Background: This is the third in a series of three papers describing the use of qualitative evide... more Background: This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations. Methods: WHO convened a group drawn from the technical teams involved in formulating recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines. Results: For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts.
Background The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks ges... more Background The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers. Methods We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MED-LINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual. Findings From 7076 hits, we included 80 papers (1994-2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking.
Background Organisational culture and place of birth have an impact on the variation in birth out... more Background Organisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings. Aim To explore how childbirth is constructed and influenced by context in three birth settings in Australia. Method This ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6-8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16). Results All home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through 'running the gauntlet', based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident. Higher rates of normal vaginal birth with equivalent perinatal outcomes have been demonstrated for homebirth and birth centre (BC) compared to obstetric units (OUs) in a range of countries [1-4]. Both midwifery care and out of hospital settings have been associated with improved outcomes for healthy women and babies when compared to birth in OUs [4,8]. Despite this there are significant obstacles to midwife led units/community based care reaching their full potential. Lack of commitment and leadership by managers to embed these options as essential services alongside standard OUs continues to be an issue [1]. Childbirth is a complex biological, cultural, political and social phenomenon, and this is never more evident than when place of birth enters the debate [2]. Robbie Davis-Floyd published an anthropological interview study identifying different birth philosophies among both staff and childbearing women in the USA, linked to place of birth [3]. She coined the term 'technocratic birth' to capture the philosophy and activities of the normative, risk averse, technically intense form of childbirth that was reported by participants in her study who used doctor led OU settings. Since her study, the term has been widely used, and single site ethnographies of both out of hospital and in-hospital birth have reinforced many of her findings [4,5]. In contrast, the philosophy and activities of what has been termed 'humanised', or 'woman centred', care have been more strongly associated with the provision of midwifery care and the use of settings outside the hospital [6]. However, many studies of childbirth outcomes do not disaggregate childbirth philosophies, type of care provider, and place of birth. While there is likely to be some interaction between these components, it is also possible that the mechanism of effect for outcome differs to some extent between them. To date, there has not been a study that combines ethnographic observation of labour and birth in different birth settings where the birth philosophies of both service users and maternity care providers using these various spaces are also explored. We report on a study that used observations of events during labour and birth, interviews and focus groups as a lens to examine the impact of the social framing of childbirth in different birth settings. We draw on the theory of Birth Territory to explain and frame findings as developed by Fahy, Foureur and Hastie in their book Birth Territory and Midwifery Guardianship: Theory for Practice, Education and Research [7]. 1.1 'Birth Territory' theoretical positioning The theory of Birth Territory was developed to explain and predict the relationships between the birth environment and the use of power and control in that environment [7 [7]]. Taking a critical post-structural feminist Conclusions A complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.
Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn he... more Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little interven...
Background Disadvantaged populations (such as women from minority ethnic groups and those with so... more Background Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences. Methods Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care. Results Forty six index s...
Background Effective postnatal care is important for optimal care of women and newborns–to promot... more Background Effective postnatal care is important for optimal care of women and newborns–to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care. Methods We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensu...
Key messages: 1. The welfare of midwives is essential both for personal wellbeing and for the pro... more Key messages: 1. The welfare of midwives is essential both for personal wellbeing and for the provision of quality care. 3. Significant levels of stress, burnout and PTSD are common in health care workers' responses to pandemics, with possible long-term consequences. 4. Staff want to continue providing high quality care but will also be very concerned about their own personal/family safety and wellbeing. Fear, uncertainty and moral distress are common. 5. Midwives' individual demographic characteristics and personal circumstances must be acknowledged, especially as some may increase vulnerability to Covid-19. 6. Trusting, open and non-judgemental relationships between managers and staff are essential for responding effectively to staff concerns, during and after the pandemic. 7. Optimise wellbeing through ensuring that midwives have access to: adequate PPE, drinks and regular breaks, appropriate working hours, psychological support. 8. Provide opportunities for positive experiences e.g. team get-togethers, whether socially distanced or virtual.
