Women's Health Issues 26-1 (2016) 100–109

www.whijournal.com

Original article

Patient-centered Care in Maternity Services: A Critical Appraisal

and Synthesis of the Literature
Claire de Labrusse, PhD Candidate, MSc, RM a,*,
Anne-Sylvie Ramelet, PhD, MSc, RN b, Tracy Humphrey, PhD, MSc, RM c,
Sara J. Maclennan, PhD, CPsychol, AFBPsS d
a
School of Midwifery, University of Health Sciences (HESAV), Lausanne, Switzerland
b
Institut universitaire de formation et de recherche en soins – IUFRS, Lausanne University, Lausanne, Switzerland
c
School of Nursing, Midwifery and Social Care, Edinburgh NAPIER University, Edinburgh, Scotland
d
Academic Urology Unit, University of Aberdeen, UK

Article history: Received 5 January 2015; Received in revised form 4 September 2015; Accepted 4 September 2015

a b s t r a c t
Background: Patient-centered care (PCC) has been recognized as a marker of quality in health service delivery. In policy
documents, PCC is often used interchangeably with other models of care. There is a wide literature about PCC, but there
is a lack of evidence about which model is the most appropriate for maternity services specifically.
Aim: We sought to identify and critically appraise the literature to identify which definition of PCC is most relevant for
maternity services.
Methods: The four-step approach used to identify definitions of PCC was to 1) search electronic databases using key
terms (1995–2011), 2) cross-reference key papers, 3) search of specific journals, and 4) search the grey literature. Four
papers and two books met our inclusion criteria.
Analysis: A four-criteria critical appraisal tool developed for the review was used to appraise the papers and books.
Main Results: From the six identified definitions, the Shaller’s definition met the majority of the four criteria outlined
and seems to be the most relevant to maternity services because it includes physiologic conditions as well as pathology,
psychological aspects, a nonmedical approach to care, the greater involvement of family and friends, and strategies to
implement PCC.
Conclusion: This review highlights Shaller’s definitions of PCC as the one that would be the most inclusive of all women
using maternity services. Future research should concentrate on evaluating programs that support PCC in maternity
services, and testing/validating this model of care.
Copyright Ó 2016 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

There is growing evidence and recognition in the literature
that patients should be involved in their own care if improve-
ments are to be made in the quality of care provided (Hunter &
Cameron, 2006). In recent years, global policy documents have
developed new patient-focused initiatives in areas such as public
health, mental health, chronic care, and maternity care
(Australian Commission on Safety and Quality in Health Care,
2014; Commonwealth Fund, 2014; U.S. Department of Health
and Human Services, 2011; Scottish Government, 2006).
* Correspondence to: Claire de Labrusse, PhD Candidate, MSc, RM, School of
Midwifery, University of Health Sciences (HESAV), 1011 Lausanne, Switzerland.
Phone: þ41 (0) 21 316 81 69; fax: þ41 21 316 80 01.
E-mail address: Claire.delabrusse@hesav.ch (C. de Labrusse).
Maternity services are commonly delivered across a variety of
settings, including the community and hospitals. Maternity ser-
vices cover three stages of care: antenatal, intranatal, and post-
natal care (National Audit Office, 2013). Although there has been
an observed increase in social and clinical complexity within
maternity services, most women tend to be healthy with no
morbidities or complications, unlike hospitalized women in
other health services (Tonidandel, Booth, D’Angelo, Harris, &
Tonidandel, 2014; Tracy et al., 2014; Vaughan, Cleary, &
Murphy, 2014). With regard to maternity-related policies, there
is a lack of consistency in the description of the models of care
with patient-centered care (PCC), woman-centered care, family
centered-care, and person-centered care being used inter-
changeably (U.S. Department of Health and Human Services

1049-3867/$ - see front matter Copyright Ó 2016 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.whi.2015.09.003

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 C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
(2011); Health Quality and Safety Commission New Zealand,
2012; Scottish Government, 2011). Davidson, Halcomb,
Hickman, Philipps, and Graham (2006) described a model of
care as “an overarching design for the provision of a particular
type of health care service that is shaped by a theoretical basis,
EBP [evidence-based practice] and defined standards.” It consists
of defined core elements and principles and has a framework
that provides the structure for the implementation and subse-
quent evaluation of care. The authors underlined the importance
of having a clearly defined and articulated model of care to
ensure that all health professionals are actually sharing the same
vision (Davidson et al., 2006).
Therefore, identifying the most appropriate model of care for
maternity services and reaching a consensus on its core domains
would help policy makers and health care providers (HCP) to
consider appropriate goals and implementation strategies to
improve the quality of care delivered and the rigorous evaluation
of that care. Taking a closer look at the four models of care
(woman-centered care [WCC], PCC, person-centered care, and
family-centered care) used in maternity services policies, family-
centered care has an emphasis on the sick child (Shields, Pratt, &
Hunter, 2006; Svavarsdottir, 2006) and person-centered care
relates mainly to older people or those with long-term condi-
tions (Health Foundation, 2014; Victorian Government
Department of Human Services, 2006). These last two terms do
not fit the health status and age profile of reproductive women
using maternity services. WCC and PCC, however, are used
within maternity services policies more frequently and are
described herein.
