Who Cares? Reconfiguring relationships in maternity care

Fragmentation and lack of responsiveness challenge the quality, effectiveness, and sustainability of health systems globally. In maternity care, integrated client-centered care is pursued as a strategy to enhance continuity and responsiveness. However, persistent barriers remain. Agreement on how to reach envisioned goals is lacking, and historically grown divisions have become systemically embedded barriers to collaboration. Also, traditional approaches and hierarchies continue to reproduce unwanted relational asymmetry between professionals, between professionals and clients, and within (expectant) families. In response to these challenges, this thesis sought to unravel barriers and improvement potential on the relational side of collaboration in maternity care in the Netherlands. The aim was to gain insight into (1) persistent barriers to continuity and responsiveness in maternity care, and (2) what could contribute to reconfiguring the relationships between professionals from multiple disciplines and organizations, between these professionals and the clients they care for, and within (expectant) families receiving this care. As a general introduction, chapter 1 sketches the historical background of interprofessional collaboration and parental involvement in maternity care in the Netherlands, followed by an outline of the theoretical concepts and methodological considerations underlying this thesis. Chapters 2 through 5 describe this thesis’ four qualitative studies in detail. Chapter 2 presents our findings regarding maternity care professionals’ perspectives on policy development, and their experiences with collaborating in local maternity care networks. Chapter 3 delineates our insights into mothers’ perspectives on client-centered maternity care. Chapter 4 presents our exploration of connections between (expectant) parents’ narratives about fathers’ involvement in maternity care and caring during the COVID-19 pandemic, and societal discourses regarding gendered roles and responsibilities in perinatal care and parenting. Chapter 5 outlines the potential of maternity care professionals’ and clients’ joint participation in facilitated reflexive dialogues with a Safety-II approach. Following this, chapter 6 presents a valorization report, describing the participatory development and implementation of two practical tools for supporting relational learning and action in maternity care. To finish, the general discussion in chapter 7 outlines this thesis’ main findings, and elaborates on the core idea that further developing continuity and responsiveness in maternity care requires the critical reconsideration, renegotiation and reconfiguration of all positions, responsibilities and structures within the system. Overall, I conclude that we have developed forms of support that people in the field were missing, and highlighted certain issues that are often overlooked. First, we have shown that maternity care professionals’ limited success in contributing to the intended changes in the maternity care system was not due to lack of willingness, but strongly related to systemic barriers that were difficult for the professionals to influence and insufficiently counterbalanced through support and guidance at the policy level. Also, we have unraveled how shortcomings in the degree to which women experienced responsiveness in maternity care related to the strong managerial approach in policy and practice, focusing mainly on the organizational dimension of integrating care processes. Furthermore, we have unveiled the hidden messages in parents’ and professionals’ interactions that express the persistence of a gender-essentialist paradigm in society, prioritizing mothers as carers and fathers as breadwinners. Finally, we have shown how care professionals’ and clients’ joint reflexive dialogues foster mutual trust, wellbeing and repertoire, and thus relational reconfiguration and resilience in maternity care. This thesis therefore argues that embedding relational reflexivity is needed to break through hierarchical and cultural boundaries in maternity care, and sketches perspectives for doing so.