Childbearing women and newborn infants continue to require care during the current COVID-19 pande... more Childbearing women and newborn infants continue to require care during the current COVID-19 pandemic. When staff and services are under extreme stress there is a real risk of increasing avoidable harm, including an increased risk of infection and reductions in the overall quality of care. Safety, quality, and avoiding harm must be key priorities in decisionmaking. Review questions Three related review questions were addressed. All considered safety, quality and minimising avoidable harm in the provision of midwifery services: 1. What is the evidence on the impact of community care vs centralisation of care during pandemics, for childbearing women, newborn infants, families, staff, and resources? 2. How to optimise availability of midwifery expertise when staffing becomes heavily affected by the midwifery workforce being off sick, self-isolating, fear of pandemic or other major unavoidable events? 3. What is the evidence on viral load of SARS-COV-2 in domestic settings and hospitals, relevant to informing the safety of community and hospital settings for health professionals? Principles for equitable, safe, effective, quality maternal and newborn care in a pandemic were developed to inform this review, derived from evidence and key resources: o Continue to provide evidence-based, equitable, safe, compassionate and respectful care for physical and mental health, wherever and whenever care takes place, by remote access if necessary o Protect the human rights of women and newborn infants, unless and only unless the public health imperative makes this impossible o Ensure strict hygiene measures and social distancing when possible o Ensure birth companionship o Prevent unnecessary interventions o Do not separate mother and newborn infant unless absolutely necessary o Promote and support breastfeeding o Protect and support staff, including their mental health needs Key findings and recommendations on each review question are briefly presented, including strategies for maintaining essential components of quality care in a pandemic situation. Detailed information on all sources identified is then presented. NB. This is a very fast-moving situation and new information will emerge on an ongoing basis; regular updates to this review will be needed. Rapid analytical review v4: 8 April 2020 RCM Professorial Advisory Group 4 o Ensure strict hygiene measures and social distancing when possible o Ensure birth companionship o Prevent unnecessary interventions o Do not separate mother and newborn infant unless absolutely necessary o Promote and support breastfeeding o Protect and support staff, including their mental health needs Methods This was a rapid analytic scoping review. Timing precluded a full systematic approach, but a structured approach was used and is summarised in the Appendix.
This very rapid review was conducted for the RCM as part of a series of COVID-19 related reviews.... more This very rapid review was conducted for the RCM as part of a series of COVID-19 related reviews. Key findings and considerations for practice are provided from page 3 onwards. Appendix one provides more details on the search strategy and findings. NB. Information is being published frequently, thus this review will need updating regularly.
IntroductionRates of medical interventions in normal labour and birth are increasing. This prospe... more IntroductionRates of medical interventions in normal labour and birth are increasing. This prospective meta-analysis (PMA) proposes to assess whether the addition of a comprehensive multicomponent birth preparation programme reduces caesarean section (CS) in nulliparous women compared with standard hospital care. Additionally, do participant characteristics, intervention components or hospital characteristics modify the effectiveness of the programme?Methods and analysisPopulation: women with singleton vertex pregnancies, no planned caesarean section (CS) or epidural.Intervention: in addition to hospital-based standard care, a comprehensive antenatal education programme that includes multiple components for birth preparation, addressing the three objectives: preparing women and their birth partner/support person for childbirth through education on physiological/hormonal birth (knowledge and understanding); building women’s confidence through psychological preparation (positive minds...
