Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review.

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 studies were included. Countries included Australia, Canada, Chile, Hong Kong, UK and USA. A narrative synthesis was undertaken, and results showed three intervention types: midwifery models of care, interdisciplinary care, and community-centred services. These intervention types have been delivered singularly but also in combination of each other demonstrating overlapping features. Overall, results show interventions had positive associations with primary (maternal, perinatal, and infant mortality) and secondary outcomes (experiences and satisfaction, antenatal care coverage, access to care, quality of care, mode of delivery, analgesia use in labour, preterm birth, low birth weight, breastfeeding, family planning, immunisations) however significance and impact vary. Midwifery models of care took an interpersonal and holistic approach as they focused on continuity of carer, home visiting, culturally and linguistically appropriate care and accessibility. Interdisciplinary care took a structural approach, to coordinate care for women requiring multi-agency health and social services. Community-centred services took a place-based approach with interventions that suited the need of its community and their norms. CONCLUSION: Targeted interventions exist in HICs, but these vary according to the context and infrastructure of standard maternity care. Multi-interventional approaches could enhance a targeted approach for at risk populations, in particular combining midwifery models of care with community-centred approaches, to enhance accessibility, earlier engagement, and increased attendance. TRIAL REGISTRATION: PROSPERO Registration number: CRD42020218357.

Intersection of social determinants of symptomatic breast cancer presentation in a rural setting: A critical ethnographic study.

AIM: The aim of the study was to explore the determinants of time to presentation of women with breast cancer symptoms within a rural setting in Kenya. DESIGN: A critical ethnographic study. METHODS: Data were collected between July 2019 and April 2020 using semi-structured interviews and focus groups with 12 women and 23 disclosure recipients, respectively. Interviews and focus group discussions were audio recorded, transcribed verbatim, translated into English and thematically analysed. Further analysis using an intersectional lens added new insights into the data. Ethics approval was obtained in both Kenya and United Kingdom. RESULTS: Participants narrated their experiences from the time they self-discovered breast cancer symptoms to the time they first came into contact with a healthcare professional. The core themes identified included local cancer knowledge, embodied experience, women's responses, social networks, cultural cancer schemas, gendered social structures and healthcare system experiences. CONCLUSION: The findings revealed that symptomatic women predominantly faced multiple intersecting barriers to timely presentation. The key drivers of timeliness to presentation of women with breast cancer symptoms were identified. Several proximal and distal determinants, including economic, social, psychological and cultural determinants intersected to shape women's timeliness to symptomatic presentation. IMPACT: This study identified intersectional structural determinants to timely symptomatic presentation of women with breast cancer symptoms. The findings have global health implications for social inequalities in female breast cancer and may inform the development of intersectional interventions to promote timely symptomatic presentation. Furthermore, this study identified an additional interval, precursory interval and revision of the Model of pathway to treatment may be needed should this interval be validated by future studies. PATIENT OR PUBLIC CONTRIBUTION: To ensure the interview guides were culturally sensitive, they were co-designed with a female breast cancer survivor, nurses providing reproductive health care to women and a bilingual expert. Both women and disclosure recipients participated in scheduling for the interviews, including the mutually agreeable days and time. Participants were frequently contacted during data analysis and report writing to clarify meaning of certain words or pieces of data.

Understanding factors affecting breastfeeding practices in one city in the Kingdom of Saudi Arabia: an interpretative phenomenological study.

BACKGROUND: Breastfeeding duration has declined in the Kingdom of Saudi Arabia (KSA) in recent decades, although accurate national data about different breastfeeding indicators by infant age are lacking. This qualitative study, the first in KSA, aimed to understand the factors affecting mothers' decisions and experiences regarding any breastfeeding practices. METHODS: A qualitative phenomenological approach was used to investigate mothers' experiences of breastfeeding. Non-probability convenience sampling and snowballing strategies were designed to recruit participants. Semi-structured interviews were conducted with 16 mothers, from two hospitals and three primary health clinics in Al-Madinah city, from December 2017 to March 2018. Interpretative phenomenological analysis was the analysis framework. RESULTS: Three themes were identified: 1) 'Up against the system': policies, staff and systems were the main barriers to exclusive breastfeeding; 2) 'Social support and negativity': family support in the first 40 postpartum days protected breastfeeding continuation and was highly appreciated, but negative comments limited breastfeeding practices thereafter; and 3) 'Managing tensions': mothers' religious beliefs about breastfeeding boosted their decisions; however, the challenge of managing tensions influenced mothers to stop breastfeeding earlier than they wished. The study revealed that mothers had no doubts about wanting to breastfeed their babies; but continuation was adversely affected by unhelpful hospital policies and staff actions, the lack of ongoing social support, and by others people's negativity, rather than by the mothers' own views. Stopping breastfeeding earlier than planned was a complex decision for most mothers. However, mothers said that they intended to breastfeed their next baby successfully. CONCLUSIONS: Healthcare professionals (maternity staff, paediatricians and pharmacists) need education and training to support exclusive breastfeeding effectively. Increasing the number of hospitals with Baby Friendly Hospital Initiative accreditation, which includes staff practice changes, is needed to protect and support exclusive breastfeeding. Ongoing professional and peer support, and improving conditions at workplaces and universities, are needed to help mothers to continue breastfeeding successfully. Effective, coordinated national policies can support mothers' decisions in relation to breastfeeding. Such changes will reduce the tensions experienced by women and help them to achieve their breastfeeding goals and to breastfeed for longer.

