How is patient‐centred care conceptualized in obstetrical health? comparison of themes from concept analyses in obstetrical health‐ and patient‐centred care

Abstract Background Due to gender inequities that exist for women of childbearing age, there exists a need to deliver care tailored to their needs and preferences. Patient‐centred care (PCC) can be used to meet these needs. This review aims to compare patient care delivery between PCC and obstetrical care. This can help us address how PCC should be delivered to women before, during and after pregnancy versus how it is delivered to patients regardless of sex. Methods A review of literature was conducted on MEDLINE, EMBASE, CINAHL and SCOPUS for English PCC and high‐quality perinatal reviews published between 2010 and 2021. The data were analysed using a modified Walker and Avant framework. Results A total of 2138 unique studies were identified, with 11 PCC and 9 high‐quality obstetrical care studies included. Common defining features between PCC and obstetrical care include respect and dignity, informed decision‐making, therapeutic alliance, effective communication, social relationships and autonomy. PCC‐specific features were holistic care, empowerment, individualized care, coordinated care and empathy. Unique high‐quality obstetrical care themes included continuity of care, privacy and confidentiality, provider education and status, physical environment and equitable maternal care. Conclusions There are shared defining attributes between PCC and obstetrical care, including respect and dignity, informed decision‐making, the therapeutic alliance, effective communication, social relationships and autonomy. However, there remain unique defining attributes for high‐quality obstetrical care and PCC. This highlights the need for a unique approach to obstetrical care. More research on care for different physiological conditions in women is needed to address patient care that addresses different parts of the lifespan and develop frameworks that can influence health policy, patient care and health system evaluation. Patient or Public Contribution This study was one part of a larger, multicomponent study of how to implement PCC for women across the lifespan. While we did not specifically consult or involve women in this dual concept analysis, our larger study (content analysis of clinical guidelines and government policies, qualitative interviews with women and clinicians, Delphi study to prioritize consensus recommendations for achieving PCC for women) was guided by the experiences and input of a 50+ women advisory panel.


| INTRODUCTION
Patient-centred care (PCC) was defined by the Institute of Medicine as care that establishes a partnership among practitioners, patients and their families to ensure that providers and systems deliver care that is attentive to the needs, values and preferences of patients. 1 Since then, considerable research has expanded our understanding of PCC and how to achieve it. For example, a scoping review of 19 studies published from 1994 to 2011 identified 25 unique frameworks or models of PCC 2 and several validated instruments with which to measure PCC. 3 Common elements of PCC include effective communication, partnership and health promotion. 2,3 Another review of 28 reviews published between 2011 and 2017 identified a variety of informational, educational and supportive interventions that can be used to achieve PCC targeted at patients, family members or providers. 4 PCC is now widely recognized as a fundamental element of high-quality health care because it has been associated with numerous beneficial outcomes for patients (i.e., increased knowledge, skill, satisfaction, quality of life; decreased admissions, readmissions and length of hospital stay), family members (increased satisfaction; decreased stress and anxiety) and provider (improved job satisfaction, confidence and quality of care; reduced stress and burnout) outcomes across multiple settings, including primary, emergency, acute and intensive care. [4][5][6] Still, many patients do not receive or experience PCC. For example, a national survey in the United States showed that, among 2718 responding adults aged 40 years or older with 10 common medical conditions, there was considerable variation in perceived PCC among patients including involvement in discussing treatment options and making decisions. 7 Suboptimal PCC was reported by half of 1794 American cancer survivors responding in 2013 to a national survey. 8 In 2016, a Commonwealth Fund national survey revealed that fewer women reported patient-centred communication with their provider compared with the general population. 9 Women continue to experience gendered inequities in access to and the quality of care in both developed and less developed countries, 10,11 leading to national and international appeals over several decades to improve PCC for women. [12][13][14][15][16] Despite evidence of inequities and appeals to improve PCC for women, little research has identified how to promote and support PCC for women. We conducted a theoretical rapid review to describe how PCC was studied among women affected by depression or cardiovascular disease, conditions with known gendered inequities. 17 Our review identified a few studies of PCC among women, and those studies failed to fully conceptualize or describe PCC. We subsequently explored women's and clinicians' views about what constitutes PCC, 18 and generated recommendations by which to achieve PCC for women. 19 PCC could address gendered inequities by engaging women in their care and tailoring care to their needs and values. Hence, further research is needed to explore how to foster PCC for women with different conditions or healthcare issues. Giving birth is one of the most common reasons for inpatient hospitalisation, and the cost of inpatient delivery is increasing over time despite declining pregnancy rates. 20 Quality of care during labour and birth affects maternal and child morbidity and mortality, and is a concern worldwide. 21 Factors such as lack of coordinated care among providers, fragmentation of care and substandard care also negatively influence patient-centred obstetric care. 22 A systematic review of 47 studies on person-centred interventions in delivery facilities found that interventions aimed to improve autonomy, supportive care, social support, health facility environment and dignity, but the person-centred objectives did not match the PCC or clinical outcomes measured. 23 The authors emphasized this lack of theoretical coherence between aims and intervention design, given that interventions to improve quality of care are more successful when selected and tailored according to preidentified barriers and theory, which may lead to more thorough measurement and evaluation of PCC in maternity care. 24 Hence, there is a need to more thoroughly conceptualize PCC in maternal care to inform the development of interventions that improve the quality of maternal care and of measures to assess their impact.
Primary research in maternity care has focused on the experiences of women in maternity care, 25,26 goals of maternity care, 27 interventions to improve quality of maternity care 28 and outcomes of high-quality maternity care. 29 However, few reviews have synthesized these elements, and no prior reviews mapped the domains of high-quality maternity care to PCC domains or a PCC framework. The purpose of this study was to compare the concepts of PCC with concepts of high-quality inpatient obstetric care in published conceptual reviews. This would identify common elements and potentially PCC elements unique to the maternal care context by which to plan and improve obstetrical care for women giving birth as inpatients. This knowledge could be used by women's health researchers, and also by clinicians, and healthcare managers and policy-makers to inform the planning, delivery and improvement of healthcare services for women.