Background Organisational culture and place of birth have an impact on the variation in birth out... more Background Organisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings. Aim To explore how childbirth is constructed and influenced by context in three birth settings in Australia. Method This ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6-8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16). Results All home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through 'running the gauntlet', based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident. Higher rates of normal vaginal birth with equivalent perinatal outcomes have been demonstrated for homebirth and birth centre (BC) compared to obstetric units (OUs) in a range of countries [1-4]. Both midwifery care and out of hospital settings have been associated with improved outcomes for healthy women and babies when compared to birth in OUs [4,8]. Despite this there are significant obstacles to midwife led units/community based care reaching their full potential. Lack of commitment and leadership by managers to embed these options as essential services alongside standard OUs continues to be an issue [1]. Childbirth is a complex biological, cultural, political and social phenomenon, and this is never more evident than when place of birth enters the debate [2]. Robbie Davis-Floyd published an anthropological interview study identifying different birth philosophies among both staff and childbearing women in the USA, linked to place of birth [3]. She coined the term 'technocratic birth' to capture the philosophy and activities of the normative, risk averse, technically intense form of childbirth that was reported by participants in her study who used doctor led OU settings. Since her study, the term has been widely used, and single site ethnographies of both out of hospital and in-hospital birth have reinforced many of her findings [4,5]. In contrast, the philosophy and activities of what has been termed 'humanised', or 'woman centred', care have been more strongly associated with the provision of midwifery care and the use of settings outside the hospital [6]. However, many studies of childbirth outcomes do not disaggregate childbirth philosophies, type of care provider, and place of birth. While there is likely to be some interaction between these components, it is also possible that the mechanism of effect for outcome differs to some extent between them. To date, there has not been a study that combines ethnographic observation of labour and birth in different birth settings where the birth philosophies of both service users and maternity care providers using these various spaces are also explored. We report on a study that used observations of events during labour and birth, interviews and focus groups as a lens to examine the impact of the social framing of childbirth in different birth settings. We draw on the theory of Birth Territory to explain and frame findings as developed by Fahy, Foureur and Hastie in their book Birth Territory and Midwifery Guardianship: Theory for Practice, Education and Research [7]. 1.1 'Birth Territory' theoretical positioning The theory of Birth Territory was developed to explain and predict the relationships between the birth environment and the use of power and control in that environment [7 [7]]. Taking a critical post-structural feminist Conclusions A complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.
The rapid development of COVID-19 has altered the context of healthcare and services around the w... more The rapid development of COVID-19 has altered the context of healthcare and services around the world. In maternal and newborn services, restrictive practices have been introduced in many settings that limit women's decisions and the rights of women and newborn infants. In many countries the immediate response of the maternity services resulted in restrictions on the place of birth, continuity of care, and mother-baby contact. The UK provides an examples of a country in which an evidence-informed approach is now developing in which essential elements of quality can be maintained. To keep women, newborn infants, families, and staff safe in all countries, balance is needed between the restrictions required to control the spread of infection and maintaining evidence-informed, effective, equitable, respectful, kind and compassionate care. A set of key principles is proposed in this paper, to inform care and service provision in this current crisis and beyond. The public health and human rights agendas should be aligned. Covid-relevant, evidenceinformed, rights-respecting, effective, compassionate, and sustainable public health and clinical policy, guidance, and practice should be developed. A pro-active strategy to inform longer-term planning for life during and after the pandemic should be grounded in evidence and co-created with women, families, and staff. Highlights • Rapid development of COVID-19 has altered healthcare and services around the world; changes have affected women, newborn infants, families, and staff Authorship declaration: All authors meet the criteria for authorship and have approved the final article. All those entitled to authorship are listed as authors.
ObjectiveTo review what is known about the relationship between stillbirth and inequalities from ... more ObjectiveTo review what is known about the relationship between stillbirth and inequalities from different disciplinary perspectives to inform stillbirth prevention strategies.DesignSystematic review using the meta-narrative method.SettingStudies undertaken in the UK.Data sourcesScoping phase: experts in field, exploratory electronic searches and handsearching. Systematic searches phase: Nine databases with no geographical or date restrictions. Non-English language studies were excluded.Study selectionAny investigation of stillbirth and inequalities with a UK component.Data extraction and synthesisThree authors extracted data and assessed study quality. Data were summarised, tabulated and presented graphically before synthesis of the unfolding storyline by research tradition; and then of the commonalities, differences and interplays between narratives into resultant summary meta-themes.ResultsFifty-four sources from nine distinctive research traditions were included. The evidence of...
