Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women’s experiences of self-monitoring

One hundred and seventy women recruited to the BuMP study provided home readings during their pregnancy. At study appointments, women were invited by the research midwife to take part in an interview study to find out more about their experiences of the pilot study, and their views about SMBP. They were given an information pack that included information about the interview and a reply slip. Fifteen women returned slips (13 from Oxfordshire, 2 from Birmingham) and interviews were conducted postpartum with all the women who volunteered. Interviewee identifiers after the quotations presented here relate to the identifiers in Table 1. Those agreeing to take part in the interviews were representative of the study population, including a range of ethnicity, age, demographic area and risk factors used for inclusion in the study. However, no women who dropped out of the self-monitoring of blood pressure study agreed to be interviewed.

Semi-structured interviews were conducted with the women in their own homes, after they had given birth and stopped monitoring their BP as part of the study. The interviews, conducted by an experienced qualitative researcher with a social science rather than health professional background (LH) were semi-structured and included women’s experiences of pregnancy, their attitudes to self-monitoring and their experiences of participating in the BuMP study. Interviews ranged in length from 30 to 60 min and typically took place between 3 and 6 months after birth in order that women had time recover from the immediate birth experience and to assimilate their pregnancy monitoring experience but that it was still relatively recent, although some maternity research indicates there is little recall bias regarding birth experiences [21]. An interview topic guide was developed, and refined as interviews were collected (see appendix for Topic Guide). Interviews were audio recorded and transcribed for analysis. Initial thematic coding and analysis was undertaken by LH. A framework that included the themes reported here was developed in collaboration with the multidisciplinary study team. A Framework analysis was undertaken, employing five stages (familiarisation with the data, identifying a thematic framework, indexing, charting and finally mapping and interpretation) [22]. Interviewing continued until data saturation was reached for the themes reported in this paper [23]. Framework analysis has been developed specifically for applied or policy relevant qualitative research, and was used in this study so that specific questions could be asked to inform future research [24]. In this study, the framework was not a priori, however, but derived from initial analysis of the interviews. Ethical approval was provided for the interviews as part of the Narratives of health and illness for Healthtalkonline 2012.’ IRAS ID 112111, approved by NRES Committee South Central- Berkshire ref.: 12/ SC/0495.

Of the 15 women interviewed, 10 were in their first pregnancy, five had previous experience of high BP or pre-eclampsia or family history of pre-eclampsia, two had age 40 or over at the time of the study, six had high BMI, one had pregnancy interval of over 10 years and one had multiple pregnancy. None of the women developed pre-eclampsia, although three were diagnosed with hypertension (>140/90 mmHg) (see Table 1).

Women who took part were willing to engage with monitoring their own BP, feeling that it could reduce some of the anxiety around their health during pregnancy. They felt able to incorporate self-monitoring into their weekly routines, although keeping up with the monitoring once they had stopped work and lost that daily routine could be harder and it was particularly hard after the baby was born.

Being involved in the study made women more aware of the risks of raised BP and pre-eclampsia. Many felt reassured and empowered, particularly if they had previous experience of the disease.

The framework analysis interrogated the interview data across five themes which themselves had emerged from early stages of analysis [21].

Our findings indicate that women participating in this qualitative study were willing to engage with SMBP, and that it could reduce anxiety around their health during their pregnancy. Although there was some variation in responses depending on whether women perceived themselves as high risk, many of the women interviewed felt reassured and empowered by SMBP, particularly if they had previous experience of pre-eclampsia. Women felt able to incorporate the monitoring into their weekly routines, with some adjustments, although this was more challenging in the post-partum period. The respondents felt that being involved in the study made them more aware of the risks of raised BP and pre-eclampsia.

