Providing patient-centred care (PCC) is one of the goals described by the Institute of Medicine (IOM) to deliver quality of care. Across several interventions described in the literature, there is no clear consensus of one that will best fit the diversity of women coming to seek care in maternity services and across the variety of healthcare providers (HCPs) who provide that care. A reason for that may be the lack of consensus about the model of care to adopt for maternity services reveals a neglected area of research. Managing quality of care should also mean considering the best model of care in practice for all women, incorporating the core and legitimate attributes of maternity care.
- patient-centred care
- maternity services
- women-centred care
- women’s health
Maternity care systems encompass the structures, a diversity of healthcare providers in their expert field of practice and policies that provide antenatal, intrapartum and postnatal care to women and perinatal care to babies. Similar to general health systems, maternity care has evolved over time, but further improvements still need to be made in the future to meet the challenges posed by changing population needs and to increase the involvement of women in their care . The unique feature of maternity services is that the population is predominantly healthy in comparison to other hospital services. Quality of care delivered during pregnancy, labour and the postnatal period refers to the six elements described by the Institute of Medicine (IOM) , i.e. (1) safe, (2) effective, (3) patient centred, (4) timely, (5) efficient and (6) equitable. However, it would be too simplistic to believe that poor quality of care concerns only low- or middle-income countries. For example, in the Mother’s Index 2013, it is of note that some high-income regions, such as certain states in the USA, have a higher infant mortality rate than less wealthy countries outside the USA [3, 4].
IOM’s quality criteria of safety and effectiveness to improve maternal and foetal outcomes have been a primary target of research for many years [5, 6]. By contrast, patient-centred care (PCC) is just emerging on the maternal and newborn health agenda, and policymakers are only now beginning to address PCC as a dimension of quality of care . The perinatal period is often associated with feelings of anxiety and sometimes even depression . Women across the spectrum of maternity care described the importance of
Women highlighted also the importance of meeting their
Therefore, a lack of consensus on the
The lack of consensus about the model of care to adopt for maternity services reveals a neglected area of research. Managing quality of care should also mean considering the best model of care in practice for all women, incorporating the core and legitimate attributes of maternity care.
2. Models of care and maternity services?
One of the most commonly used models within maternity service policies is WCC and is viewed as the cornerstone of the partnership between the midwife and the woman [24–27]. The women-centred philosophy of care emerged after a set of modernising reforms of the NHS and focus on the individualised needs and with the expectation that healthcare professionals would work in collaboration with the women to meet their needs . Within maternity service provision of care, providing WCC would mean that the diversity of HCPs providing maternity care are trained and have the required skills and expertise to meet the women’s individual needs.
Women-centred care has been closely linked the midwifery practice, as most of the women have a midwife as their primary health care provider throughout pregnancy, labour and the postnatal period. Whilst the midwife is expert of the care of uncomplicated pregnancies, she also provides a pivotal role in coordinating the journey through pregnancy for all women .
The RCM contributed to the developing philosophy of ‘woman-centred care’ and stated that it is the term used ‘[for a philosophy of maternity care] that gives priority to the wishes and the needs of the user, and emphasised the importance of informed choice, continuity of care, user involvement, clinical effectiveness, responsiveness and accessibility’ (, p. 1). The UK and Australian Departments of Health and the Australian College of Midwives also recommend this model of care for maternity services [31–33]. Leap described the wider concept of WCC as a concept that includes the need to address women’s emotional, physical, psychological and cultural need and expectations with continuity and control over the care delivered by a single or a group of HCP . This addresses that relationship between the woman and the woman is the key component of the ‘women-centred care’ which incorporated respectfulness and sensitivity of the midwife . Developing on the idea that WCC was closely linked to midwifery practice, women-centred midwifery was presented by as :
Focuses on the woman’s individual needs, aspirations and expectations, rather than the needs of the institution or professionals
Recognises the need for women to have choice, control and continuity from a known caregiver or caregivers
Encompasses the needs of the baby, the woman’s family and other people important to the woman, as defined and negotiated by the woman herself
Follows the woman across the interface of community and acute settings
Addresses social, emotional, physical, psychological, spiritual and cultural needs and expectations
Recognises the woman’s expertise in decision-making
According to the RCM , midwife-led care is the key to achieve a direct link with the defined scope of WCC. The RCM  also emphasised that to truly achieve WCC, it needs to be led by midwives through the care they deliver during uncomplicated pregnancies, birth and postnatal care. Similarly, some international definitions of WCC also place an emphasis on uncomplicated pregnancies and normal birth [32, 38]. This has been defined as the care provided by midwives who act as ‘the lead professional in the planning, organisation, and delivery of care given to woman (who are healthy and at low risk of complications) from initial booking to the postnatal period’ . If, as some professional bodies suggest, midwives can only deliver WCC in the context of uncomplicated childbirth, then it would be exclusive to this discrete group, thus excluding this model of care from a significant and growing proportion of women who have or develop complications or risk factors. However, in the UK, we know that midwives do provide care to
It is estimated that 40% of women are not suitable for midwife-led care at the onset of pregnancy , and therefore this proportion of women would not benefit from a WCC model. Furthermore, in clinical situations or countries where healthcare professionals other than midwives are the primary care provider of pregnant women (e.g. family physician or obstetrician), it is not clear whether WCC can be still offered to them .