Background: WHO has recognised the need to improve its guideline methodology to ensure that guide... more Background: WHO has recognised the need to improve its guideline methodology to ensure that guideline decisionmaking processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines. Methods: WHO convened a writing group drawn from the technical teams involved in its recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Results: We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria (how stakeholders value different outcomes, equity, acceptability and feasibility, etc.), weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding 'research evidence' sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health. Conclusions: This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process.
Cochrane Database of Systematic Reviews Data collection and analysis Two authors undertook data e... more Cochrane Database of Systematic Reviews Data collection and analysis Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane e ectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour. Main results We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate-or high-confidence); service design and provision (24 findings, 15 moderate-or highconfidence); and what matters to women and sta (17 findings, 11 moderate-or high-confidence) The third domain was subdivided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using highor moderate-confidence findings: For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow sta to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time. The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of su icient resources and sta ing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring sta who make e ective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require su icient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies. Authors' conclusions This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing e ectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.
Several studies have identified how mistreatment during labour and childbirth can act as a barrie... more Several studies have identified how mistreatment during labour and childbirth can act as a barrier to the use of health facilities. Despite general agreement that respectful maternity care (RMC) is a fundamental human right, and an important component of quality intrapartum care that every pregnant woman should receive, the effectiveness of proposed policies remains uncertain. We performed a systematic review to assess the effectiveness of introducing RMC policies into health facilities providing intrapartum services. We included randomized and non-randomized controlled studies evaluating the effectiveness of introducing RMC policies into health facilities. We searched PubMed, CINAHL, LILACS, AJOL, WHO RHL, and Popline, along with ongoing trials registers (ISRCT register, ICTRP register), and the White Ribbon Respectful Maternity Care Repository. Included studies were assessed for risk of bias. Certainty of evidence was assessed using GRADE criteria. Five studies were included. All ...
Design and provision of good quality maternity care should incorporate what matters to childbeari... more Design and provision of good quality maternity care should incorporate what matters to childbearing women. This qualitative systematic review was undertaken to inform WHO intrapartum guidelines. Using a pre-determined search strategy, we searched Medline, CINAHL, PsycINFO, AMED, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-August 2016 (updated to January 2018), reporting qualitative data on womens' childbirth beliefs, expectations, and values. Studies including specific interventions or health conditions were excluded. PRISMA guidelines were followed. Authors' findings were extracted, logged on a study-specific data form, and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed. 35 studies (19 countries) were included in the primary search, and 2 in the update. Confidence...
Factors that influence the provision of good-quality routine antenatal services: a qualitative ev... more Factors that influence the provision of good-quality routine antenatal services: a qualitative evidence synthesis of the views and experiences of maternity care providers.
The birth story has been widely understood as a crucial source of knowledge about childbirth. Wha... more The birth story has been widely understood as a crucial source of knowledge about childbirth. What has not been reported is the effect that birth stories may have on primigravid women's understandings of birth. Findings are presented from a qualitative study exploring how two generations of women came to understand birth in the milieu of other's stories. The prior assumption was that birth stories must surely have a positive or negative influence on listeners, steering them towards either medical or midwifery-led models of care. A Heideggerian hermeneutic phenomenological approach was used. Twenty UK participants were purposively selected and interviewed. Findings from the initial sample of 10 women who were pregnant in 2012 indicated that virtual media was a primary source of birth stories. This led to recruitment of a second sample of 10 women who gave birth in the 1970s-1980s, to determine whether they were more able to translate information into knowledge via stories tol...
Background: Antenatal care models vary widely around the world, reflecting local contexts, driver... more Background: Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models. Methods: A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions. Results: Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.