| Approach
The main purpose of this review is to compare and contrast the elements of PCC and high-quality obstetrical care found in the literature. To do so, we conducted a concept analysis, which is a 'process of determining the likeness and unlikeness between concepts' 30 that has been used by others to compare models of quality of life 31 and patient participation. 32 More specifically, we used the Walker and Avant 30 concept analysis approach. Other approaches such as the Rogers' evolutionary concept analysis or Haase's simultaneous concept analysis built upon this model, but the Walker and Avant model remains the approach most widely used. 33 The approach includes choosing a concept, determining the purpose of analysis, identifying all uses of the concept, defining attributes, identifying antecedents and consequences and defining empirical referents. This provides a comprehensive understanding of each topic independent of each other as well as a comparison of the defining attributes, antecedents, consequences and empirical referents that are shared between these two topics. This was completed by conducting a review of literature between 2010 and 2021 for reviews that examine patient care in PCC and obstetrical care. The two primary objectives of this review are to (1) gain an understanding of how PCC and obstetrical care has been conceptualized since 2010 and (2) to compare the characteristics of patient care between these two concepts. This will provide a foundation for PCC for women based on the identified values and preferences of female patients in the birthing process.

| Eligibility criteria
Detailed inclusion and exclusion criteria (File S1) were based on persons/participants, issue/intervention, comparisons and outcomes. 34 In brief, for the PCC concept analysis, the persons or participants were any patients aged 18+ or healthcare professionals in any primary, secondary or tertiary setting of care. The interventions were reviews that examine or describe elements and processes that constitute person-centred care. The comparisons were what participants view as PCC or PCC barriers, or assess if PCC was delivered, or evaluate PCC outcomes after an intervention, before and after an intervention or compared between interventions. The outcomes were views, beliefs or preferences, enablers, barrier or challenges, interventions that promote or support PCC and impacts of PCC.
Reviews were excluded if they focused on a specific population or clinical situation (e.g., palliative care, paediatric population, emergency).
The high-quality obstetrical care concept analysis included patients 18+ receiving obstetrical or reproductive care during labour and delivery or the perinatal period or healthcare professionals who provide obstetrical care. The intervention was high-quality perinatal care. Comparisons were also performed on participant views, highquality obstetrical care delivery, evaluation of perinatal outcomes after an intervention, before and after an intervention or compared between interventions. The outcomes were views, beliefs or preferences, enablers, barriers or challenges, interventions that promote or support high-quality obstetrical care and impacts of high-quality care. Reasons for exclusion were if the reviews focused on a specific aspect of obstetrical care outside the immediate labour and delivery experience (antenatal care, breastfeeding, ectopic pregnancies or termination). Both American and British spellings were used and variations of search terms with or without hyphens. The systematic review for obstetrical studies included terms such as obstetric, birth, postnatal, perinatal, labour and delivery to search for the obstetric reviews that examine the labour process. This was combined with terms for healthcare quality, quality improvement, patient satisfaction, quality assurance, quality indicators, programme evaluation and provider-patient relations. These results were limited to Englishlanguage reviews that are reviews of literature. A total of 2136 records were exported from all databases once duplicates were removed. were also excluded, such as end-of-life care, residential or long-term care, palliative care, emergency medicine, paediatric populations or any other focused group. Studies that were clinically focused on the illness rather than the care experience were not included. Articles that mentioned PCC in the background or conclusion without explicitly focusing on PCC were also excluded. or 'autonomy' and 'ownership and control', were combined into one term.