WCC is the most commonly used model of care within
maternity services policy and is seen as the cornerstone of the
partnership between the midwife and the woman (Carolan &
Hodnett, 2007; Hodnett, 2000, 2002; Moscucci, 2003). The
definition given by the Royal College of Midwives (RCM) defines
WCC as a nonmedical model, which represents choice, conti-
nuity of care, and control for women (RCM, 2001, 2008). The
Department of Health (UK and Australia), and the Australian
College of Midwives also recommend this model of care for
maternity services (Australian College of Midwives, 2011;
Department of Health, 2004; Department of Health New South
Wales, 2010). The RCM (2008) argues that midwife-led care is
the key to achieving WCC making a direct link between the
scope of WCC and midwife-led care. The RCM (2008) stresses
that, to achieve truly WCC, this needs to be led by midwives
through the care they deliver during uncomplicated pregnan-
cies, birth, and postnatal care. Furthermore, midwife-led care
has been defined as the care provided by midwives being “the
lead professional in the planning, organization and delivery of
care given to woman (who are healthy and at low risk of
complications) from initial booking to the postnatal period”
(Sandall, Soltani, Gates, Shennan, & Devane, 2013, p. 3). This
model cannot be applied to women who are at high risk of
obstetric complications, and thus has some shortcomings when
one looks at the diversity of women using maternity services
(Nursing and Midwifery Council, 2004; Pope, Graham, & Patel,
2001). It is estimated that 40% of women are not suitable for
midwife-led care at booking according to a recent survey con-
ducted by the RCM (2010). This means that, right from the onset
of the pregnancy, many women would be excluded by the WCC
model. Furthermore, one could question what happens to the
women who are cared for by health professionals other than
midwives. The WCC model would also not be appropriate for
countries, where the family physician or the obstetrician are
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101
primarily responsible for prenatal care (Sandall et al., 2013).
Some international definitions of WCC also emphasize uncom-
plicated pregnancies and normal birth (American College of
Nurses Midwives, 2014; Department of Health New South
Wales, 2010). Although there is a lack of reference within the
literature to support which model of care would be the most
relevant for women with medical or obstetric risk factors or
complications, WCC remains the dominant model for maternity
care. Arguably, however, the restriction of this model to normal
pregnancy, labor, and postnatal care (RCM, 2008) demonstrates
that WCC is not the most inclusive model of care for maternity
services. Therefore, an alternative and more accessible model of
care for maternity services that includes a continuum from
wellness to illness for women who present in various states of
health during the course of their pregnancy is needed (Travis &
Ryan, 2004).
PCC, which has also been used in maternity services policy
offers such an alternative (Australian Commission on Safety and
Quality in Health Care, 2011; Docteur & Coulter, 2012; Ministry of
Health British Columbia, 2015). PCC as a marker of quality has
been recommended in health service delivery (Scottish
Executive Health Department, 2007), because the evidence
suggests that PCC increases HCP’s levels of empathy and affective
responses, as well as patient satisfaction with their care and their
perception of control (Lewin, Skea, Entwistle, Zwarenstein, &
Dick, 2009; Picker Institute & Planetree, 2008). There are
numerous definitions of PCC, but one of the most influential
models that formed the foundation of the PCC approach was
developed by Gerteis, Edgman-Levitan, Daley, and Delbanco
(1993) for the Picker Institute and has seven key domains,
namely: 1) respect for patient’s values, preferences and
expressed needs, 2) coordination and integration of care, 3) in-
formation, communication, and education, 4) physical comfort,
5) emotional support and alleviation of fear and anxiety, 6)
involvement of family and friends, and 7) transition and conti-
nuity. Where other models may not be inclusive of the diversity
of care that women may need, the coordination and integration
of care domain of the PCC model of care encompasses various
care pathways that can fit with the uncertainty of childbirth.
Additionally, this domain is not dependent on the discipline of
the HCP. Instead, it is inclusive of the variety of HCPs that some
women may encounter (e.g., midwives, obstetricians, nurses,
pediatricians, neonatologists, and allied health professionals)
and the dynamic nature of risk within pregnancy, which means
that women can flow from one pathway of care to another
without it affecting their model of care. Finally, the PCC domain
“respect for patient’s values, preferences and expressed needs” is
comprehensive enough to consider the general and the specific
issues of the diversity of women’s needs and expectations using
maternity services. When one of the most referenced definitions
of PCC is reviewed, it seems that PCC may be more appropriate
model of care for maternity services. However, if PCC is appli-
cable per se for maternity services, it is not clear which definition
of PCC (out of several definitions) best suits the diversity of
women (complicated or physiologic care, diversity of the socio-
demographics characteristics) and the HCPs providing care in
maternity services.
Earlier reviews about maternity services have used the terms
PCC without justifying their choice and defining the model of
care (Black & Brocklehurst, 2003; Hildingsson, Waldenstrom, &
Radestad, 2002; Hundley et al. 1994). The purpose of this
paper, rather than develop a new model of care for maternity
services, is to critically appraise and synthetize the literature
102 C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
looking at the definitions of PCC to find the most relevant one for
maternity services.
The Review
Aim
The aim was to identify and critically appraise the literature to
find which existing definition of PCC is the most relevant to
maternity services.
Design
The authors undertook a critical appraisal of the literature
and a synthesis to find a suitable definition of the model of PCC
for maternity services. The review was performed in five stages:
literature search, inclusion/exclusion of papers, screening, data
extraction, data analysis (critical appraisal), and data synthesis.
Literature Search Methods
In the systematic approach of searching and collecting liter-
ature, the authors chose an inclusive approach to the process
reflecting the large and diverse amount of data about PCC. A four-
step search methodology inspired by Greenhalgh and Peacock
(2005) was conducted: an electronic search, cross-referencing
and hand-search of key papers, and search of specific journals
and of grey literature. The first step was an electronic search of
five relevant databases: Pubmed, Ovid, Medline, CINAHL, and the
Cochrane Library. This was to identify studies in French and
English in the initial study period January 1995 and June 20111.