Background: This is the third in a series of three papers describing the use of qualitative evide... more Background: This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations. Methods: WHO convened a group drawn from the technical teams involved in formulating recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines. Results: For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts.
Background The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks ges... more Background The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers. Methods We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MED-LINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual. Findings From 7076 hits, we included 80 papers (1994-2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking.
Background Organisational culture and place of birth have an impact on the variation in birth out... more Background Organisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings. Aim To explore how childbirth is constructed and influenced by context in three birth settings in Australia. Method This ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6-8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16). Results All home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through 'running the gauntlet', based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident. Higher rates of normal vaginal birth with equivalent perinatal outcomes have been demonstrated for homebirth and birth centre (BC) compared to obstetric units (OUs) in a range of countries [1-4]. Both midwifery care and out of hospital settings have been associated with improved outcomes for healthy women and babies when compared to birth in OUs [4,8]. Despite this there are significant obstacles to midwife led units/community based care reaching their full potential. Lack of commitment and leadership by managers to embed these options as essential services alongside standard OUs continues to be an issue [1]. Childbirth is a complex biological, cultural, political and social phenomenon, and this is never more evident than when place of birth enters the debate [2]. Robbie Davis-Floyd published an anthropological interview study identifying different birth philosophies among both staff and childbearing women in the USA, linked to place of birth [3]. She coined the term 'technocratic birth' to capture the philosophy and activities of the normative, risk averse, technically intense form of childbirth that was reported by participants in her study who used doctor led OU settings. Since her study, the term has been widely used, and single site ethnographies of both out of hospital and in-hospital birth have reinforced many of her findings [4,5]. In contrast, the philosophy and activities of what has been termed 'humanised', or 'woman centred', care have been more strongly associated with the provision of midwifery care and the use of settings outside the hospital [6]. However, many studies of childbirth outcomes do not disaggregate childbirth philosophies, type of care provider, and place of birth. While there is likely to be some interaction between these components, it is also possible that the mechanism of effect for outcome differs to some extent between them. To date, there has not been a study that combines ethnographic observation of labour and birth in different birth settings where the birth philosophies of both service users and maternity care providers using these various spaces are also explored. We report on a study that used observations of events during labour and birth, interviews and focus groups as a lens to examine the impact of the social framing of childbirth in different birth settings. We draw on the theory of Birth Territory to explain and frame findings as developed by Fahy, Foureur and Hastie in their book Birth Territory and Midwifery Guardianship: Theory for Practice, Education and Research [7]. 1.1 'Birth Territory' theoretical positioning The theory of Birth Territory was developed to explain and predict the relationships between the birth environment and the use of power and control in that environment [7 [7]]. Taking a critical post-structural feminist Conclusions A complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.
Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn he... more Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little interven...
Background Disadvantaged populations (such as women from minority ethnic groups and those with so... more Background Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences. Methods Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care. Results Forty six index s...
Background Effective postnatal care is important for optimal care of women and newborns–to promot... more Background Effective postnatal care is important for optimal care of women and newborns–to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care. Methods We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensu...
Key messages: 1. The welfare of midwives is essential both for personal wellbeing and for the pro... more Key messages: 1. The welfare of midwives is essential both for personal wellbeing and for the provision of quality care. 3. Significant levels of stress, burnout and PTSD are common in health care workers' responses to pandemics, with possible long-term consequences. 4. Staff want to continue providing high quality care but will also be very concerned about their own personal/family safety and wellbeing. Fear, uncertainty and moral distress are common. 5. Midwives' individual demographic characteristics and personal circumstances must be acknowledged, especially as some may increase vulnerability to Covid-19. 6. Trusting, open and non-judgemental relationships between managers and staff are essential for responding effectively to staff concerns, during and after the pandemic. 7. Optimise wellbeing through ensuring that midwives have access to: adequate PPE, drinks and regular breaks, appropriate working hours, psychological support. 8. Provide opportunities for positive experiences e.g. team get-togethers, whether socially distanced or virtual.
