“We can’t let her fall through the cracks”: Emergency department patient-centeredness for early pregnancy bleeding during obstetrician shortages Open Access

Abstract

As of 2018, 79 out of 159 counties in Georgia did not have an obstetrician/gynecologist in the county which left many women with early pregnancy bleeding to seek care in emergency departments (ED). Given the sociopolitical context in recent years restricting access to comprehensive reproductive health services, the ED is a promising but understudied context to fill service delivery gaps for women needing pregnancy care The aim of this research is to understand how ED providers develop cost-oriented, patient-centered, post-emergency department (ED) follow-up, referral, and discharge instructions for early pregnancy bleeding in rural Georgia counties.

 Guided by the Anderson and Newman Framework of Health Services Utilization framework, this qualitative study utilized semi-structured, in-depth, in-person interviews to understand 32 provider experiences of managing early pregnancy bleeding in the ED. Purposive sampling selected 10 hospitals outside of the metropolitan area of Atlanta with varying levels of access to an OB to illustrate differences in management experiences. Qualitative interview data were coded using both inductive and deductive methods in an iterative fashion and predominant themes were identified.

Four emergent themes from the 32 interviews are presented via the Anderson Behavioral Model of Health Services Use through a patient-centered care model by Meade and Bower which includes four key constructs: 1) environment, 2) population characteristics, 3) health behavior, 4) outcomes. The Meade & Bower model will overlap these factors within its five dimensions of patient centeredness 1) biopsychosocial perspective (including psychological and social domains of patient needs), 2) therapeutic alliance (provider empathy and sensitivity in provider-patient relationship), 3) patient-as-person (understanding how patients experience their illness as individuals), 4) sharing power and responsibility (equal decision making between patient and provider and 5) doctor-as-person (provider awareness of one’s influence on their patient). In sum, providers shared mixed experiences serving patients with early pregnancy bleeding; many reported on the lack of cost-efficient resources and Medicaid delays, while many EDs with the least amount of OB resources demonstrated great resourcefulness and support of patients by developing discharge plans based on their patient’s characteristics.  Future research is needed to provide understanding into the patient perspective on the role of ED settings to meet their pregnancy care needs.

Table of Contents

CHAPTER ONE: INTRODUCTION. 1

Theoretical Framework. 6

CHAPTER TWO: REVIEW OF THE LITERATURE. 10

Obstetric Crisis and Implications. 10

Early Pregnancy Bleeding in Emergency Departments. 13

Health Insurance and Disparity. 16

Discharge Planning and Follow-up. 17

CHAPTER THREE: STUDENT CONTRIBUTION. 22

Overview of PRECEDE. 22

Setting and sampling. 24

Data Collection. 25

Data Analysis. 26

Ethical Considerations. 27

CHAPTER FOUR: MANUSCRIPT. 28

Abstract. 28

Introduction. 29

Materials and Methods. 30

Theoretical Framework. 30

Design Overview. 31

Setting and sampling. 31

Data Collection. 32

Data Analysis. 34

Ethical Considerations. 35

Results. 35

Predisposing characteristics. 36

Enabling resources. 38

Need. 40

Health Behavior. 42

Outcomes. 42

Environment. 43

Discussion. 45

Funding. 47

Acknowledgements. 47

Disclosure Statement. 47

CHAPTER FIVE: PUBLIC HEALTH IMPLICATIONS. 48

Discussion. 48

Strengths and Weaknesses. 50

Future Directions. 51

Conclusions. 52

REFERENCES. 53

APPENDICES. 61

Appendix A. Interview Guide. 61

Appendix B. Recruitment Script. 62

Appendix C. Consent Information. 63

Appendix D. Codebook. 66

About this Master's Thesis

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Public Health Education Health Sciences, Obstetrics and Gynecology
Keyword	patient-centered care early pregnancy loss health insurance discharge planning follow-up appointment emergency department care referral
Committee Chair / Thesis Advisor	Dawn L. Comeau, Emory University
Committee Members	Kelli S. Hall, Emory University

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