Salutogenically focused outcomes in systematic reviews of intrapartuminterventions: A systematic review of systematic reviews

Valerie Smith, RM, PhD (Lecturer in Midwifery)a,n, Deirdre DalyRM, MSc (Lecturer in Midwifery)a, Ingela Lundgren, RM, PhD (Professor of Midwifery)b,Tine Eri, RM, PhD (Lecturer in Midwifery)c, Carina BenstoemRM, MSc (Research Associate)d, Declan Devane, RM, PhD (Professor of Midwifery)e

a School of Nursing & Midwifery, University of Dublin, Trinity College Dublin, Dublin, Irelandb Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Swedenc Faculty of Health Sciences, Vestfold University College, Norwayd Midwifery Research and Education Institute, Department of Obstetrics, Gynaecology and Reproductive Medicine, Hannover Medical School,Hannover, Germanye School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland

a r t i c l e i n f o

Article history:Received 17 April 2013Received in revised form31 October 2013Accepted 4 November 2013

Keywords:SalutogenesisSalutogenically-focused outcomesSystematic reviewIntrapartum interventions

a b s t r a c t

Introduction: research on intrapartum interventions in maternity care has focused traditionally on theidentification of risk factors' and on the reduction of adverse outcomes with less attention given to themeasurement of factors that contribute to well-being and positive health outcomes. We conducted asystematic review of reviews to determine the type and number of salutogenically-focused reportedoutcomes in current maternity care intrapartum intervention-based research. For the conduct of thisreview, we interpreted salutogenic outcomes as those relating to optimum and/or positive maternal andneonatal health and well-being.Objectives: to identify salutogenically-focused outcomes reported in systematic reviews of randomisedtrials of intrapartum interventions.Review methods: we searched Issue 9 (September) 2011 of the Cochrane Database of Systematic Reviews forall reviews of intrapartum interventions published by the Cochrane Pregnancy and Childbirth Group usingthe group filter “hm-preg”. Systematic reviews of randomised trials of intrapartum interventions wereeligible for inclusion. We excluded protocols for systematic reviews and systematic reviews that had beenwithdrawn. Outcome data were extracted independently from each included review by at least two reviewauthors. Unique lists of salutogenically and non-salutogenically focused outcomes were established.Results: 16 salutogenically-focused outcome categories were identified in 102 included reviews. Maternalsatisfaction and breast feeding were reported most frequently. 49 non-salutogenically-focused outcomecategories were identified in the 102 included reviews. Measures of neonatal morbidity were reported mostfrequently.Conclusion: there is an absence of salutogenically-focused outcomes reported in intrapartum intervention-based research. We recommend the development of a core outcome data set of salutogenically-focusedoutcomes for intrapartum research.

& 2013 Elsevier Ltd. All rights reserved.

Contents

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e152Aim of review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e152Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e152

Criteria for considering reviews for inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e152Search methods for identification of reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e152Data collection and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e152

Contents lists available at ScienceDirect

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Midwifery

0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.midw.2013.11.002

n Corresponding author. School of Nursing and Midwifery, University of Dublin, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland.E-mail address: smithv1@tcd.ie (V. Smith).

Midwifery 30 (2014) e151–e156

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e153Screening and selection of included reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e153Salutogenically focused reported outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e153

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e154Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e156Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e156References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e156

Introduction

The concept of salutogenesis was first introduced by AaronAntonovsky while he was studying the psychological impact ofsurviving concentration camps (Antonovsky, 1987). Antonovskyexplored how some people who had experienced extremelystressful life events remained resilient and positive about theirlives. Antonovsky asked ‘what creates health?’ and began toform a new theoretical framework for health, which he coined‘salutogenesis’. A key component of salutogenesis is that of a‘sense of coherence’, which postulates that an individual whocan view the world as manageable (i.e. easily find resources forcoping), comprehensible (perceived clarity, order and structure)and meaningful (has purpose) is more likely to view their lifeas coherent. In this sense, no matter how extreme an indivi-dual's experience might be, they will have the ability to copepositively with adverse events. Salutogenesis was the firsttheory of its kind to explore health systematically in terms ofmovement along the health continuum, thereby eliminatinga distinct dichotomy of being in a state of health or being in astate of disease.