These two languages were chosen on the basis that these lan-
guages were spoken fluently by two of the authors. A combina-
tion of the most recurrent descriptors and MeSH terms on the
topic were used such as “patient–centred,” “patient centered
care,” “patient-centered,” “patient centered care” and “patient
experience.”
Inclusion and Exclusion of Papers (Screening)
Limits included age “adolescents” AND “adults 13–44 years”
and methodology, that is, “reviews” and in CINAHL “systematic
reviews.” No documents in French were found. The second step
used hand searching of reference lists on key papers, with search
of specific journals for the third step and finally a search of the
grey literature (nonconventional or fugitive publications such as
reports, theses, and conference papers). The exclusion criteria
were as follows: i) publications in a language different than
English or French, ii) population younger than 13 years and older
than 44 years (because of the reproductive age), and iii) publi-
cations focusing on a context of care radically different than
maternity services such as palliative care, cancer care, acute
disease (i.e., pulmonary or heart), or oral care.
Data Extraction, Analysis, and Synthesis
In the first step of the electronic searches, 217 references were
imported; duplicates were eliminated, leaving 152 citations.
These articles were reviewed by the first author based on the
inclusion and exclusion criteria using title and abstract screening
1
A revised search conducted in 2015 using the same search terms did not
identify any newer models for consideration.
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to reduce the 152 articles to 26 articles. The 26 remaining articles
were retrieved and the full-text papers were read to confirm the
relevance of each, deeming 24 to be irrelevant to the research
topics and the population, and two eligible for the review. In our
initial search of the literature, the four most cited articles
and reports were highlighted as: Rowe, Garcia, Macfarlane, and
Davidson (2002), Mead and Bower (2000), Richards and
Coulter (2007), and Shaller (2007). The second step of the
search included cross-referencing and hand searching of the
reference lists of these four key papers. This piece of work
identified 13 other literature reviews and randomised controlled
trials and two books reviews. When the full texts were screened,
only one literature review was eligible for the review. The two
book reviews were key publications about PCC which were also
included in the review: Crossing the Quality Chasm (Institute of
Medicine [IOM], 2001) and Transforming the Clinical Method
(Stewart et al., 2003). The third step was a search in specific
journals that tend to publish predominantly on PCC: Social Sci-
ence and Medicine and Health Expectations, using the same key-
words as the electronic searches; this did not identify new
papers. Finally, the grey literature was searched on four major
websites on PCC: Picker Institute, Institute of Healthcare
improvement, The King’s Fund, and the Commonwealth Fund
identified 13 reports, but only one was eligible for the review. A
total of four studies and two books were included in the review
(Figure 1). Six definitions of PCC were identified (Table 1). We
acknowledge that there is some conceptual overlap between
Shaller’s (2007) and the IOM (2001), Stewart et al. (2003), and
Delbanco and Gerteis, 2010, because Shaller’s domains are the
results of an overview PCC concepts from Cronin’s model (2004)
that included the IOM (2001), Stewart et al. (1995), and Gerteis
et al. (1993).
Nevertheless, this review aims to critically appraise the
definitions of the domains rather than the concepts, and their
relevance to maternity services. To find the definition of PCC that
would best fit with maternity services, four criteria were devel-
oped to determine whether the definitions reflect the population
of interest (childbearing women and HCPs), and the strategies to
implement PCC. First, is the definition inclusive of physiologic as
well as pathologic pregnancy? Second, is the definition inclusive
of the different characteristics of the population using maternity
services? Third, is the definition inclusive of the diversity of
practitioner caring for women using maternity services? And
finally, is the definition inclusive of strategies to facilitate the
implementation of PCC?
Figure 1. Data extracted for the narrative review of the literature.
 C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
Table 1
Patient-centered Care Definitions Selected for Critical Appraisal
Authors Reference
Stewart (2003) Patient-centered Medicine. Transforming
the clinical method
Delbanco & Gerteis (2010) A patient-centered view of the
clinician–patient relationship
Shaller (2007) Patient-centered care: What does it take?
Coulter (2005) Trends in patients’ experience of the NHS
IOM (2001) Crossing the quality chasm, 2001
Mead & Bower (2000) Patient-centredness: A conceptual framework and
review of the empirical literature
Abbreviations: IOM, Institute of Medicine; NHS, National Health Service.
Results
The first three authors independently and critically appraised
the six documents using the criteria developed (Table 2). The
authors critically appraised the document in a narrative way, to
be as inclusive as possible. Discrepancies in the results were
discussed and a consensus between the authors was reached. A
synthesis of the critical appraisal is presented in Table 3.
Criteria 1: Is the Definition Inclusive of Physiologic as Well as
Pathologic Pregnancy?
Pathologic pregnancy
Four papers included in the review focused on the definition
of pathology (Delbanco & Gerteis, 2010; Stewart et al., 2003;
IOM, 2001; Coulter, 2005). The documents described a range of
conditions and employed various terms that focus on pathology.
The terminology used such as illness and disease (Stewart et al.,
2003; Delbanco & Gerteis, 2010) or disability or disfigurement
(IOM, 2001), within the definitions are relevant only to patho-
logic pregnancy. A description of the stages of illness and
patient’s perception of those stages of illness gave a deeper un-
derstanding of the phenomenon and defining the goals and the
priorities of treatment and/or management. This gives more
emphasis on the pathology as the essence of the definition
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103
Definition
Exploring both the disease and the illness experience.