Childbearing women and newborn infants continue to require care during the current COVID-19 pande... more Childbearing women and newborn infants continue to require care during the current COVID-19 pandemic. When staff and services are under extreme stress there is a real risk of increasing avoidable harm, including an increased risk of infection and reductions in the overall quality of care. Safety, quality, and avoiding harm must be key priorities in decisionmaking. Review questions Three related review questions were addressed. All considered safety, quality and minimising avoidable harm in the provision of midwifery services: 1. What is the evidence on the impact of community care vs centralisation of care during pandemics, for childbearing women, newborn infants, families, staff, and resources? 2. How to optimise availability of midwifery expertise when staffing becomes heavily affected by the midwifery workforce being off sick, self-isolating, fear of pandemic or other major unavoidable events? 3. What is the evidence on viral load of SARS-COV-2 in domestic settings and hospitals, relevant to informing the safety of community and hospital settings for health professionals? Principles for equitable, safe, effective, quality maternal and newborn care in a pandemic were developed to inform this review, derived from evidence and key resources: o Continue to provide evidence-based, equitable, safe, compassionate and respectful care for physical and mental health, wherever and whenever care takes place, by remote access if necessary o Protect the human rights of women and newborn infants, unless and only unless the public health imperative makes this impossible o Ensure strict hygiene measures and social distancing when possible o Ensure birth companionship o Prevent unnecessary interventions o Do not separate mother and newborn infant unless absolutely necessary o Promote and support breastfeeding o Protect and support staff, including their mental health needs Key findings and recommendations on each review question are briefly presented, including strategies for maintaining essential components of quality care in a pandemic situation. Detailed information on all sources identified is then presented. NB. This is a very fast-moving situation and new information will emerge on an ongoing basis; regular updates to this review will be needed. Rapid analytical review v4: 8 April 2020 RCM Professorial Advisory Group 4 o Ensure strict hygiene measures and social distancing when possible o Ensure birth companionship o Prevent unnecessary interventions o Do not separate mother and newborn infant unless absolutely necessary o Promote and support breastfeeding o Protect and support staff, including their mental health needs Methods This was a rapid analytic scoping review. Timing precluded a full systematic approach, but a structured approach was used and is summarised in the Appendix.
This very rapid review was conducted for the RCM as part of a series of COVID-19 related reviews.... more This very rapid review was conducted for the RCM as part of a series of COVID-19 related reviews. Key findings and considerations for practice are provided from page 3 onwards. Appendix one provides more details on the search strategy and findings. NB. Information is being published frequently, thus this review will need updating regularly.
IntroductionRates of medical interventions in normal labour and birth are increasing. This prospe... more IntroductionRates of medical interventions in normal labour and birth are increasing. This prospective meta-analysis (PMA) proposes to assess whether the addition of a comprehensive multicomponent birth preparation programme reduces caesarean section (CS) in nulliparous women compared with standard hospital care. Additionally, do participant characteristics, intervention components or hospital characteristics modify the effectiveness of the programme?Methods and analysisPopulation: women with singleton vertex pregnancies, no planned caesarean section (CS) or epidural.Intervention: in addition to hospital-based standard care, a comprehensive antenatal education programme that includes multiple components for birth preparation, addressing the three objectives: preparing women and their birth partner/support person for childbirth through education on physiological/hormonal birth (knowledge and understanding); building women’s confidence through psychological preparation (positive minds...
