How did we agree the boundaries of maternity care for ARM@DA? Considerations for a realist review

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Hello, we are Helen Spiby and Kerry Evans, midwife researchers on the ARM@DA team, contributing an understanding of maternity policy and practice. We are co-investigators on the project and have been involved from the very beginning in identifying the research focus and establishing this as a priority in a maternity context changed by the pandemic.

Remote consultations are not new to the maternity context. It will always be the case that some women live at a distance from some or all their maternity care providers. Previously, remote consultations were only available by telephone in the UK setting. Important decisions take place as a result of telephone conversations – whether it’s to travel to the maternity unit during labour or for support with infant feeding and it’s important for both families and maternity professionals that these go well. The pandemic brought rapid changes to digital maternity consultations, for example video is now used more widely and there is growth in the role of at-home self-monitoring devices. At the centre though are important considerations about which aspects of maternity care can safely be provided digitally.

In Mark’s blog about conducting the literature search for ARM@DA he talked about identifying search terms. These search terms needed to be broad enough that all the relevant data on digital consultation in maternity care would be captured, but also focussed enough that the team wouldn’t be overwhelmed with papers to screen. One of the tricky parts of the screening process was establishing the screening inclusion criteria. Part of our job on the project has involved helping to define which aspects of maternity care should be included in the ARM@DA realist review and which areas fall out of scope.

So, where are the boundaries to maternity care?

Maternity care professionals often work with other professionals to provide care to women in pregnancy and following birth. For example, diabetic teams, specialist mental health services, medicine and physiotherapy services may all contribute to a woman’s care. All these contributions are important but not all these professionals will consider themselves as providers of maternity services. As a general rule, we tried to think about whether a service/intervention was something that a maternity care professional would provide themselves or signpost a woman to. For example women may be signposted to other healthcare professionals or services for support with smoking cessation or specific mental health support; therefore papers about these topics would be excluded.

We considered some of the service provision that we knew had moved online during the pandemic, for example, group antenatal education provision. This enabled us to further define the purpose of the online encounter – whether education or information-oriented, monitoring of specific medical conditions or usual components of maternity care.

To help us define our inclusion criteria further still, we considered it from a commissioning perspective; what would be included in maternity service commissioning and what might be commissioned through other systems? However we recognised that this process was not always clear cut, not least because there was likely to be regional and international variation in the delivery and commissioning of maternity services. For papers that fell into this ‘grey area’, wider discussion in the research team was often necessary.

Fundamental to all of this were the team’s consultations with maternity care professionals, with both clinically-facing and strategic roles, service providers and women and carers about the types of digital care that were introduced before or during the pandemic. From these, we developed a working definition which helped to establish the inclusion criteria for our literature search. This enabled us to utilise only those papers which were most useful to the ARM@DA research questions.