Antonovsky's question of ‘what creates health’ is relevant topregnancy and childbirth, which has long been considered on twoparallel views: one views pregnancy and childbirth as a normalphysiological event in line with health and salutogenesis whereasthe second views pregnancy and childbirth as a pathology, whichonly becomes normal in retrospect. Research in maternity care hasfocused traditionally on the reduction of adverse outcomes withlittle consideration for what is optimum, for whom and in whatcontext. In this sense, much research in maternity care has focusedon the prevention of adversity rather than on the promotion ofhealth. The problem with only focusing on adversity is linked witha critique of the so-called ‘risk society’ (Beck, 1992) in which asuper-valuing of risk leads to a paradoxical decrease in well-being.The consequences of risk aversion in maternity care, contrary toevidence suggesting that risk in maternity care is ambiguous andill-defined (Smith et al., 2012), are that interventions designed tomanage high-risk pregnancy and labour have become over-extended to routine use in all childbearing women. The accelera-tion of this way of managing birth has resulted in increasedintervention in childbirth; for example, rates of caesarean birthare over 80% in some maternity units in Europe and as high as 38%in one EU country (EURO-PERISTAT, 2008). Such an interventionistapproach suggests that there is little understanding of whatcontributes to/enhances the health and the well-being of womenand what constitutes salutogenically focused outcomes in mater-nity care. As a first step, we evaluate current maternity careintrapartum intervention-based research to determine the typeand number of salutogenically-focused reported outcomes and todo so by means of a systematic review of reviews. This systematicreview of reviews constitutes one element of an initiative aimed atdeveloping a minimum core data set of salutogenically-focusedoutcomes for reporting in maternity care research. The conductand reporting of this review adheres to, in as far as is possible, thePRISMA checklist of reporting of systematic reviews (Moher et al.,2009).

Aim of review

To identify salutogenically-focused outcomes reported in sys-tematic reviews of intrapartum interventions.

For the purposes of this review, we used a broad definition ofthe term ‘salutogenesis’ as it relates to optimum (and/or positive)maternal and neonatal health and well-being. Guiding our defini-tion were certain attributes from the ‘salutogenesis umbrella’(Fig. 1), including, for example, coping, locus of control, senseof coherence and attachment. We defined a salutogenically-focused outcome as an outcome reflecting positive health andwell-being rather than illness or adverse event prevention oravoidance.

Methods

Criteria for considering reviews for inclusion

Systematic reviews of randomsied trials of intrapartum interven-tions were eligible for inclusion. An intrapartum intervention wasdefined as any intervention that occurred from the latent phase oflabour (i.e. a period of time when there are painful uterine contrac-tions, and there is some cervical change, including cervical efface-ment and dilatation up to 4 cm; National Institute of Health andClinical Excellence, 2007) up to, and including, the time of birth ofthe placenta and membranes. We excluded protocols for systematicreviews and systematic reviews that had been withdrawn.

Search methods for identification of reviews

We searched Issue 9 (September) 2011 of the Cochrane Databaseof Systematic Reviews for all reviews published by the CochranePregnancy and Childbirth Group using the group filter ‘hm-preg’(a tag used to identify reviews registered with the CochranePregnancy and Childbirth Group where ‘hm’ stands for ‘home’ codeand ‘preg’ is the Group's suffix) and restricting retrieved citations tocompleted reviews only (i.e. excluding protocols for reviews). Cita-tions were exported to Endnote. Each citation was reviewed inde-pendently by at least two members of the team against the inclusioncriteria in two stages as follows: (1) title and abstract screening and(2) full text screening of citations judged relevant or potentiallyrelevant for inclusion from stage 1.

Data collection and management

Data were extracted from each included review independentlyby at least two review authors using a purposively developeddata extraction form. Any disagreements were resolved throughwithin pair discussions or deferral to the team for discussion andconsensus (a consensus meeting was held with all team mem-bers in attendance to agree on the final list of salutogenically-focused outcome categories). Unique lists of salutogenically-focused and non-salutogenically-focused outcome categorieswere identified.