Background Organisational culture and place of birth have an impact on the variation in birth out... more Background Organisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings. Aim To explore how childbirth is constructed and influenced by context in three birth settings in Australia. Method This ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6-8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16). Results All home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through 'running the gauntlet', based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident. Higher rates of normal vaginal birth with equivalent perinatal outcomes have been demonstrated for homebirth and birth centre (BC) compared to obstetric units (OUs) in a range of countries [1-4]. Both midwifery care and out of hospital settings have been associated with improved outcomes for healthy women and babies when compared to birth in OUs [4,8]. Despite this there are significant obstacles to midwife led units/community based care reaching their full potential. Lack of commitment and leadership by managers to embed these options as essential services alongside standard OUs continues to be an issue [1]. Childbirth is a complex biological, cultural, political and social phenomenon, and this is never more evident than when place of birth enters the debate [2]. Robbie Davis-Floyd published an anthropological interview study identifying different birth philosophies among both staff and childbearing women in the USA, linked to place of birth [3]. She coined the term 'technocratic birth' to capture the philosophy and activities of the normative, risk averse, technically intense form of childbirth that was reported by participants in her study who used doctor led OU settings. Since her study, the term has been widely used, and single site ethnographies of both out of hospital and in-hospital birth have reinforced many of her findings [4,5]. In contrast, the philosophy and activities of what has been termed 'humanised', or 'woman centred', care have been more strongly associated with the provision of midwifery care and the use of settings outside the hospital [6]. However, many studies of childbirth outcomes do not disaggregate childbirth philosophies, type of care provider, and place of birth. While there is likely to be some interaction between these components, it is also possible that the mechanism of effect for outcome differs to some extent between them. To date, there has not been a study that combines ethnographic observation of labour and birth in different birth settings where the birth philosophies of both service users and maternity care providers using these various spaces are also explored. We report on a study that used observations of events during labour and birth, interviews and focus groups as a lens to examine the impact of the social framing of childbirth in different birth settings. We draw on the theory of Birth Territory to explain and frame findings as developed by Fahy, Foureur and Hastie in their book Birth Territory and Midwifery Guardianship: Theory for Practice, Education and Research [7]. 1.1 'Birth Territory' theoretical positioning The theory of Birth Territory was developed to explain and predict the relationships between the birth environment and the use of power and control in that environment [7 [7]]. Taking a critical post-structural feminist Conclusions A complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.
The rapid development of COVID-19 has altered the context of healthcare and services around the w... more The rapid development of COVID-19 has altered the context of healthcare and services around the world. In maternal and newborn services, restrictive practices have been introduced in many settings that limit women's decisions and the rights of women and newborn infants. In many countries the immediate response of the maternity services resulted in restrictions on the place of birth, continuity of care, and mother-baby contact. The UK provides an examples of a country in which an evidence-informed approach is now developing in which essential elements of quality can be maintained. To keep women, newborn infants, families, and staff safe in all countries, balance is needed between the restrictions required to control the spread of infection and maintaining evidence-informed, effective, equitable, respectful, kind and compassionate care. A set of key principles is proposed in this paper, to inform care and service provision in this current crisis and beyond. The public health and human rights agendas should be aligned. Covid-relevant, evidenceinformed, rights-respecting, effective, compassionate, and sustainable public health and clinical policy, guidance, and practice should be developed. A pro-active strategy to inform longer-term planning for life during and after the pandemic should be grounded in evidence and co-created with women, families, and staff. Highlights • Rapid development of COVID-19 has altered healthcare and services around the world; changes have affected women, newborn infants, families, and staff Authorship declaration: All authors meet the criteria for authorship and have approved the final article. All those entitled to authorship are listed as authors.
ObjectiveTo review what is known about the relationship between stillbirth and inequalities from ... more ObjectiveTo review what is known about the relationship between stillbirth and inequalities from different disciplinary perspectives to inform stillbirth prevention strategies.DesignSystematic review using the meta-narrative method.SettingStudies undertaken in the UK.Data sourcesScoping phase: experts in field, exploratory electronic searches and handsearching. Systematic searches phase: Nine databases with no geographical or date restrictions. Non-English language studies were excluded.Study selectionAny investigation of stillbirth and inequalities with a UK component.Data extraction and synthesisThree authors extracted data and assessed study quality. Data were summarised, tabulated and presented graphically before synthesis of the unfolding storyline by research tradition; and then of the commonalities, differences and interplays between narratives into resultant summary meta-themes.ResultsFifty-four sources from nine distinctive research traditions were included. The evidence of...
