title: Priorities and strategies for improving disabled women's access to maternity services when they are affected by domestic abuse: a multi-method study using concept maps.
abstract: BACKGROUND
  Domestic abuse is a significant public health issue. It occurs more frequently among disabled women than those without a disability and evidence suggests that a great deal of domestic abuse begins or worsens during pregnancy. All women and their infants are entitled to equal access to high quality maternity care. However, research has shown that disabled women who experience domestic abuse face numerous barriers to accessing care. The aim of the study was to identify the priority areas for improving access to maternity services for this group of women; develop strategies for improved access and utilisation; and explore the feasibility of implementing the identified strategies.
  
  
  METHODS
  This multi-method study was the third and final part of a larger study conducted in the UK between 2012 and 2014. The study used a modified concept mapping approach and was theoretically underpinned by Andersen's model of healthcare use. Seven focus group interviews were conducted with a range of maternity care professionals (n = 45), incorporating quantitative and qualitative components. Participants ranked perceived barriers to women's access and utilisation of maternity services in order of priority using a 5-point Likert scale. Quantitative data exploration used descriptive and non-parametric analyses. In the qualitative component of each focus group, participants discussed the barriers and identified potential improvement strategies (and feasibility of implementing these). Qualitative data were analysed inductively using a framework analysis approach.
  
  
  RESULTS
  The three most highly ranked barriers to women's access and utilisation of maternity services identified in the quantitative component were: 1) staff being unaware and not asking about domestic abuse and disability; 2) the impact of domestic abuse on women; 3) women's fear of disclosure. The top two priority strategies were: providing information about domestic abuse to all women and promoting non-judgemental staff attitude. These were also considered very feasible. The qualitative analysis identified a range of psychosocial and environmental barriers experienced by this group of women in accessing maternity care. Congruent with the quantitative results, the main themes were lack of awareness and fear of disclosure. Key strategies were identified as demystifying disclosure and creating physical spaces to facilitate disclosure.
  
  
  CONCLUSIONS
  The study supports findings of previous research regarding the barriers that women face in accessing and utilising maternity services, particularly regarding the issue of disclosure. But the study provides new evidence on the perceived importance and feasibility of strategies to address such barriers. This is an important step in ensuring practice-based acceptability and ease with which improvement strategies might be implemented in maternity care settings.
authors.affiliation: School of Nursing, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK. c.bradbury-jones@bham.ac.uk.
authors.forename: Caroline
authors.initials: C
authors.lastname: Bradbury-Jones
authors.affiliation: Scottish Improvement Science Collaborating Centre, University of Dundee, Dundee, UK. j.breckenridge@dundee.ac.uk.
authors.forename: Jenna P
authors.initials: JP
authors.lastname: Breckenridge
authors.affiliation: School of Sociology, Social Policy and Social Work, Queen's University Belfast, Belfast, UK. j.devaney@qub.ac.uk.
authors.forename: John
authors.initials: J
authors.lastname: Devaney
authors.affiliation: Gender Based Violence Nurse Advisor, NHS Fife, Fife, UK. fiona.duncan2@nhs.net.
authors.forename: Fiona
authors.initials: F
authors.lastname: Duncan
authors.affiliation: Social Dimensions of Health Institute, University of Dundee, Dundee, UK. t.kroll@dundee.ac.uk.
authors.forename: Thilo
authors.initials: T
authors.lastname: Kroll
authors.affiliation: School of Sociology, Social Policy and Social Work, Queen's University Belfast, Belfast, UK. a.lazenbatt@qub.ac.uk.
authors.forename: Anne
authors.initials: A
authors.lastname: Lazenbatt
authors.affiliation: School of Nursing, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK. j.taylor.3@bham.ac.uk.
authors.forename: Julie
authors.initials: J
authors.lastname: Taylor
mesh_terms: D001291:Attitude of Health Personnel; D006233:Persons with Disabilities / Q000523:psychology*; D017579:Domestic Violence / Q000523:psychology*; D005239:Fear; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D011247:Pregnancy; D036301:Qualitative Research