In the process of current identification of WCC, midwifery has been named as being the cornerstone of WCC. In the 1990s, childbirth was becoming ‘hypermedicalised’, relying more and more on technology, and intervention rates were increasing rapidly and particularly the caesarean section rates. A parliamentary enquiry then determined ‘the extent to which resources and professional expertise were used to achieve the most appropriate and cost effective care of pregnant women and delivery and acre of newborn babies’. This was the
Fahy  wrote an editorial on the definition of WCC in which she argued that midwifery is a discipline that supports the relationship ‘with the woman’ and that maternity services should support this women-centred midwifery care by providing continuity of relationship during pregnancy and labour. Then, Berg et al.  looked at the definition of midwifery care concepts for Sweden and Iceland in the recent literature to identify a midwifery model of WCC that would best fit their context. Their results, as the most current statement about the midwifery care model, addressed that the new midwifery model was similar to the midwifery care model described by the International Confederation of Midwives which gives a focus on normality during pregnancy.
Several projects in Australia and the UK have addressed the importance and the effectiveness of providing WCC for low risk with midwife-led care and high-risk women in collaboration with obstetricians and other HCPs [46, 47]. Leap  already addressed the tension that WCC is seen as exclusively linked to normal birth and midwifery-led care . In most circumstances, a midwife would take the role of lead professional for all healthy women with straightforward pregnancies. Additionally, for women with complications, an obstetrician would be the lead professional, and the midwives will provide midwifery care in collaboration with other professionals . The Cochrane review  compared midwife-led models of care to other models of care (e.g. obstetrician or family doctor or shared model of care) and suggested that women who received midwife-led models of care were less likely to experience intervention in comparison with women who received other models of care. The review included studies with women classified as both ‘high and low’ risk, with the exclusion of women currently experiencing both acute maternal complication and substance misuse. The authors note that the same results may not be applicable with women experiencing obstetrical complications and not being under midwife-led care. It is only recently that the RCOG have embraced this concept in their guidelines. In the revised position statement in 2008, the RCM stipulated that “truly WCC must encompass midwifery-led care of normal pregnancy, birth and the postnatal period and services that are planned and delivered close to women and the communities in which they live or work.” (, p. 2). This statement highlights WCC as including uncomplicated pregnancy, with midwife-led care being provided in midwife-led settings such as home, freestanding and alongside hospital birth centres for women defined as having a low clinical risk.
Finally, the key concepts of quality in maternal and newborn care presented in the Lancet Midwifery  included: safe, effective, accessible, appropriate, affordable, equitable, efficient, and woman-centred care. This framework for maternal and newborn care referenced the WHO Quality of Care report  as the primary reference, but they use the term patient-centred care not women-centred care, which highlights one example of the terms PCC and WCC not being used consistently. This may be due to a lack of clarity about their dimensions and in which context one should be used and not in the other. The results of this study have highlighted the gaps in WCC as needing to be more inclusive of women, regardless of risk or model of care. Until there is more consistency and acceptance about WCC for all women, regardless of model of care, it may be that, as this study suggests that PCC may be a more inclusive model.
More recently, contemporary policy documents have alluded to WCC being for all women—not just those receiving midwife-led care [50, 51]. If WCC is to apply to all women using maternity services, then it would be beneficial to reflect this in its definition. For example, specifying that WCC is for all women, regardless of risk, pathway of care or lead healthcare professional. This would be more inclusive and support maternity services to apply this concept more broadly, enabling all women to benefit from this philosophy of care.
Identifying the most appropriate model of care for maternity services with a clear definition of each domain would help governments and professionals to develop goals and implementation strategies to improve the quality of care delivered. The review of other models used in maternity service policies shows that family-centred care places an emphasis on the sick child [52, 53] and person-centred care relates mainly to elderly people or those with long-term health conditions [54, 55]. Thus, these last two terms do not match the state of health and age of women in their reproductive life using maternity services . Therefore, an alternative model of care is necessary for women who present various status of health when being pregnant. PCC has also been used in maternity service policies and offers such an alternative [57–59].