V. Smith et al. / Midwifery 30 (2014) e151–e156e152

Findings

Screening and selection of included reviews

Fig. 2 provides a flow diagram detailing the process for andresults of screening and selecting the systematic reviews forinclusion.

Salutogenically focused reported outcomes

Fig. 3 details the results of the data extraction process.Following the data extraction process, a list of 135

salutogenically-focused outcomes were identified and collapsedinto 16 outcome categories (for example, any positive reference tobreast feeding) (Table 1).

436 systematic reviews identified from Cochrane Pregnancy & Childbirth group (Sept 2011)

Reviewer pair 1n = 147

Included n = 39

Reviewer pair 2n = 143

Includedn = 36

Reviewer pair 3n = 145

Includedn = 27

Total included n = 102

Random allocation of reviews for independent screening

Fig. 2. Screening and selection of reviews for inclusion.

Fig. 1. Salutogenesis umbrella. (Reproduced with permission from Bengt Lindström (Lindström and Eriksson, 2010.)).

V. Smith et al. / Midwifery 30 (2014) e151–e156 e153

The list of the 1632 unique non-salutogenically-focused reportedoutcomes in the 102 included reviews collapsed into 49 outcomecategories (for example, Apgar score) are provided in Table 2. Thenumber of times the outcome was reported is also provided.

Discussion

The aim of this review was to identify salutogenically-focusedreported outcomes in systematic reviews of intrapartum interven-tions. Sixteen salutogenically-focused outcome categories (represent-ing 135 individual reported outcomes across all reviews) wereidentified in the 102 reviews. Measures of maternal satisfaction andbreast feeding were the most frequently reported salutogenically-focused outcomes. This compares unfavourably to a unique list of 49non-salutogenically-focused outcome categories (representing 1632

individually reported outcomes across all reviews) reported in theincluded reviews, with certain outcomes (e.g. neonatal morbidity andbleeding/blood loss outcomes) reported more frequently than otheroutcomes.

The findings of our review support the hypothesis that theeffectiveness of intrapartum interventions is measured againstadverse outcomes rather than increases in measures of health andwell-being and/or elements of salutogenesis (e.g. a ‘sense ofcoherence’ (SOC)). Avoidance of adversities are crucial elementswhen considering maternity care provision and this is not to saythat they should not be included when measuring the effects ofinterventions. However, the consistent, dominant focus on risk-reduction continues to form the basis for policy and practicedevelopment (Royal College of Midwives, 2005) with little con-sideration for outcomes indicative of maternal and neonatalpositive health or well-being. In maternity care, salutogenesis

Reviews includedn = 102

Salutogenically focused outcome categories

n = 23

Consensus meetingoutcome categories

excludedn = 7

Number of outcome categories

n = 16

Non-salutogenically focused outcome

categoriesn = 49

Within pair independant data extraction and pooling of outcomes

Fig. 3. Data extraction process.

V. Smith et al. / Midwifery 30 (2014) e151–e156e154

has been described as both a descriptor of the birth process and asan outcome of that process (Downe, 2001). Positive views of birthand the birth experience, even for women undergoing medicallymanaged and technological birth or for women who experiencebirth contrary to their preconceived expectations or desires, arestrongly related to salutogenesis and the elements of manage-ability, comprehensibility and meaningfulness (Downe, 2001). Inthis sense, irrespective of the type of birth experienced, womenwho can easily find resources for coping, achieve perceived clarity,order and structure and emotionally reconcile with a sense ofpurpose, will undergo a salutogenic birth. The baseline argumenthere, in promoting a salutogenically orientated approach tomaternity care, is a dedicated move away from a mono-focus on‘risk factors’ and an alternative move towards a ‘health factors’focused approach (Day-Stirk and Palmer, 2003).

