Feeling reassured by being assessed in a birthing unit 1. Hoping for reassurance from the test 2. Re-defining reassurance after learning the results 3. As part of the assessment for PTL, women underwent multiple assessments and tests of which fFN testing was only one. Women recounted being placed on fetal monitors, having cervical exams, blood work, ultrasounds and other procedures as outlined by this participant: They took my blood pressure…They kept monitoring my blood pressure and then they did a urine sample and a whole bunch of blood work.
The busy nature of the birthing unit was clearly noticed by participants. Interestingly, women interpreted their own experience within the busy units as reassuring whether or not they had been triaged as a priority.
One woman remarked how she could overhear other women in labour and staff caring for them while she waited to be seen. She explains that overhearing the busy unit activity and other women in labour, was reassuring. Participant 1 Alternatively, women also felt reassured when they had been triaged as the priority case.
Participant 14 Most women expressed a sense of reassurance from the confidence and trust that they had in the birthing unit team. Participant 4 Participants were clearly reassured by being assessed for PTL in a birth unit environment.
Regardless of whether the women were triaged as a priority or not, the experience of being assessed in a busy unit by specialized practitioners was reassuring. In combination with the other assessments that women underwent, the availability of the fFN screening test contributed to their hope for reassurance. Two sub-themes emerged as important conditions for maintaining hope: Needing clear explanations Only two women had heard about fFN testing prior to their test.
Women identified having the fFN screening test explained to them as an important condition to their experience of hoping for reassurance. One woman explains the importance of understanding the meaning of results in order for women to perceive value in fFN testing. Participant 9 This participant continues with words that reflect her hope for reassurance from the fFN results. Needing a support person while waiting for the results Most of the participants were either thankful that they had a support person with them or expressed the wish that their support person had remained with them while they waited for test results.
When women described their experience waiting they spoke of feeling increasingly anxious. Another participant agreed that having had her husband present when she received the fFN results would have helped: Participant 2 The presence of a support person during this period of hoping for reassurance from the test results and when women received their results was commonly described as essential. Re-defining reassurance after learning the results Being informed of the fFN results marked the beginning of a period of time where women re-defined what they would consider to be reassuring.
The following quotes are used to illustrate how women with negative and positive fFN testing results re-defined what would be required to feel reassured. Negative fFN testing results Women with negative fFN results expressed feeling reassured by knowing that they are not likely to give birth within the next 7—14 days. Positive fFN testing results Interestingly, women with positive fFN results also re-interpreted what they found reassuring. After receiving their results, women described feeling reassured by the speed with which care decisions were made.
Decisions included hospital admission or transfer, consultations and administration of steroids to enhance fetal lung maturity. Participant 3 Once their symptoms stabilized, some women with positive screening results re-defined what would provide them with reassurance yet again.
Participant 16 Upon learning their positive fFN test results, the women described feeling reassured by the speed of the care decisions made by the health care team. Like women with negative fFN results, once women with positive fFN results were stabilized, they identified that they would feel reassured by knowing the cause of their PTL.
Discussion This paper reports the findings from a study of women who presented to birthing units for assessment of symptoms of PTL. Study participants experienced a variety of symptoms of PTL and expressed feeling uncertain about the need to seek health care. After some delay in seeking care, nine of the women in this study sought the advice of a health care professional, which is consistent with findings from Kingston and Chalmers [ 21 ] who found that health care providers were considered to be the most important source of information in pregnancy by Canadian women.
Consistent with current practice recommendations, the registered nurses, physicians and midwives consulted by the women in this study all advised the women to go to the birthing unit for an immediate assessment [ 22 , 23 ]. Rather than ask a health care provider for advice, up to eight of the seventeen women first consulted their partner or a colleague about whether to seek health care.
This finding emphasizes the importance of including partners, family members and others in the routine information given to all pregnant women about the signs and symptoms of PTL.
Women described arriving at the hospital for assessment of their symptoms feeling uncertain that they needed urgent care and expecting to be reassured that they were not in PTL. Rather than describing having to be seen at the birthing unit as anxiety provoking, women described feeling reassured by being assessed in a busy specialized unit. Having to present oneself at the birthing unit for fFN testing was clearly acceptable and reassuring for the women in this study.
Women transitioned from feeling reassured to hoping for reassurance and beginning to feel anxious while they waited for their fFN results. This finding is interesting because stress and anxiety are known to be a serious concern for women already diagnosed with preterm labour.
For example, Lowenkron reported that women with PTL experienced a moderate amount of stress, appraising their situation as threatening with negative connotations such as feeling frustrated, fear of possible bad outcomes and loss of control of their lives [ 24 ].
