Guidelines and management of mild hypertensive conditions in pregnancy in rural general practices in Scotland: issues of appropriateness and access

Abstract

Objectives: To assess the diagnosis and management of mild non-proteinuric hypertension in pregnancy in rural general practices against guideline recommendations. Design: Postal survey and telephone interview. Setting: All 174 designated rural general practices in Scotland. Sample: 171 GPs and 158 midwives responsible for antenatal care stratified by distance from a specialist maternity hospital. Main outcome measures: Accuracy of diagnosis and appropriateness of management compared with guideline. Results: At least one respondent replied for 91% (158/174) of rural practices. Response rates were 68% (117/170) for GPs and 77% (121/158) for midwives. Both GP and midwife replied for 46% (80/174) of practices. Most GPs (80%, 87/109) and midwives (63%, 71/113) overdiagnosed the scenario. Intended management was therefore most often referral or admission to specialist hospital (59%, 132/224), both courses of action beyond guideline recommendations. There was an association between distance of practice from specialist maternity hospital and professionals' report of intended referral or admission. Explanatory factors from telephone interviews included a poor knowledge base, cautious risk assessment, and perceived inflexibility of guidelines for remote situations. Conclusions: There is a lack of accuracy in the diagnosis of a common antenatal problem and intended management is consistent with overdiagnosis. The results suggest that women in rural settings may experience more antenatal referrals and admissions than are clinically appropriate according to the guidelines. At a time of increasing centralisation of maternity services, this could increase inappropriate referrals and increase costs to service and patients. Quality of care may be improved by developing consensual local guidelines with rural maternity care professionals and support maintained skills and confidence in decision making.

Cuidados pré-natais e avaliação do manejo da hipertensão arterial em gestantes do SUS no Município do Rio de Janeiro, Brasil

“…Tucker et al 22 avaliaram o pré-natal de hipertensas na Escócia e concluíram que ocorreu diagnóstico excessivo, com mais encaminhamentos e internações no pré-natal do que o recomendado, segundo as normas locais. Além disso, embora a maioria dos profissionais de saúde tenha alertado à paciente de que a pressão arterial estava elevada, quase um terço das gestantes não foi esclarecido dos riscos que a doença acarreta na gravidez.…”

Quality of prenatal care questionnaire: psychometric testing in an Australia population

“…Clinical care processes that have been identified as components of quality antenatal care encompass: assessment, screening, and monitoring [ 6 – 10 ]; information exchange, health promotion, teaching, and counselling [ 5 – 9 , 11 – 13 ]; woman-centred care, shared decision making, and self-care [ 6 – 8 , 11 , 13 ]; continuity of care [ 5 – 8 ]; normalization of pregnancy and promotion of normal processes [ 7 , 8 ]; and adherence to evidence-based clinical practice guidelines [ 14 , 15 ]. Interpersonal care processes that contribute to quality antenatal include: listening carefully and understanding [ 7 , 8 , 12 ]; showing respect [ 5 – 9 , 12 , 13 ]; adequate time with care provider [ 6 , 8 , 9 , 12 ]; approachable interpersonal style [ 8 , 13 ]; emotional support [ 8 , 13 ]; and cultural sensitivity and competence [ 6 – 8 ].…”

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review

“…Organisation characteristics include the number of care providers involved in care provision, location, communication, collaboration, and geography [30,58,69,93,[99][100][101][102][103][104][105][106][107][108][109][110][111][112][113]. Health care providers' perceived risk, knowledge, expertise, confidence, personal views, awareness and attitude, financial considerations and women's characteristics and preference, amongst others, are described as decisive factors [17][18][19]26,46,[86][87][88]95,99,100,105,107,109,[114][115][116][117][118]. Providers' behaviour is considered influenceable via, for example, education [97,[119][120][121], and guidelines [19,97,115,122].…”

“…The practice of risk selection in terms of detecting and assessing risk is not reserved to a certain profession, but rather performed by all professionals involved in care provision. The criteria, policy, procedures and division of professional tasks and responsibilities, are laid down in local and international, monodisciplinary and multidisciplinary agreements, defining women's and children's needs for healthcare services accordingly [26,51,59,84,85,115,120,122,[132][133][134][135][136].…”

“…Others understand risk selection as a means of organizing care [20][21][22]. Sometimes, risk selection is defined as a tool, for example in the application of risk indicators [23,24], the use of guidelines and protocols [25,26], and screening instruments [27][28][29]. Often, risk selection is seen as a safety system, meant to minimize morbidity and mortality mainly due to undertreatment [30][31][32].…”