Understanding the whole person.
Finding common ground.
Incorporating prevention and health promotion.
Enhancing the patient–doctor relationship.
Being realistic.
Respect for patients values, preferences, and expressed needs.
Coordination of care and integration of services within the clinical setting.
Communication between patient and providers.
Enhancing physical comfort.
Emotional support and alleviation of fears and anxiety.
Involvement of family and friends.
Transition and continuity from the one locus of care to another.
Education and shared knowledge.
Involvement of family and friends.
Collaboration and team management.
Sensitivity to nonmedical and spiritual dimensions of care.
Respect for patients needs and preferences.
Free flow and accessibility of information.
Fast access to reliable health advice.
Effective treatment delivered by trusted professionals.
Involvement in decisions and respect for preferences.
Clear, comprehensive information and support for self-care.
Attention to physical and environment needs.
Emotional support, empathy, and respect.
Involvement of, and support for family and carers.
Continuity of care and smooth transition.
Respect for patient’s values, preferences, and expressed needs.
Coordination and integration of care
Information, communication, and education.
Physical comfort.
Emotional support, relieving fear, and anxiety.
Involvement of family and friends.
Biopsychosocial perspective.
The “patient as a person.”
Sharing power and responsibility.
Therapeutic alliance.
The “doctor as a person.”
(Stewart et al., 2003). Alternatively, Mead and Bower (2000)
integrated the illness experience or the patient’s understanding
of illness into their definition rather than the patient being the
recipient of a disease. This includes a biological and psychological
aspect of non-acute medical situations, being more balanced and
more inclusive of the nonpathologic experience that patient may
want when receiving care.
Physiologic pregnancies
None of the reviewed papers focused solely on the physio-
logic care or the exclusion of pathologies. Two authors used
terms that were inclusive of physiologic pregnancies, intranatal,
and postnatal care such as “clinical status, progress, prognosis,
processes of care“ (Shaller, 2007, p. 3). In Shaller (2007) and
Mead and Bower (2000) pathology-oriented terms such as
disease, illness, and sickness were absent.
Health promotion and prevention of disease are important
topics for maternity services. Matters such as preconceptual care,
substance abuse and tobacco consumption have public health
targets published in health policies (Department of Health,
2004). Two authors included health promotion as “enabling
people to take control over and to improve their health” (Stewart
et al., 2003, p. 102) and “information, communication and edu-
cation in order to provide autonomy, self-care and health-pro-
motion” (Shaller, 2007, p. 3). Health promotion was approached
104 C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
Table 2
Criteria for the Critical Appraisal
Criteria
Is the definition inclusive of physiologic as well as pathologic pregnancy?
Is the definition inclusive of the different characteristics of the population using
maternity services?
Is the definition inclusive of the diversity of practitioners caring for women
using maternity services?
Is the definition inclusive of strategies facilitating the implementation of PCC?
Abbreviations: HCP, health care provider; PCC, patient-centered care.
differently by some authors who presented the experience of
care, but with less emphasis on information provision, guidance
or reassurance for women (Mead & Bower, 2000). Health pro-
motion was approached finally from a disease prevention
perspective: risk avoidance, risk reduction, early identification,
and complication reduction (Stewart et al., 2003). These are
relevant to maternity services and routinely practiced during
maternity care (Kramer & McDonald, 2006; Castrucci, Culhane,
Chung, Bennett, & McCollum, 2006).
Criteria 2: Is the Definition Inclusive of the Different
Characteristics of the Population Using Maternity Services?
Social diversity
Delbanco and Gerteis (2010) and Shaller (2007) addressed the
necessity to respect patient’s needs, autonomy and dignity. This
reflects women’s diversity and variability of preferences and
needs. Some authors went beyond the traditional notion of
family with the inclusion of same sex couples. This made it
representative of women from other minorities (e.g., teenagers,
single mothers, immigrants; Stewart et al., 2003). The selected
populations on some documents were teenagers and children,
inpatient and outpatients, but the proportion of these population
that would include pregnant women is unknown (Coulter, 2005).
Clinical situations
Some documents focused solely on conditions such as end of
life pain, palliative care, suffering, and respiratory management.
These are acute medical conditions that are not part of routine
care delivered in maternity services (IOM, 2001). Other spe-
cialties such as cancer care or accident and emergency (leg
fracture; Mead & Bower, 2000) were also felt to be irrelevant for
maternity services. Pain management is a recurrent topic, but is
addressed differently from one service author to another, for
instance in relation to cancer care or inpatients (Coulter, 2005),
or indeed about patient misconceptions, such as low expectation
for pain relief, or the view that a patient endures far more pain
than necessary (Delbanco & Gerteis, 2010). Shaller (2007)
included pain management in relation to patient daily activity,
which is relevant to women with minor disorders during
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Inclusion or Exclusion Details of the Criteria
Does the definition emphasize medical disorders only?
Does it include elements about physiologic pregnancy (prevention, anticipatory
care, minor disorders during pregnancy)?
Does it include psychological well-being aspects of care?
Specific to reproductive age, in general absence of medical disorders, with or
without partner and family, living in rural/urban area, first baby or subsequent
babies, and includes diverse social issues (supportive social environment as
much as domestic abuse past or current, psychological disorders, substance
abuse).