This study included women with a range of ages, social circumstances and previous experiences including those with a previous history of pre-eclampsia and those simply at higher risk. However, it cannot be certain how far findings apply to women at higher risk of pre-eclampsia in general. We do not have insights from those who declined to be in the BuMP study at all, or women who withdrew, or from women who participated but did not respond to the interview invitation. Participants were generally White British, educated to degree level and may not be representative of the wider population. There was also an imbalance in numbers between women from Oxford and Birmingham, so the experiences from both sites were not equally represented. The supportive role of the research midwife in the Oxford sites was highlighted as a major factor in the success of the pilot in that location, but in Birmingham staffing changes were required due to ill health. However, this qualitative work with a small sample does provide valuable information to inform future research. The self-monitoring regime tested in the pilot study was feasible and acceptable to women, offering reassurance and empowerment. The qualitative component of the full trial will explore how far these findings may be generalisable to a more diverse range of women. This study included 15 women but given the relatively focused nature of the research questions, data saturation was reached (i.e. no new data on these themes emerge in the last few interviews) suggesting that the conclusions would not have been altered by a larger sample size. [23] Nonetheless, further research will enable us to assess whether further issues would be identified with a larger and more diverse sample.

We are mindful that this research takes place amidst debates around the medicalisation of maternity care [26‐29] and the complexities of articulating risk (for mother and baby) in contemporary childbirth practice [12]. However, the wider context of self-care and self-monitoring having the potential to enhance care, self-efficacy and empowerment should be acknowledged [30‐33].

In terms of motivations and adherence to self-monitoring, the results from this study are similar to other trials of SMBP in the general population [34] and self-monitoring in other conditions such as asthma and diabetes [35‐37]. However, this is the first qualitative study that authors are aware of regarding women’s experiences of self-monitoring their BP in pregnancy. Women in pregnancy are making decisions about both their own health and their baby’s health, which makes this a different experience from SMBP in the general population. Women with previous experience of pre-eclampsia are often not fully aware of their risks of hypertensive and cardiovascular problems in subsequent pregnancies or outside pregnancy [38].

Pregnancy is an anxious time for some women, even during a normal antenatal period and labour, in part generated by fears and uncertainty about the outcome [39]. Studies of women’s anxiety levels during labour and how they are affected by additional fetal monitoring [40] have shown that women can be reassured by active monitoring. Although the very use of fetal monitoring can imply birth is a risky process needing careful monitoring, women appeared reassured. It has been argued that asking women to monitor their BP will also raise their anxiety: a study of women who were offered screening for pre-eclampsia found that the screening process changed the way that women regarded their pregnancy, shifting it from a normal life event to something to worry about [15]. This was not born out by our findings, but our study focused on women identified with a higher risk of pre-eclampsia, according to NICE guidelines. As with patient experiences of SMBP outside of pregnancy, women gained knowledge, engagement and confidence in taking control of their own care [29, 34, 41, 42].

There is a potential concern that while SMBP might give women the opportunity to reassure themselves; this could be false in the case of pre-eclampsia with normal blood pressure. A potential learning point from this pilot study is that women should be given more education around pre-eclampsia and its symptoms and indeed several reported they would find this helpful. Several women described feeling reassured by normal BP in the context of feeling unwell but should be aware of the potential importance of other symptoms regardless of BP. These additional educational messages will be tested in a larger forthcoming trial, which will also assess outcomes with respect to timing of detection of pre-eclampsia.

As the availability and acceptability of SMBP increases [16], it is perhaps interesting to think of self-monitoring practices as adding to the cultural props that women can draw on during a time of anxiety. Machin and Scammell’s (1997) ethnographic work [43] on experiences of labour (using a ritual theory approach, exploring pregnancy and birth as a rite of passage), found that women relied upon and were reassured by the medical model of childbirth because that was the cultural tool offered to them. This could potentially be the case for self-monitoring and will be explored further in the qualitative component of the trial.

Using digital health solutions, such as mobile phone text monitoring, for the detection and management of medical conditions in pregnancy is a rapidly developing area of research. Technologies under investigation include SMBP, self-testing of blood sugar in women with gestational diabetes and self-testing for proteinuria [44‐47]. Self-monitoring and self-testing combined with digital technology may detect problems earlier and engage patients in their care, providing rapid feedback to improve clinical management and allow electronic capture of data. This work shows that the development of home monitoring and testing for raised blood pressure is likely to be acceptable to many women at higher risk.