This work comprises one element of an initiative exploring theconcept of salutogeneis in maternity care provision. Focusingsolely on intrapartum intervention-based research limits ourreview to a select group of maternity service users (i.e. womenundergoing labour and birth only) and to measurements ofeffectiveness against outcomes specific to the intrapartum period.However, our review was intentionally focused neither on specificpopulations nor on any particular intervention per se, rather onreported outcomes and whether they were salutogenic or not.We identified a paucity of salutogenically-focused outcomes whencompared to non-salutogenically focused outcomes. This hasimplications for maternity care research in that the avoidance ofill-health or adversity remains the key driver for measuring theeffectiveness of interventions. Adopting a more salutogenically-focused approach to maternity care research by incorporatingsalutogenically-focused outcome measures, such as the onesidentified here, has the potential to provide evidence on women's(or other research participants') levels of well-being and on theirsense of coherence (i.e. by collecting data on measures of coping,satisfaction, mother–infant interactions, etc.). It will allow forpositive measures of maternal health to be identified and perhapsclarify more easily, in the context of the comparative effects ofmaternity care interventions, which interventions are promotionalof positive health and well-being. For example, measuring mater-nal satisfaction as a core outcome measure will provide evidenceon the effectiveness of interventions from a SOC perspective.Incorporating salutogenically-focused outcome measures in mater-nity care research will encourage health care providers, policy-makers and maternity service users to consider maternity care froma health-orientated client-based perspective rather than from a

Table 2Unique list of non-salutogenically focused reported outcomes.

Non-salutogenically-focused outcomes No. of times individualoutcome was reported

Composite of infant morbidity outcomes(short-/long-term; including any disability,HIE, asphyxia, seizures, RDS, PVL, cerebralpalsy, etc.)

141

Bleeding/blood loss (of any type and variouslydefined)

129

Maternal infection (fever/temperature/sepsis,etc.)

74

Apgar score (at 1, 5 or 10 minutes or o7 or‘low’ at r5 minutes)

76

Fetal death, neonatal loss or stillbirth 65Hospitalisation (length of stay, admission,readmission, etc.)

60

‘Pain’ of any type including assessment 56Caesarean birth (for any reason) 55Analgesia (request for/any type, epidural,narcotics, GA, etc.)

52

‘Drugs’ other than analgesics (administration/side effects, etc.)

50

Neonatal admission to NICU/SCBU 49Maternal mortality or serious morbidity (notspecified)

48

Labour length/duration (length of any stage,prolonged labour, etc.)

47

Neonatal infection (fever/sepsis includingspecific types of infections)

43

Any instrumental/assisted vaginal birth 41Perineal/vaginal trauma (of any type includingepisiotomy)

38

Preterm (birth, retinopathy of prematurity,gestational age at birth)

37

Nausea/vomiting/dehydration 35Adverse event/outcome, serious complication –

maternal33

Maternal negative related-expression (anxiety,dissatisfaction, fatigue, depression, low self-esteem, PTSD, etc.)

32

Labour and/or birth trauma 32Resuscitation measures, arrest or LOC (maternalor infant)

31

Miscellaneous/other (fetal-maternalhaemorrhage, zavanelli procedure,pulmonary oedema, additional tests, cordprolapse, etc.)

30

Induction and/or labour augmentation (ARM/oxytocin)

29

Any pH levels o7.20 and BD 412.0 25Blood transfusion 25Cost/economic outcomes 22Blood pressure (hyper-/hypotension) 22Uterine (expulsive effort, hyperstimulation,rupture, etc.)

22

Fetal heart rate monitoring 20Placenta (retained, manual removal, etc.) 20Wound (haematoma, wound healing, fistula ofany type, etc.)

19

Fetal blood sampling (umbilical cord blood, FBS,lactate)

17

Mode of birth (unspecified) 16Anaemia (or any reference to Hb levels/ironadministration)

16

Incontinence (any type) 16Jaundice 16Meconium stained liquor/meconium aspirationsyndrome

13

Negative expression of breast feeding (failure,not established, etc.)

12

Anaesthesia with gastric reference(Mendelson's syndrome, etc.)

11

Negative expression of mother–infantinteraction (detachment, difficulty withinfant, prolonged crying, etc.)

10

Maternal admission to ICU 8Birth weight 8

Table 1Unique list of salutogenically focused reported outcomes.