Can the definition fit the different care pathways and various HCP in maternity
services:
1) Midwife-led care: The midwife is responsible for the planning and delivery
of care to the woman during pregnancy and birth (rarely the same one);
2) Obstetrical-led care: The obstetrician is responsible for the planning of care
which is delivered by obstetricians and midwives, as well as other spe-
cialists if necessary. The HCP that are involved during maternity care, for
example, midwives, obstetricians, student’s students, social services,
nurses, health visitors, pediatrician, sonographers, physiotherapist, spe-
cialists in the event of acute or chronic disorders under treatment (e.g.,
diabetic team, thyroid clinic, cardiac clinic).
Are some strategies or interventions detailed in the definition to achieve PCC?
pregnancy, such as symphysis pubis dysfunction or back pain
together with fear and anxiety of some women’s feelings about
the pain of childbirth. Physical comfort and attention to patient’s
discomfort were approached both by the IOM (2001) and Shaller
(2007). However, only Shaller (2007) discussed elements such as
massage, music, alternative practices, healing, and human touch.
These are important aspects in maternity care.
Partner and family involvement
The role of family and friends was considered by most of the
authors (IOM, 2001; Coulter, 2005; Stewart et al., 2003; Shaller,
2007; Delbanco & Gerteis, 2010). Families were noted as being
involved in decision making and giving support as caregivers.
The authors recognized their needs and contributions (IOM,
2001). Stewart et al. (2003) included maternity services in this
section, considering the family and the impact of illness on
maternal–infant bonding. More generally, Stewart et al. (2003)
suggested that clinicians should take into account contextual
elements such as social support (present or absent), employ-
ment, financial security, and community-oriented primary care.
These are relevant for women who work during their pregnancy
and hospitalization because this can have a detrimental effect on
their job security. Shaller (2007) went a step further and
encouraged an involvement of the family not only in patient care,
but also in decision making at an institution level (e.g., policy and
program development, implementation, evaluation in health
care facility). Family involvement was briefly described by
Coulter (2005) for times when staff needed to speak with family
or carers, but without giving explicit information about their
involvement outside of convalescence care. Mead and Bower
(2000) did not address this dimension and focused the defini-
tion on patient’s involvement only.
Psychological aspect of care
Aspects such as compassion, empathy, and respect were
described by two authors Stewart et al. (2003) and Shaller
(2007). Delbanco and Gerteis (2010) referred to more physical
elements of care, such as maintaining personal hygiene, eating,
and moving or walking. Even women accessing maternity ser-
vices with significant morbidity were unlikely to need help with
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Table 3
Synthesis of the Critical Appraisal of Definitions of Patient-centered Care (PCC) against Criteria to Fit Maternity Services
Authors/Criteria
Delbanco & Gerteis (2010)
Title: A patient-centered view of the
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clinician-patient relationship. Up to
date.
Stewart (2003)
Title: Patient-centered Medicine.
Transforming the clinical method.
Radcliff Medical Press.
Shaller (2007)
Title: Patient-centered care, what
does it takes?
The Commonwealth Fund.
Mead & Bower (2000)
Title: Patient-centredeness: a
conceptual framework and review of
the empirical literature. Social
Science and Medicine.
IOM (2001)
Title: Crossing the quality chasm.
National Academy Press.
Coulter (2005)
Title: Trends in patient’s experience
of the NHS. Picker Institute.
Abbreviations: A&E, Accident & Emergency; HCP, health care provider; PCC, patient-centered care.
Is the Definition Inclusive of Physiologic
as Well as Pathologic Pregnancy?
There is a focus on acute and chronic
sickness, spectrum of ill-health, medical
care and treatment of ill-health. No
mention of health promotion.
Health promotion is addressed in
relation to well-being and absence of
pathology. The definition focuses on
illness and morbidity, patients with
long-term disabilities or chronic
disease.
Terminology such as clinical status,
progress, prognosis and processes are
used, without specific terminology
related to ill-health. Health promotion
and self-care are mentioned.
The term “dysfunctional states” is used,
with is wider than ill-health situations.
Health promotion is addressed. There is
a focus on understanding of patient
experience of illness.
Health promotion is included on “how
to stay well.” The definition addresses
vulnerabilities than can accompany
illness or injury. There is a focus on
illness and injury; on end of life pain
and respiratory management.
The definition gives an emphasis on
acute and chronic ill-health (e.g., A&E,
cancer care, coronary heart disease) and
outpatient appointments. The
definition does not address health
promotion.
Is the Definition Inclusive of the
Different Characteristics of the
Population Using Maternity Services?
The definition acknowledges diversity
of ethnicity, social background and
cultural differences, socioeconomic
factors of patient. Mention of diversity
of family and significant others and
patient’s diversity in needs. Pain
management is addressed in relation to
ill-health only.
Acknowledgement of patient’s diversity
in needs and family circumstances. The
definition refers to diversity in patient’s
world.
Pain management is addressed in
relation to ill-health situation, medical
treatment and hospital confinement
only.
The definition mentioned pain
management and quality of life. There is
an attention to patient’s needs.
Complete and unbiased communication
to patients and family is incorporated as
well, along with patient, families and
friend’s knowledge, values and belief.
There is a focus on fear and anxiety in
relation to mental illness.
Patient involvement only is addressed,
with no inclusion of family and friends.
The definition does n-ts address
women-specific needs.
The definition includes accommodating
family and friends, and recognizing
their needs and contributions. The
definition incorporates physical and
emotional needs. There is a focus on
suffering and anxiety that accompany
illness and injury.
The definition includes patient’s
involvement in decision making. It
addresses anxieties, fears, privacy,
respect, dignity and strong beliefs.
Children and teenagers are addressed
specifically, but not the rest of
maternity services population.