| Search results
The search yielded 2324 studies, and 188 duplicates were removed (see Figure 1). A total of 119 full-text articles were screened by B. J. and K. D. Of these, 99 were excluded due to publication type (n = 27), focus not being on PCC or perinatal quality of care (n = 26), not assessing interactions between patient and provider (n = 21), assessed only a specific PCC or obstetrical intervention or application (n = 11), did not focus on the target population (n = 10) and focused on illness rather than care experience (n = 4). Ultimately, 20 studies were included, which consisted of 11 PCC and 9 high-quality obstetrical care reviews (refer to Table 1 for the characteristics of the included studies).
Of the nine high-quality perinatal care reviews, six offered definitions related to respectful maternity care or woman-centred care.
Only 4 of the 11 PCC reviews provided definitions of PCC.

| Defining attributes
High-quality obstetrical care and PCC shared several common defining features including respect and dignity, informed decision-making, Individualized care, which tailored care to the individual perspectives, needs, values and beliefs of the patient, was present in all PCC studies. Holistic care was present in 64%, empowerment in 27%, coordinated care in 11% and empathy in 55% of the PCC studies (see Table 2).
Themes that were unique to high-quality obstetrical care included continuity of care, privacy and confidentiality, provider education and status, physical environment and equitable maternal care. The prevalence of these themes was 11% for continuity of care, 33% for privacy and confidentiality, 22% for provider education and status, 22% for physical environment and 22% for equitable maternal care (see Table 3). Provider education and status referred to the education and training that health providers receive and the perception of their own role and status. Studies discussed the physical environment as having access to hygienic facilities, quiet and private spaces and adequate space for the labour and delivery process. Equitable maternal care was defined as the availability of services to all pregnant women regardless of race, religion, ethnicity or cultural background.
On average, each PCC study incorporated 5.45 themes (median of 5; range: 3-9). Each obstetrical study incorporated 3.11 themes (median of 3; range: 1-6).     themes. There were five PCC and six obstetrical unique themes.  30 This was demonstrated in this concept analysis and fulfilled the aim of the study, which was to effectively identify clear similarities and differences between obstetrical care and PCC. A thorough comparison using this framework included defining features, antecedents, consequences and outcomes. By analysing or comparing high-quality perinatal care to PCC, we identified possible gaps in the way in which obstetrical care has been studied.
Several strengths of this study include a comprehensive search of multiple databases, compliance with the reporting of reviews 63 and appropriate application of a pre-existing model of concept analysis. 30 There were several limitations to this study. We did not search the grey literature, which may have excluded several articles of interest from the search. In addition, the studies that were included varied widely from high-income countries to low-and middle-income countries. The perspectives and priorities regarding maternity health differ significantly across these different contexts. For instance, hygiene and mistreatment were common themes in low-and middle-income countries, but not in high-income country studies. In addition, the focus of the obstetrical care was specifically on the perinatal period during the labour and delivery. This excluded other periods of interest, such as antenatal care or postnatal care. We also included the general delivery experience and excluded specific clinical situations, such as ectopic pregnancies and termination of pregnancy. These situations may offer another perspective in terms of high-quality obstetrical care.

| CONCLUSION
There have been many studies that have reviewed PCC and highquality obstetrical care as separate entities; however, there continues to be variation in how PCC and high-quality obstetrical care is defined. Our aim with this review was to present findings from reviews on the concept of PCC and high-quality obstetrical care since 2010 to understand how they have been conceptualized. Furthermore, more research is needed both within PCC and obstetrical health to organize, define and categorize information related to women's healthcare. A paradigm shift in women's health as a concept is essential to deliver care that is more encompassing of the needs and priorities of women in different aspects of their health and over the course of their lifespan. With more research in care delivery for different conditions for women, information on the preferences and needs of female patients can be used to create a comprehensive and holistic framework for PCCW. This framework can then be utilized in policy and guideline development to effectively meet and address the needs of female patients, or provide a female patient perspective to existing guidelines that tend not to emphasize women's experiences.