These findings are supported by studies with other populations that have compared levels of reassurance among patients provided with different amounts of information about diagnostic tests.
For example, in a randomized controlled trial Petrie et al. Similarly, in a recent systematic review of randomized controlled trials, the authors concluded that diagnostic tests alone do not reassure patients.
They recommend providing clear explanations prior to diagnostic tests [ 27 ]. Although we cannot conclude from this qualitative study that women experience increased anxiety while waiting for their fFN results, this phenomenon is one that has been reported in other studies of women waiting for prenatal screening test results [ 28 ].
Bracing is a coping strategy commonly used by patients awaiting medical test results and is characterized by decreased optimism about their result. It is thought that bracing helps patients to prepare for a potentially poor result, and it is especially evident when there is a short waiting time between having the test and receiving the results.
These studies provide theoretical support for our finding that the women in our study described increasing anxiety while waiting for the results of their fFN test. Upon receiving and understanding their fFN results, women with a negative result were initially reassured. However they subsequently articulated concerns about what remained unknown — if they were not in preterm labour then what did cause the symptoms that they experienced?
Women with positive fFN results could no longer hope for reassurance from the test results and re-framed how they felt reassurance — the quick action and attention of their physician and the birthing unit team to address their PTL. Once they were stabilized, women with positive fFN results re-framed reassurance once again — as a need to know the cause of their PTL. These findings support those from other studies that, once diagnosed with PTL, women search for the cause of their PTL [ 19 , 20 , 30 - 32 ].
Our study findings add the understanding that women who are assessed in birthing units but determined not to be in PTL may experience similar anxiety related to not knowing the cause of their symptoms.
Over time, and as some women are stabilized and discharged home with activity restriction, it may be that there is a continual process of re-defining reassurance. The notion that women re-frame what they find reassuring provides guidance to health care providers in anticipating and providing timely interventions to reduce anxiety in women undergoing assessment for and living with PTL.
Fetal fibronectin testing was experienced by the women in this study as only one of many tests that they underwent after presenting to the birthing unit with symptoms of PTL. Nevertheless the process of fFN testing was experienced as being acceptable and valuable, in that women perceived the birthing unit to be a reassuring environment.
We have described this emotional process as one where women transition between seeking, feeling, hoping for and re-defining reassurance. Strengths and limitations One important strength of this study is the inclusion of a diverse group of women with respect to language English and French , geography urban and rural , parity and fFN results.
Secondly, interviews were conducted by registered nurses with a thorough understanding of the clinical context and skills in qualitative interviewing. The findings from this study should be interpreted cautiously as they are based on the experiences of a small group of women from one province in Canada.
Furthermore, the women who participated in this study generally had a high level of social support, were well educated, and were mostly employed. While the results of this study may be transferable to settings with similar populations of women, future research should seek to examine and compare the fFN testing experience of women who are positioned differently e.
In particular, it is the availability of the fFN test that requires women be assessed in hospital, an environment that they described as contributing to being reassured. Conclusions Our findings describe the experience of fFN testing from the perspective of study participants who presented to birthing units with symptoms of PTL. Women described being assessed for PTL as an emotional process that begins with expecting reassurance that they are not in PTL, feeling reassured by the birthing unit environment, hoping for reassurance from screening results, and re-defining reassurance upon being notified of their fFN results.
The fFN testing process and results are components of care that provide important reassurance for women regardless of negative or positive results. The importance of reassurance for women experiencing symptoms of PTL should not be underestimated given the literature reporting the anxiety related to PTL symptoms [ 12 , 19 , 32 ].
These findings indicate the importance of providing comfort measures to minimize anxiety and increase reassurance during fFN testing, including clearly explaining test results to women and their partners. Neonatal intensive care unit; PTB: Competing interests The authors declare that they have no competing interests. AES conceived of, and contributed to the design of the study, contributed to the interpretation of the data and critically revised the manuscript.
JR participated in data collection and analysis, assisted in drafting and revising the manuscript. MW contributed to the design of the study, interpretation of the findings, and critically revised the manuscript. All authors read and approved the final manuscript. We would also like to acknowledge the important contributions of the research coordinators Bdour Dandies and Carly Lang; research assistants Michelle Foulkes and Diane Courville; the regional coordinators and hospital staff who assisted us with recruiting women for the study.
The study was funded by ECHO: World Health Organization; Canadian Institute for Health Information. Too Early, Too Small: The evaluation of the fetal fibronectin test for prediction of preterm delivery in symptomatic patients. Journal of Obstetrics and Gynaecology of Canada.
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Health Care for Women International.