Salutogenically-focused outcome categories No. of times individualoutcome was reported

Maternal satisfaction with care, experience, etc. 51Breast feedingn (e.g. initiation, duration, success) 32Controln(perceived/personal control) 12Spontaneous vaginal birth (or ‘normal vaginal birth’) 6Positive relationship with infant/bonding 6Well-being (mother/father, psychological/emotional) 5nCaregiver experience/satisfaction 5Viewsn (mother's and/or father's) 4Mobility during labour 3Pregnancy prolongation 3Spontaneous rupture of membranes 2Comfort 2Maternal perception of pain experiencedn 2Maternal parenting confidence 1Relaxation 1Intact perineum 1

n Positive reference.

V. Smith et al. / Midwifery 30 (2014) e151–e156 e155

perspective typified bymorbidity andmortality, the latter of which is,at times and despite best health care treatment efforts, uncontrol-lable and uncertain in any event.

Given the relative absence of salutogenically-focused reportedoutcomes identified in our systematic review of reviews, we recom-mend the development of a core data set of salutogenic outcomes forreporting in maternity care research. Development of a data set suchas this has the potential to incorporate measures of effect based onhealth and well-being outcomes rather than solely on adversity and/orill-health. Data set development needs to consider involvement ofclinically-based health care professionals, maternity health careresearchers and users of maternal health services. Ideally, it is hopedthat a database such as this would inform choice and selection ofoutcomes for reporting in studies and in systematic reviews of suchstudies in an effort to move towards a more salutogenically-focusedapproach to maternity care provision.

Conclusion

This systematic review of reviews represents a first step in abroader research-based initiative aimed at exploring the concept

of salutogenesis in maternity care research which ultimately aimsto develop a minimum core data set of salutogenically-focusedoutcomes for reporting in maternity care research. Furtherresearch is needed to identify salutogenically-focused outcomesthat span the pregnancy, childbirth and postpartum continuum.Methods for conducting this research are currently being proposed.

Acknowledgements

This work was performed as part of the COST Action IS0907‘Childbirth Cultures, Concerns, and Consequences: Creating aDynamic EU Framework for Optimal Maternity Care’ which isfunded by the EU 7th Framework Programme.

References

Antonovsky, A., 1987. Unravelling the Mystery of Health: How People ManageStress and Stay Well. Jossy-Bass, California.

Beck, U., 1992. Risk Society. Towards a New Modernity. Sage, London.Day-Stirk, F., Palmer, L., 2003. The RCM virtual institute for birth: promoting

normality. Midwives 6, 64–65.Downe, S., 2001. Defining normal birth. MIDIRS Midwifery Digest 11, s31–s33.EURO-PERISTAT Project, 2008. European Perinatal Health Report. ⟨http://www.

europeristat.com⟩.Lindström, B., Eriksson, M., 2010. The Hitchhiker’s Guide to Salutogenesis: Saluto-

genic Pathways to Health Promotion. Helsinki, Folkhälsan Research Center.Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., 2009. The PRISMA Group Preferred

Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMAStatement. PLoS Med 6 (7), e1000097, http://dx.doi.org/10.1371/journal.pmed.1000097.

National Institute of Health and Clinical Excellence, 2007. Intrapartum Care. Care ofHealthy Women and Their Babies During Childbirth. National Institute ofHealth and Clinical Excellence, London.

Royal College of Midwives, 2005. Midwives rebirthing midwivery, ⟨http://www.rcm.org.uk/midwives/features/rebirthing-midwifery⟩ (accessed 10 January2013).

Smith, V., Devane, D., Murphy-Lawless, J., 2012. Risk in maternity care: a conceptanalysis. International Journal of Childbirth 2, 126–135.

Table 2 (continued )

Non-salutogenically-focused outcomes No. of times individualoutcome was reported

Headache 7Surgical reference (type of surgery, duration ofsurgery, etc.)

7

Thromboembolic event (DVT, PE) 6Fetal position (mal-presentation, change, etc.) 5Transition to extra-uterine life 4Symphysiotomy 2

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