Is the Definition Inclusive of the
Diversity of Practitioners Caring for
Women Using Maternity Services?
The definition acknowledges that no
single provider is responsible of all
aspect of patient care.
Multidisciplinary team (social worker,
physiotherapist, speech therapist, etc.)
is mentioned.
There is a focus on doctor–patient
relationship only.
Multidisciplinary team is incorporated.
Doctors only are named as HCP along
with doctor–patient behavior.
The definition specifies that there is a
transition from settings and to self-care
setting. The type of provider of PCC is
unclear.
Multidisciplinary teams encountered
Is the Definition Inclusive of Strategies
Facilitating the Implementation of PCC?
Strategies are named: Patient feedback,
mindfulness communication, patient
feedback, staff training in crisis
intervention, webpages, emails with
HCP and softening hospital
environment. But strategies are not
always described.
Strategies are named: Motivational
C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
interview, shared decision making, grid,
and medical education.
Strategies are named: Care for
caregivers, leadership, strategic vision,
involvement of patient and families at
multiple levels, supportive work
environment, systematic measurement
and feedback, quality of built
environment, and supportive
technology.
This article aims to review and develop
empirical evidence on PCC and not
implementation strategies.
Strategies are presented (e.g.,
technology based, share decision
making, interdisciplinary teams
training programs, informed choice,
and access to their health record).
The paper presents empirical evidence
and not addressing implementation
strategies.
105
106 C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
personal care or mobilization. Emotional support was high-
lighted by Delbanco and Gerteis (2010) only in relation to the
burden of the illness on patients and family in the event of the
specific situations named (i.e., hygiene, mobility, nutrition).
Mental illness is, however, relevant to maternity services. An
estimated 10% to 15% of women suffer from postnatal depression
(Coulter, 2005; IOM, 2001; Stewart et al., 2003). Emotional needs
were either described in relation to end of life situations (IOM,
2001) or to fear and anxiety (Shaller, 2007). Given that end of
life situations (IOM, 2001) are fortunately rare in maternity care,
Shaller’s description of emotional needs as inclusive of fear and
anxiety is more applicable to psychological needs during the
perinatal period. Finally, only Coulter (2005) addressed religious
beliefs, although the focus was on cancer care.
Criteria 3: Is the Definition Inclusive of the Diversity of
Practitioners Caring for Women Using Maternity Services?
Medical doctors or/and multidisciplinary team
All the documents reviewed, except Mead and Bower (2000),
included a variety of HCPs that deliver the care to the patient.
Multidisciplinary teams are important to maternity services as
different HCPs are required to cover the range of clinical care
during pregnancy, childbirth and postnatal period. Four authors
included HCPs such as social workers, nurses, doctors, physio-
therapists, and managers (Stewart et al., 2003; Delbanco &
Gerteis, 2010; Shaller, 2007; Coulter, 2005). The IOM (2001)
does not specify the type of HCPs but included a “smooth tran-
sition from one setting to another or from a healthcare to as self-
care setting” (p. 50), which implies the inclusion of all HCPs
providing care in the settings concerned.
Criteria 4: Is the Definition Inclusive of Strategies Facilitating the
Implementation of PCC?
Four authors presented a range of strategies to implement
PCC (Stewart et al., 2003; Delbanco & Gerteis, 2010; Shaller,
2007; IOM, 2001). Two authors did not address this aspect as
their papers were aimed at evaluating health services or
empirical knowledge about PCC (Coulter, 2005; Mead & Bower,
2000). Feedback from the patients were named by the four
authors as an integral part of assessing experiences of care in
maternity services. Stewart et al. (2003) and Delbanco and
Gerteis (2010) both proposed motivational interviews as strate-
gies for addictive behaviors, to promote a shared understanding
of a problem and to inform decision making. Other strategies
proposed were support groups and mindfulness education pro-
grams to highlight the importance of the nontechnical aspect of
care, which has a significant impact upon patients’ satisfaction
(e.g., a hug or use of humor; Delbanco & Gerteis, 2010). Grids
detailing problems, goals, roles of patients and doctors, and PCC
education in health promotion were also suggested (Stewart
et al., 2003). The IOM provided additional strategies and tech-
nical support such as a web platform to access knowledge and
discussion groups, emails between HCPs and patients, and
involvement of visitors in treatment. All these are relevant for
maternity services to involve family the care provided. Finally,
transparency and free flow of information strategies were
described (e.g., preparation of a prompt sheet for patients to
remember questions), using all expertise and knowledge of the
team and patient’s access to their clinical record. Shaller (2007)
proposes a plan with seven factors that contribute to imple-
mentation of PCC: 1) leadership, 2) strategic vision of the
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organization, 3) involvement of family and friends in three levels,
4) care of the care givers, 5) systematic measurement and
feedback, 6) quality of the built and work environment, and 7)
supportive technology. Shaller’s (2007) description of strategies
in domains 3, 4, 5, 6, and 7 are similar to the strategies described
by the IOM (2001), Stewart et al. (2003), and Delbanco and
Gerteis (2010). However, Shaller (2007) puts forward a stron-
ger involvement of the family and friends, evaluation of the
service, guidelines and policies, leadership, and the strategic
vision of the organization.
Synthesis of the Findings
Criteria 1: Physiologic and pathologic pregnancy
It became evident that three definitions (IOM, 2001; Stewart
et al., 2003; Coulter, 2005) emphasize acute or chronic disease.