3. Reflection on Shaller’s PCC model and redefinition 
PCC has been recommended as a marker of quality in health service delivery . 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 et al.  for the Picker Institute and incorporates seven key domains: (1) respect for patient values, preferences and expressed needs; (2) coordination and integration of care; (3) information, 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 continuity.
Whereas 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 encompasses various care pathways that can fit with the uncertainty of childbirth. Of note, this domain is not dependent on the HCP function and incorporates the variety of healthcare professionals that some women may encounter, including the dynamic nature of risk within pregnancy. This has the advantage to allow women to easily transit from one pathway of care to another without any effect on their model of care. Finally, the PCC ‘respect for patient values, preferences and expressed needs’ domain is comprehensive enough to consider the general and specific issues of women’s needs and expectations when using maternity services. When one of the most referenced definitions of PCC is reviewed, it appears that PCC may be a more appropriate model of care for maternity services, as per described; see . Shaller’s  framework of PCC described a brief outline of the six domains including:
Domain 1: Education and shared knowledge
Domain 2: Involvement of family and friends
Domain 3: Collaboration and team management
Domain 4: Sensitivity to non-medical and spiritual dimensions
Domain 5: Respect for patient need and preferences
Domain 6: Free-flow and accessibility of information
A comparison of the data collected in the multiple case study approach about maternity services with the existing literature highlighted further elements in each one of the domains. A revised model could integrate a stronger appreciation of the importance to provide individualised information by their care provider (d1), highlighting the opportunity for a greater involvement of the family and friends (d2), with a continuity of care (d3), an awareness of anxiety in any pregnancies and the midwife as the person to refer to in this situation (d4), and the development of clear and achievable expectations (d5), using multiple interventions that support communication. A revised model of PCC presented below is inspired by the Shaller definitions (plain text) and includes additional or alternative terms about the domains. This revised model provides more details and uses semantics that are generalisable to other services not just for maternity services but also for other health areas.
4. Proposed revised model of PCC
5. Relating the revised model to existing literature
The proposed revised definitions of PCC are close to the person-centred care definition published by the Scottish government in the Healthcare Quality Strategy for NHS Scotland (2010) and so beyond the disease-oriented definition, including shared decision-making and mutual partnership with the person and their families.
It became apparent that policies were shifting their terminology from PCC in those reviewed after 2009 [64–70] to person-centred care in the last policy analysed . Over the past 5 years, the model of person centredness has increasingly appeared in UK health policy and, more specifically, in Scotland in the past 5 years. Today, person-centred care is also central to the four UK countries, i.e. Vision 2020 for Scotland , the Health and Social Care Act , Department of Health Northern Ireland , and the Welsh White Paper . Whereas prior PCC definitions focused on the pathology [2, 76] and the person-centred model on oncological and gerontological care [55, 77], the recent definitions of person-centred care by the Health Foundation  have tried to include principles, rather than a definition, for example:
‘(1) Affording people dignity, compassion and respect. (2) Offering coordinated care, support or treatment. (3) Offering personalised care, support or treatment. (4) Supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life’ (, p. 6).
The Health Foundation proposed four principles of person-centred care rather than definitions as they can be restrictive. Unfortunately, it omitted to explain how each one of the principles could be delivered in practice, which can be more easily evaluated and improved upon than proposing broad approaches that are not clearly linked to one principle. The levels of the principles do not yet provide the level of details that Shaller’s model proposes, which supports a clearer implementation and evaluation process. Through this research the Shaller’s model has been demonstrated to be appropriate for maternity services as it offers a model of care that includes a continuum from wellness to illness for women who present in various states of health during the course of their pregnancy. The similarities of the themes used between PCC and person-centred care (e.g. respect, support and positive reinforcement) and between PCC and WCC (e.g. individual needs (emotional, physical, psychological, spiritual), choice, continuity and decision) provide evidence of PCC’s relevance and potential. The research also demonstrates how this could be further improved.
A clear definition of the model of care is essential for policymakers and practitioners to improve the system in place. Giving a definition of the PCC model in the policy will help the implementation of the intervention and set the scene for its evaluation and the further revision of the policy and the model itself . Clarity and transparency of the model of care chosen and its accompanying definition will benefit its implementation along the whole pathway . To date, Shaller’s theoretical framework appears to be the most inclusive model and remains the representation of PCC reported at global level. The domains have also recently been used in describing person-centred care [80–83]. It could be because its definitions and key factors for achieving PCC are the most representative to complex health systems, with the acknowledgement that no other theoretical framework has been able to address both the diversity of women’s clinical conditions and HCPs’ provision of roles.
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