In recent years, obstetricians have needed to manage more complex pregnancies involving acute and chronic medical disorders, and a greater number of pregnancies each year are now delivered by critical care services.1 Data from the United States show that poorly controlled maternal medical conditions can have an adverse impact on pregnancy outcomes.2 Given the multitude of maternal complications that may arise and the high stakes associated with management of the critically ill parturient, establishment of a high-risk prenatal care model to improve pregnancy outcome is essential. First, we developed the “321” management model for high-risk pregnancies, which includes multidimension comprehensive maternal care (Fig. S1, https://links.lww.com/MFM/A22). This qualitative study then aimed to explore the satisfaction and experience of high-risk pregnancy patients managed by the “321” model.
“321” management procedure
Within the “321” model, “3” indicates either outpatient, inpatient, or emergency management. Outpatient is used for screening high-risk factors or finding early warnings of disease changes through symptoms and examination. Emergency is for handling emergency situations and receiving admissions. Inpatient is for standard management and termination. These three sectors are intimately connected, and obstetricians are responsible for care from all three directions. The second meaning of “3” is antepartum, interpartum, and postpartum management. These two groups of “3” ensured that patients received continuous care throughout the whole perinatal period. “2” represents standardized treatment according to updated guidelines and simulation drills for clinical staff. Each week, there were discussions for learning new guidelines, and emphasis was placed on new changes that could be applied during treatment. Moreover, once a month a simulation drill was performed, such as postpartum hemorrhage, emergency cesarean section, or eclampsia. “1” represents the multidisciplinary team for critical maternal care.
This study was approved by the ethics board of the third affiliated hospital of Guangzhou Medical University (2018 No. 022). Written informed consent was obtained from all participants. The study was conducted between October 2019 and September 2020. We interviewed 11 high-risk women during pregnancy (four patients had pre-eclampsia, three had placenta accreta, three had placenta previa, and one twin pregnancy) who were treated with the “321” model and five high-risk obstetricians were included who used the “321” model to manage outpatient and inpatient cases. A semistructured interview guide was developed, and structured interviews were conducted face-to-face in hospital meeting rooms. Each interview schedule consisted of four open-ended questions drafted based on topics: (1) Can you tell us about your experience of management using the “321” model? (2) What were the good things about management with the “321” model? (3) Can you tell us about any challenges you encountered with the management? and (4) Can you tell us about any change you would recommend that could enhance your experience of this management model? Each interview lasted approximately 20 to 40 minutes, and all interviews were audio recorded using a digital recorder. A qualitative content analysis approach was used to develop the codebook. Each interview was transcribed verbatim from audio recordings and coded independently by two researchers within 24 hours of the interview. Any discrepancy in coding was jointly reviewed, and consensus was reached by discussion. Codes were organized into relevant themes and subthemes. Qualitative interview data were analyzed using NVivo 10 software (QSR International, Doncaster, Australia) to organize and code the verbatim transcript.
Four themes surrounding emotional experience, practical experience, management challenges, and patients’ education were identified (Table 1). Some participants expressed concern about high-risk pregnancy and adverse outcome; however, under this model, they reported satisfaction and described access to quality care throughout pregnancy. Some providers and patients reported that this patient-centered care model supplied continuity for high-risk patients, including outpatient-inpatient-emergency. Such comprehensive care under the umbrella of one specialist team ensured effective and timely treatment. Most participants reported that because of limited manpower and the large number of patients, doctors were unable to give detailed responses to patients’ problems. Patients also cited uncertainty surrounding appointments with their physicians as a significant source of stress; however, they ultimately found providers and staff to be reassuring. Furthermore, both patients and providers suggested that because of patients’ lack of medical knowledge, more information regarding diseases and related care methods should be supplied using other media platforms, including pamphlets or mobile apps with commonly asked questions or a list of recommended online resources.
Table 1 -
Core themes surrounding “321” model management for high-risk pregnancy.
“… I am actually high-risk, so we need more specialized care during pregnancy. Doctors gave more attention to me…. I think that is the care I need.”
“When I was diagnosed with preeclampsia, I felt pressure and was very worried….”
“They are a high-risk pregnancy, we know they will face more complicated events during pregnancy than would a normal pregnancy, so we need to be focused and continuously monitor the patient.”
“… a specialist team was responsible for all patients throughout pregnancy, so we knew their situation very well and we could predict their progress and take preventive action.”
“I am of advanced age and had the complication of placenta previa accreta, I received antenatal care from a high-risk obstetrician. When I started to bleed, I was operated on quickly and had a good outcome.”
“…the doctor recommend amniocentesis and told me the relative risk. When I said I needed more information and time to think, the doctor said you can think outside for a while or consult another hospital.”
“I registered with a senior doctor for prenatal care, but sometimes he suspends his medical service at short notice. At other times I waited in a queue, and suddenly he had to attend an emergency operation....”