This leaves clinical situations like physiologic changes during the
pregnancy (e.g., heartburn, nausea, vomiting, sleep disturbances,
constipation, back pain, anemia, and mood swings) to be seen as
pathologic (Cunningham et al. 2010). However, a large percent-
age of women (approximately 60%) start their pregnancy with no
medical disorders that would necessitate them seeing an
obstetrician and 40% of women give birth with no complications
(National Institute for Health and Care Excellence, 2014). These
definitions would therefore exclude many pregnant women who
present normal physiologic changes as they are not diseases
(Leap, 2009; Mason, 2010; Tucker et al. 1996). Shaller (2007) uses
terms such as “clinical situation or processes of care” integrating
the unpredictability of pregnancy and childbirth and its com-
plications, as well as predictable physiologic changes. Again,
there is a need for a model that can incorporate physiologic and
pathologic pathways.
Criteria 2: Different characteristics of the population
Four subcategories could be compared between the six doc-
uments: social circumstances, clinical situations, involvement of
family and friends, and psychological aspects of care. The authors
all placed value on respect for patient’s needs and preferences in
relation to social diversity. The main difference seen was with
Shaller’s (2007) inclusion of nonmedical approaches to care that
are commonly used in maternity services. These were described
as including emotional support, awareness of patient’s knowl-
edge and values, and alternative therapies such as massage,
acupressure/acupuncture, aromatherapy, and a shower or bath.
Shaller (2007) also makes a distinction between family and
friends’ involvement in care, and the effect that the clinical situ-
ation can have on their degree of involvement. Shaller (2007)
highlights the importance of users and carers experiences in
helping to construct the system and amend the policies that guide
the provision of services. Finally, psychological aspects of care
were approached by most authors including fears and anxiety,
emotions commonly described during antenatal, intrapartum,
and postnatal care. However, the IOM (2001) used these terms in
the context of suffering, loneliness, injury, or illness, which are
inadequate to describe physiologic mood disorders that can
happen during pregnancy. Similarly, Shaller’s (2007) definition of
PCC does not include acute mental disorders that go beyond fears
and anxiety; neither definition fully encompasses the re-
quirements for emotional support in maternity services.
Criteria 3: Diversity of practitioners
The appraisal did not identify strong differences between
documents that included HCPs other than medical doctors. These
 C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
definitions grouped together a range of professions that women
may encounter during their care in maternity services from
physiotherapists, midwives, social services, and so on.
Criteria 4: Strategies facilitating the implementation of PCC
Four of the six documents reported the following strategies:
Stewart’s grid and educational program (2003), the IOM’s tech-
nical support, care of the carer’s, transparency/free flow of in-
formation (2001), and Delbanco and Gerteis’s support groups,
mindfulness program, and the nontechnical aspects of care
(2010). These last four strategies are similar to these of Shaller
(2007): care of the care givers, systematic measurement and
feedback, quality of the work environment, and the supportive
technology. Shaller (2007) not only included strategies that were
presented in all other documents, but in addition included
important information on leadership and the strategic vision of
the organization.
Discussion
To the best of our knowledge and to date, this is the first
critical appraisal of the definitions of PCC and its applicability to
maternity services. This review has allowed the identification
and critical appraisal of diverse definitions of PCC and an
assessment of their suitability for use in maternity services.
There was a need to assess a “best fit” to reflect on the spectrum
of risk in pregnancy, the characteristics of the women seeking
care, the diversity of health care professionals providing mater-
nity care, and the appropriateness of implementation strategies.
The results of this review revealed six definitions of PCC, with no
consensual description of the domains; their commonalities and
differences were reviewed. The six papers have individually
described PCC, using five to eight domains with their definitions.
The type and quantity of data collected on the definitions varied
between the six papers, with the amount of data from the two
books being greater than the articles and reports. Nevertheless, the
evidence published by the authors when analyzed helped to un-
derstand the different emphasis that they placed on their defini-
tions of PCC. To find the most relevant definition to PCC in maternity
services, four criteria were developed and used to compare them.
For criteria one (inclusivity of pathologic and physiologic
pregnancy), Delbanco and Gerteis (2010), Stewart et al. (2003), the
IOM (2001), and Coulter (2005) focused mainly on disease,
whereas Shaller (2007) and Mead and Bower (2000) used non–
pathology-oriented terms. Shaller (2007) set himself apart by
including ill-health and pathologic pathways of care, with a
greater emphasis on the involvement of family and friends
compared to the other authors, for criteria two. The diversity of
practitioners in criteria three did not differ a great deal between
authors who include other HCPs and not just doctors. Finally, for
criteria four, similar strategies were described by the authors with
the exception of Shaller who added leadership and strategic vision.
By presenting a definition including 1) a sensitivity to phys-
iology and pathologic pathways of care, 2) an awareness of the
different social and clinical situations, 3) having the strongest
involvement of partner and family, and 4) strategies to imple-
ment PCC, Shaller (2007) seems to present the most inclusive
definition of PCC that fits with maternity services.
Strength and Limitations of the Review Results
One of the strengths of this narrative review is that is uses
four different sources to represent the scientific, empirical, and
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107
professional literature. Most of the other reviews in this area
focused on discipline-related concepts and therefore focused
their search strategies on electronic databases only (Kitson,
Marshall, Bassett, & Zeitz, 2012; Mead & Bower, 2002; Rowe
et al., 2002; Stewart, 2001).
