Abortion care at 20 weeks and over in Victoria: a thematic analysis of healthcare providers' experiences.

BACKGROUND: In many countries, abortions at 20 weeks and over for indications other than fetal or maternal medicine are difficult to access due to legal restrictions and limited availability of services. The Abortion and Contraception Service at the Royal Women's Hospital in Victoria, Australia is the only service in the state that provides this service. The views and experiences of these abortion providers can give insight into the experiences of staff and women and the abortion system accessibility. The aim of this study was to examine health providers' perceptions and experiences of providing abortion care at 20 weeks and over for indications other than fetal or maternal medicine, as well as enablers and barriers to this care and how quality of care could be improved in one hospital in Victoria, Australia. METHODS: A qualitative study was conducted at the Abortion and Contraception Service at the Royal Women's Hospital. Participants were recruited by convenience and purposive sampling. Semi-structured interviews were conducted one-on-one with participants either online or in-person. A reflexive thematic analysis was performed. RESULTS: In total, 17 healthcare providers from medicine, nursing, midwifery, social work and Aboriginal clinical health backgrounds participated in the study. Ultimately, three themes were identified: 'Being committed to quality care: taking a holistic approach', 'Surmounting challenges: being an abortion provider is difficult', and 'Meeting external roadblocks: deficiencies in the wider healthcare system'. Participants felt well-supported by their team to provide person-centred and holistic care, while facing the emotional and ethical challenges of their role. The limited abortion workforce capacity in the wider healthcare system was perceived to compromise equitable access to care. CONCLUSIONS: Providers of abortion at 20 weeks and over for non-medicalised indications encounter systemic enablers and barriers to delivering care at personal, service delivery and healthcare levels. There is an urgent need for supportive policies and frameworks to strengthen and support the abortion provider workforce and expand provision of affordable, acceptable and accessible abortions at 20 weeks and over in Victoria and in Australia more broadly.

Strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings: A mixed-methods systematic review.

Stigma and discrimination are fundamental causes of health inequities, and reflect privilege, power, and disadvantage within society. Experiences and impacts of stigma and discrimination are well-documented, but a critical gap remains on effective strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We aimed to address this gap by conducting a mixed-methods systematic review and narrative synthesis to describe strategy types and characteristics, assess effectiveness, and synthesize key stakeholder experiences. We searched MEDLINE, CINAHL, Global Health, and grey literature. We included quantitative and qualitative studies evaluating strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We used an implementation-focused narrative synthesis approach, with four steps: 1) preliminary descriptive synthesis, 2) exploration of relationships between and across studies, 3) thematic analysis of qualitative evidence, and 4) model creation to map strategy aims and outcomes. Of 8,262 articles screened, we included 12 articles from 10 studies. Nine articles contributed quantitative data, and all measured health worker-reported outcomes, typically about awareness of stigma or if they acted in a stigmatizing way. Six articles contributed qualitative data, five were health worker perspectives post-implementation and showed favorable experiences of strategies and beliefs that strategies encouraged introspection and cultural humility. We mapped studies to levels where stigma can exist and be confronted and identified critical differences between levels of stigma strategies aimed to intervene on and evaluation approaches used. Important foundational work has described stigma and discrimination in sexual and reproductive healthcare settings, but limited interventional work has been conducted. Healthcare and policy interventions aiming to improve equity should consider intervening on and measuring stigma and discrimination-related outcomes. Efforts to address mistreatment will not be effective when stigma and discrimination persist. Our analysis and recommendations can inform future intervention design and implementation research to promote respectful, person-centered care for all.

'No-Frills Prils': GPs' views on drug costs and therapeutic interchange of angiotensin-converting enzyme inhibitors: a qualitative study.

Medications form a significant portion of spending in primary health care. Angiotensin-converting enzyme inhibitors (ACE-Is) are among the most prescribed blood pressure medications in general practice. Medications within this class are considered therapeutically equivalent, but the cost of each ACE-I varies. Our aim was to explore cost and other factors that influence general practitioners (GPs) to prescribe a specific ACE-I and understand their views on therapeutic interchange within this drug class. We conducted a qualitative study of Australian GPs using thematic analysis. We found that GPs were aware of therapeutic equivalency within the ACE-I class, but unaware of the cost differences. Although GPs tended to adopt a prescribing preference, they were open to fewer prescribing options if there was a decreased cost to patients and the PBS, or potential to minimise prescribing error. Our findings have immediate relevance for national prescribing policies and the Pharmaceutical Benefits Scheme (PBS). The wide selection of ACE-Is that are available results in diverse prescribing patterns and may not be cost-effective for patients or the PBS. Restricting the number of drug options within the ACE-I class in primary care appears to be an acceptable drug cost-containment strategy according to our sample of GPs.