“Doctors could summarize the problems frequently encountered and asked by patients, and this content could be made into a video or paper. Alternately some popular science articles could be written that would allow us to know more, or an electronic knowledgebase could be made….”
Maternal care is the cornerstone of modern obstetrics, especially in high-risk pregnancies. Multidisciplinary care, a rapid response team, and group prenatal care are all extensively used in the care of high-risk pregnancies, and many studies confirm the effectiveness of these care models.3 Our “321” model contains unique factors. Patients are managed from a multidimension and multiangle perspective to improve the quality of care, such as from improving obstetricians’ clinical skills, and multidisciplinary team participation. Women at high-risk often benefit from giving birth in hospitals that offer a broad array of specialty and subspecialty services.4
It is worth noting that patient-centered care is maintained in our “321” model.
Patient-centeredness is one of the six key dimensions of quality healthcare, in addition to safety, effectiveness, timeliness, efficiency, and equity.5 Reports on fertility care confirm that, apart from effective medical treatment, women also appreciate patient-centered care.5 Other advantages of the “321” model include continuous care and effectiveness. Continuous care is also a feature of good quality care and emphasizes maternal health for improving women’s satisfaction with services.4 Moreover, studies describe three problems that pregnant women experience when using public maternal care services: a lack of information for seeking care, inconvenient transportation to a hospital, and inadequate preparedness in the care system.4,6 In our study, patients under the “321” model experienced better prenatal care, and high-risk pregnancies received more focalized quality care from a high-risk pregnancy team. With the development of this clinical standard treatment and model for high-risk pregnancy, patients did not have to seek information or be inadequately prepared for care.
There is a consensus in obstetrics care, that high-risk pregnancies require superior physical facilities, and medical and support personnel to assist in providing care for the complex maternal and fetal conditions.7 However, in our study, staff shortages due to high patient volumes and the heavy workload placed on health providers were the essence of patients’ complaints. This was similar to findings in a meta-synthesis of experiences of the quality of health care in women with severe maternal morbidity,8 and these were also key factors for negative experience as found in previous studies.9 Hospital administrators should address and improve this situation; periodic evaluation and distribution of human resources are also needed to monitor this management. Health providers need to be able to provide clear and precise information of patients’ condition and treatment protocols to calm patients’ worries and make them feel safer.8 Emotional care and expectations also need to be addressed to maintain security and raise the self-esteem and trust of patients.8,10
This study was funded by Natural Science Foundation of Guangdong Province (2020A1515010273 and 2022A1515012405).
WS and DC performed the design. WS performed the analysis. WS performed the writing of the original draft. PD, WS, DC, XW, JC, FH, CS, and LY performed the writing—review and editing.
Conflicts of Interest
Dunjin Chen is an Associate Editor of Maternal-Fetal Medicine. The article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research group.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
1. Leovic MP, Robbins HN, Starikov RS, et al. Multidisciplinary obstetric critical care delivery: the concept of the “virtual” intensive care unit. Semin Perinatol 2018;42(1):3–8. doi:10.1053/j.semperi.2017.11.002.
2. Carson MP, Chen KK, Miller MA. Obstetric medical care in the United States of America. Obstet Med 2017;10(1):36–39. doi:10.1177/1753495X16677403.
3. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol 2014;123(3):722–725. doi:10.1097/01.AOG.0000444442.04111.c6.
4. WHO. Recommendations on Health Promotion Interventions for Maternal and Newborn Health[M]. Geneva, Switzerland: World Health Organization; 2015.
5. van den Berg MMJ, Dancet EAF, Erlikh T, et al. Patient-centered early pregnancy care: a systematic review of quantitative and qualitative studies on the perspectives of women and their partners. Hum Reprod Update 2018;24(1):106–118. doi:10.1093/humupd/dmx030.
6. Okonofua F, Ogu R, Agholor K, et al. Qualitative assessment of women's satisfaction with maternal health care in referral hospitals in Nigeria. Reprod Health 2017;14(1):44. doi:10.1186/s12978-017-0305-6.
7. Obstetric Care Consensus No. 2: levels of maternal care. Obstet Gynecol 2015;125(2):502–515. doi:10.1097/01.AOG.0000460770.99574.9f.
8. Norhayati MN, Surianti S, Nik Hazlina NH. Metasynthesis: experiences of women with severe maternal morbidity and their perception of the quality of health care. PLoS One 2015;10(7):e0130452. doi:10.1371/journal.pone.0130452.
9. Handelzalts JE, Waldman Peyser A, Krissi H, et al. Indications for emergency intervention, mode of delivery, and the childbirth experience. PLoS One 2017;12(1):e0169132. doi:10.1371/journal.pone.0169132.
10. Carvalheira AP, Tonete VL, Parada CM. Feelings and perceptions of women in the pregnancy-puerperal cycle who survived severe maternal morbidity. Rev Lat Am Enfermagem 2010;18(6):1187–1194. doi:10.1590/s0104-11692010000600020.