A critical appraisal of the research documents was under-
taken using a grid developed to answer the review questions and
gain a consensus agreement on the comments. No quality
appraisal of the documents was done because the focus of the
review was to have a historical overview of the concept, the
diverse background, the possible development, and the variety of
documents. By analyzing the quality of the different sources, we
may have had to eliminate some key documents that could have
been important in the analyses. Nevertheless, to overcome this
limitation, we would recommend that Shaller’s domains of PCC
as a model of care are tested and validated, because this is the
first attempt to synthetize knowledge on PCC within maternity
services.
Implications for Practice and/or Policy
Setting up a model of care that is too strongly linked to
pathologic circumstances can be detrimental to maternity ser-
vices particularly when looking at policies’ goals to normalize
birth and to reduce unnecessary interventions (Department of
Health New South Wales (2010); Scottish Government Health
Directorate, 2009). The relevant domains of PCC for maternity
services should cover the needs of all women and help to forge
policies that neither accentuate nor ignore potential complica-
tions during or at the end of pregnancy. The model should
emphasize pregnancy and birth as physiologic events, because
the majority of pregnancies start with no or little risk of com-
plications, but must include possible pathologies. Shaller’s
(2007) domains of PCC take the uncertainty of childbirth into
consideration rather than other definitions that tend to reduce
the domains to complicated or normal births, only. It is impor-
tant that PCC terms and domains are chosen carefully as they will
be used in policies and action plans. Shaller (2007) described
strategies to implement PCC at both an organizational level: 1)
leadership development and training, 2) internal rewards and
incentives, 3) training in quality improvement, 4) practical tools
derived from an expanded evidence base, and then at a system
level, namely, 1) public education and patient engagement, 2)
public reporting of standardized measure, and 3) accreditation
and certification requirements. As highlighted by Davidson et al.
(2006), giving a strong theoretical underpinning on the model of
care for a specific health care service, will help in the develop-
ment of PCC strategies and their evaluation, and therefore will
strengthen care that is already provided. This would achieve the
goal of improving quality of care by enhancing clinical quality,
safety, and response to individual needs (Australian Commission
on Safety and Quality in Healthcare, 2010). Keeping these ele-
ments in mind and with the results of this review, we conclude
that Shaller’s domains of PCC seem to be the most inclusive for
the women receiving care and the HCP delivering care in ma-
ternity services.
However, if Shaller’s (2007) domains of PCC can be recom-
mended, it is still unclear how to design and best put into
operation interventions that can deliver PCC to patients. Several
interventions have been targeting organizational and system
levels with no clear precision and practical implication for pro-
fessionals (Iowa Department of Public Health, 2010; Scottish
Government, 2006). Maternity services have tried to
108 C. de Labrusse et al. / Women's Health Issues 26-1 (2016) 100–109
implement PCC strategies for over 20 years; however, if im-
provements are to be made, the adoption of one clearly defined
model of care by all key stakeholders groups (such as Shaller’s
from this critical appraisal), could help policymakers in
achieving PCC. It would seem that what is needed now to
improve the quality of care in maternity services is an evaluation
of programs that support PCC, such as those run by interpro-
fessional teams (Picker Institute & Planetree, 2008) or pro-
cedures that are established at a national level (Scottish
Government, 2006), to assess the extent to which these pro-
grams support PCC and HCPs and women perceptions of these
programs.
Conclusion
This review highlights the advantages of adopting PCC as a
model for maternity services. PCC models support the achieve-
ment of high quality care across the entire pathways for both
women and HCP. The six domains of Shaller’s PCC definition best
address the context and the content of maternity services.
However, what seems to be important is how the six domains of
PCC fit in practice. Using Shaller’s (2007) definitions and strate-
gies in the development of maternity services’ policies could
strengthen the implementation of PCC interventions in practice.
It remains unclear today how best to support PCC in mater-
nity services and what implementation strategies would be most
effective. Specific PCC projects in maternity services have been
conducted but it has looked at PCC strategies and how to
improve patient experience (Goodrich & Corwell, 2008;
Whitford et al. 2014). Detailed evaluation of these projects, rec-
ommendations generated and the measurement of PCC compo-
nents would allow for improvement initiatives targeted towards
women in maternity services, and, if appropriate, facilitate the
development of future policy documents (National Quality
Forum, 2012; Lewin et al. 2001).
Acknowledgments
CDL thanks the School of Health Sciences (HESAV) at the
University of Applied Sciences Western Switzerland for their
support.
Source of funding: This research received no specific grant
from any funding agency in the public, commercial, or not-for-
profit sectors.
Conflict of interest: No conflict of interest has been declared
by the authors.
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Author Descriptions
Claire de Labrusse, PhD Candidate, MSc, RM, is a lecturer in the Midwifery School of
the University of Health Sciences Western Switzerland (MSc Midwifery, PhD
candidate health services research University of Aberdeen). Her research area is
expert skills in midwifery and patient-centred care in maternity services.
Anne-Sylvie Ramelet, PhD, MSc, RN, is a professor at the University of Lausanne
(Switzerland)dInstitut Universitaire de formation et de recherches en soins. Her
research interest is pain research in pediatrics and neonatology: patient and family-
centred care in pediatrics; family support.
Tracy Humphrey, PhD, MSc, RM, is a professor of Midwifery and Head of Women
and Children at the School of Nursing and Midwifery, Robert Gordon University. Her
research and international focus use mixed-methods approaches to inform
midwifery practice and health outcomes for women and families.
Sara J. MacLennan, PhD, CPsychol, AFBPsS, is a senior lecturer in the Academic
Urology Unit, University of Aberdeen. She is an associate fellow of the British
Psychological Society and registered health psychologist. Her research focused on
behavior in relation to long-term conditions and reproductive health.