Women's sleep position during pregnancy in low- and middle-income countries: a systematic review.

BACKGROUND: Approximately 2.6 million babies are stillborn each year globally, of which 98% occur in low- and middle-income countries (LMICs). A 2019 individual participant data meta-analysis of 6 studies from high-income countries found that maternal supine going-to-sleep position increased the risk of stillbirth. It is not clear whether this impact would be the same in LMICs, and the normal sleep behaviour of pregnant women in LMICs is not well understood. OBJECTIVE: Determine the prevalence of different sleeping positions among pregnant women in LMICs, and what (if any) positions were associated with stillbirth using a systematic review. SEARCH STRATEGY: We systematically searched the databases Medline, Embase, Emcare, CINAHL and Global Index Medicus for relevant studies, with no date or language restrictions on 4 April 2020. Reference lists of included studies were also screened. SELECTION CRITERIA: Observational studies of maternal sleep position during pregnancy in LMICs DATA COLLECTION AND ANALYSIS: Recovered citations were screened and eligible studies were included for extraction. These steps were performed by two independent reviewers. Risk of bias was assessed using the Newcastle-Ottawa Scale. MAIN RESULTS: A total of 3480 citations were screened but only two studies met the inclusion criteria. The studies were conducted in Ghana and India and reported on different maternal sleep positions: supine and left lateral. In Ghana, a prevalence of 9.7% for supine sleeping position amongst 220 women was found. The primary outcome could not be extracted from the Indian study as sleep position information was only reported for women who had a stillbirth (100 of the 300 participants). CONCLUSION: There is limited information on maternal sleeping position in LMICs. Since sleep position may be a modifiable risk factor for stillbirth, there is a need for further research to understand the sleep practices and behaviours of pregnant women in LMICs. PROSPERO registration: CRD42020173314.

The cost-effectiveness of tranexamic acid for treatment of postpartum hemorrhage: A systematic review.

BACKGROUND: Postpartum hemorrhage (PPH) is responsible for nearly one quarter of maternal deaths. A 2017 multicountry trial found that incorporating tranexamic acid (TXA) into the PPH management package was effective in reducing maternal death due to bleeding. OBJECTIVE: To systematically review studies assessing the cost-effectiveness of tranexamic acid for PPH treatment. SEARCH STRATEGY: Nine databases were searched using variations of keywords 'tranexamic acid', 'postpartum hemorrhage' and 'cost effectiveness'. SELECTION CRITERIA: Eligible studies were any type of economic or effectiveness evaluation studies on tranexamic acid for treating women with PPH. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened citations and extracted data on cost effectiveness measures. Quality was assessed using the Consensus on Health Economic Criteria list. MAIN RESULTS: Four studies were included, of which two were abstracts. Three studies concluded that early administration of TXA was cost-saving or cost-effective. One abstract reported TXA was not cost-effective in the USA unless the probability of death due to hemorrhage is higher. CONCLUSION: Available evidence (four studies in three countries) suggests that this life-saving intervention may be below willingness to pay thresholds (cost-effective) or cost saving. Further studies conducted in different populations and settings are needed to inform health policy decision-making to reduce PPH-associated morbidity and mortality.

Cost-effectiveness of uterine tamponade devices for the treatment of postpartum hemorrhage: A systematic review.

BACKGROUND: Uterine tamponade is widely promoted for treating refractory postpartum hemorrhage (PPH); however, its cost-effectiveness may vary depending on unit costs and setting. OBJECTIVE: To review available data on cost-effectiveness of uterine tamponade devices when used for PPH treatment. SEARCH STRATEGY: PubMed and EMBASE were searched (1980 to January 2020), as well as the National Health Services Economic Evaluation database from inception (1995) to March 2015. SELECTION CRITERIA: Eligible studies were any type of economic evaluation, or effectiveness studies that provided cost or economic data. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened studies, extracted data, and assessed quality. MAIN RESULTS: Eleven studies using a range of devices (condom catheter, uterine suction devices, Bakri, Inpress, Ellavi) were identified. Cost of condom catheter devices or kits ranged from US$0.64 to US$6, whereas purpose-designed device costs were up to US$400. Two studies that took a health system perspective assessed the cost-effectiveness of using uterine balloon tamponade and suggested that it was highly cost-effective because of the low cost per disability-adjusted life-year averted, although both used effect estimates from case series. CONCLUSIONS: Evidence on the cost-effectiveness of uterine tamponade devices was limited and not generalizable. Rigorous economic evaluations based on updated effect estimates are needed.

Third- and fourth-degree tears: A review of the current evidence for prevention and management.

BACKGROUND: Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development. AIMS: We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres. MATERIALS AND METHODS: We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic. RESULTS: Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births. CONCLUSIONS: Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.