn (e.g. initiation, duration, success) Controln(perceived/personal control) Spontaneous vaginal birth (or ‘normal vaginal birth’) Positive relationship with infant/bonding Well-being (mother/father, psychological/emotional) n Caregiver experience/satisfaction Viewsn (mother's and/or father's) Mobility during labour Pregnancy prolongation Spontaneous rupture of membranes Comfort Maternal perception of pain experiencedn Maternal parenting confidence Relaxation Intact perineum n
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Table 2 Unique list of non-salutogenically focused reported outcomes.
No. of times individual outcome was reported 51 32 12 6 6 5 5 4 3 3 2 2 2 1 1 1
Positive reference.
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 manageability, comprehensibility and meaningfulness (Downe, 2001). In this sense, irrespective of the type of birth experienced, women who can easily find 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). 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 salutogenicallyfocused 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 maternal satisfaction as a core outcome measure will provide evidence on the effectiveness of interventions from a SOC perspective. Incorporating salutogenically-focused outcome measures in maternity care research will encourage health care providers, policymakers and maternity service users to consider maternity care from a health-orientated client-based perspective rather than from a
Non-salutogenically-focused outcomes
Composite of infant morbidity outcomes (short-/long-term; including any disability, HIE, asphyxia, seizures, RDS, PVL, cerebral palsy, etc.) Bleeding/blood loss (of any type and variously defined) Maternal infection (fever/temperature/sepsis, etc.) Apgar score (at 1, 5 or 10 minutes or o7 or ‘low’ at r 5 minutes) Fetal death, neonatal loss or stillbirth Hospitalisation (length of stay, admission, readmission, etc.) ‘Pain’ of any type including assessment Caesarean birth (for any reason) Analgesia (request for/any type, epidural, narcotics, GA, etc.) ‘Drugs’ other than analgesics (administration/ side effects, etc.) Neonatal admission to NICU/SCBU Maternal mortality or serious morbidity (not specified) Labour length/duration (length of any stage, prolonged labour, etc.) Neonatal infection (fever/sepsis including specific types of infections) Any instrumental/assisted vaginal birth Perineal/vaginal trauma (of any type including episiotomy) Preterm (birth, retinopathy of prematurity, gestational age at birth) Nausea/vomiting/dehydration Adverse event/outcome, serious complication – maternal Maternal negative related-expression (anxiety, dissatisfaction, fatigue, depression, low selfesteem, PTSD, etc.) Labour and/or birth trauma Resuscitation measures, arrest or LOC (maternal or infant) Miscellaneous/other (fetal-maternal haemorrhage, zavanelli procedure, pulmonary oedema, additional tests, cord prolapse, etc.) Induction and/or labour augmentation (ARM/ oxytocin) Any pH levels o 7.20 and BD 412.0 Blood transfusion Cost/economic outcomes Blood pressure (hyper-/hypotension) Uterine (expulsive effort, hyperstimulation, rupture, etc.) Fetal heart rate monitoring Placenta (retained, manual removal, etc.) Wound (haematoma, wound healing, fistula of any type, etc.) Fetal blood sampling (umbilical cord blood, FBS, lactate) Mode of birth (unspecified) Anaemia (or any reference to Hb levels/iron administration) Incontinence (any type) Jaundice Meconium stained liquor/meconium aspiration syndrome Negative expression of breast feeding (failure, not established, etc.) Anaesthesia with gastric reference (Mendelson's syndrome, etc.) Negative expression of mother–infant interaction (detachment, difficulty with infant, prolonged crying, etc.) Maternal admission to ICU Birth weight
No. of times individual outcome was reported 141
129 74 76 65 60 56 55 52 50 49 48 47 43 41 38 37 35 33 32
32 31 30
29 25 25 22 22 22 20 20 19 17 16 16 16 16 13 12 11 10
8 8
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Table 2 (continued ) Non-salutogenically-focused outcomes
Headache Surgical reference (type of surgery, duration of surgery, etc.) Thromboembolic event (DVT, PE) Fetal position (mal-presentation, change, etc.) Transition to extra-uterine life Symphysiotomy
No. of times individual outcome was reported 7 7 6 5 4 2
perspective typified by morbidity and mortality, the latter of which is, at times and despite best health care treatment efforts, uncontrollable and uncertain in any event. Given the relative absence of salutogenically-focused reported outcomes identified in our systematic review of reviews, we recommend 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 a first 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: Salutogenic 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 analysis. International Journal of Childbirth 2, 126–135.