Background: WHO has recognised the need to improve its guideline methodology to ensure that guide... more Background: WHO has recognised the need to improve its guideline methodology to ensure that guideline decisionmaking processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines. Methods: WHO convened a writing group drawn from the technical teams involved in its recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Results: We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria (how stakeholders value different outcomes, equity, acceptability and feasibility, etc.), weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding 'research evidence' sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health. Conclusions: This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process.
Cochrane Database of Systematic Reviews Data collection and analysis Two authors undertook data e... more Cochrane Database of Systematic Reviews Data collection and analysis Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane e ectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour. Main results We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate-or high-confidence); service design and provision (24 findings, 15 moderate-or highconfidence); and what matters to women and sta (17 findings, 11 moderate-or high-confidence) The third domain was subdivided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using highor moderate-confidence findings: For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow sta to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time. The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of su icient resources and sta ing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring sta who make e ective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require su icient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies. Authors' conclusions This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing e ectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.
Several studies have identified how mistreatment during labour and childbirth can act as a barrie... more Several studies have identified how mistreatment during labour and childbirth can act as a barrier to the use of health facilities. Despite general agreement that respectful maternity care (RMC) is a fundamental human right, and an important component of quality intrapartum care that every pregnant woman should receive, the effectiveness of proposed policies remains uncertain. We performed a systematic review to assess the effectiveness of introducing RMC policies into health facilities providing intrapartum services. We included randomized and non-randomized controlled studies evaluating the effectiveness of introducing RMC policies into health facilities. We searched PubMed, CINAHL, LILACS, AJOL, WHO RHL, and Popline, along with ongoing trials registers (ISRCT register, ICTRP register), and the White Ribbon Respectful Maternity Care Repository. Included studies were assessed for risk of bias. Certainty of evidence was assessed using GRADE criteria. Five studies were included. All ...
Design and provision of good quality maternity care should incorporate what matters to childbeari... more Design and provision of good quality maternity care should incorporate what matters to childbearing women. This qualitative systematic review was undertaken to inform WHO intrapartum guidelines. Using a pre-determined search strategy, we searched Medline, CINAHL, PsycINFO, AMED, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-August 2016 (updated to January 2018), reporting qualitative data on womens' childbirth beliefs, expectations, and values. Studies including specific interventions or health conditions were excluded. PRISMA guidelines were followed. Authors' findings were extracted, logged on a study-specific data form, and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed. 35 studies (19 countries) were included in the primary search, and 2 in the update. Confidence...
Factors that influence the provision of good-quality routine antenatal services: a qualitative ev... more Factors that influence the provision of good-quality routine antenatal services: a qualitative evidence synthesis of the views and experiences of maternity care providers.
The birth story has been widely understood as a crucial source of knowledge about childbirth. Wha... more The birth story has been widely understood as a crucial source of knowledge about childbirth. What has not been reported is the effect that birth stories may have on primigravid women's understandings of birth. Findings are presented from a qualitative study exploring how two generations of women came to understand birth in the milieu of other's stories. The prior assumption was that birth stories must surely have a positive or negative influence on listeners, steering them towards either medical or midwifery-led models of care. A Heideggerian hermeneutic phenomenological approach was used. Twenty UK participants were purposively selected and interviewed. Findings from the initial sample of 10 women who were pregnant in 2012 indicated that virtual media was a primary source of birth stories. This led to recruitment of a second sample of 10 women who gave birth in the 1970s-1980s, to determine whether they were more able to translate information into knowledge via stories tol...
Background: Antenatal care models vary widely around the world, reflecting local contexts, driver... more Background: Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models. Methods: A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions. Results: Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.
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Papers by Soo Downe