Sustaining quality education and practice learning in a pandemic and beyond: 'I have never learnt as much in my life, as quickly, ever'.

The context of healthcare and of healthcare education has radically changed as a result of the Covid-19 pandemic. To identify positive strategies for midwifery education in this context, five case studies from the UK and beyond were conducted using an appreciative enquiry approach, from the perspectives of students, the maternity services, cross-university collaboration, and digital learning. A health system analysis was used to identify strategies to cope, adapt, and transform for the future, at the levels of individuals, teams, and the whole system. Findings showed that the implementation of effective responses was possible. Responding effectively and rapidly to a shock as profound as this pandemic requires courageous, respectful, evidence-based, innovative, collaborative, cross-sectoral working and leadership across education institutions, practice settings, the regulator, government, and with students themselves. Pre-existing trusting relationships and collaborative systems supported rapid responses. Effective digital learning requires a pro-active, student-centred approach, and addressing the problems of inequitable access to equipment and space. Joint problem-solving and focussing on the key outcomes that matter contribute to developing successful strategies and robust processes. The pandemic provides an opportunity for student midwives to be re-imagined as essential members of midwifery teams and not 'just students'. Transformative actions identified include whole-system working, tackling longstanding problems including racism, poverty, prejudice, and systemic discrimination, and keeping students at the heart of the education system.

Guidance for the Conduct and Reporting of Clinical Trials of Breast Milk Substitutes.

Importance: Breast milk substitutes (BMS) are important nutritional products evaluated in clinical trials. Concerns have been raised about the risk of bias in BMS trials, the reliability of claims that arise from such trials, and the potential for BMS trials to undermine breastfeeding in trial participants. Existing clinical trial guidance does not fully address issues specific to BMS trials. Objectives: To establish new methodological criteria to guide the design, conduct, analysis, and reporting of BMS trials and to support clinical trialists designing and undertaking BMS trials, editors and peer reviewers assessing trial reports for publication, and regulators evaluating the safety, nutritional adequacy, and efficacy of BMS products. Design, Setting, and Participants: A modified Delphi method was conducted, involving 3 rounds of anonymous questionnaires and a face-to-face consensus meeting between January 1 and October 24, 2018. Participants were 23 experts in BMS trials, BMS regulation, trial methods, breastfeeding support, infant feeding research, and medical publishing, and were affiliated with institutions across Europe, North America, and Australasia. Guidance development was supported by an industry consultation, analysis of methodological issues in a sample of published BMS trials, and consultations with BMS trial participants and a research ethics committee. Results: An initial 73 criteria, derived from the literature, were sent to the experts. The final consensus guidance contains 54 essential criteria and 4 recommended criteria. An 18-point checklist summarizes the criteria that are specific to BMS trials. Key themes emphasized in the guidance are research integrity and transparency of reporting, supporting breastfeeding in trial participants, accurate description of trial interventions, and use of valid and meaningful outcome measures. Conclusions and Relevance: Implementation of this guidance should enhance the quality and validity of BMS trials, protect BMS trial participants, and better inform the infant nutrition community about BMS products.

How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field.

BACKGROUND: Research funders in Canada and abroad have made substantial investments in supporting collaborative research approaches to generating and translating knowledge as it is believed to increase knowledge use. Canadian health research funders have advocated for the use of integrated knowledge translation (IKT) in health research, however, there is limited research around how IKT compares to other collaborative research approaches. Our objective was to better understand how IKT compares with engaged scholarship, Mode 2 research, co-production and participatory research by identifying the differences and similarities among them in order to provide conceptual clarity and reduce researcher and knowledge user confusion about these common approaches. METHODS: We employed a qualitative descriptive method using interview data to better understand experts' perspectives and experiences on collaborative research approaches. Participants' responses were analysed through thematic analysis to elicit core themes. The analysis was centred around the concept of IKT, as it is the most recent approach; IKT was then compared and contrasted with engaged scholarship, Mode 2 research, co-production and participatory research. As this was an iterative process, data triangulation and member-checking were conducted with participants to ensure accuracy of the emergent themes and analysis process. RESULTS: Differences were noted in the orientation (i.e. original purpose), historical roots (i.e. disciplinary origin) and partnership/engagement (i.e. role of partners etc.). Similarities among the approaches included (1) true partnerships rather than simple engagement, (2) focus on essential components and processes rather than labels, (3) collaborative research orientations rather than research methods, (4) core values and principles, and (5) extensive time and financial investment. Core values and principles among the approaches included co-creation, reciprocity, trust, fostering relationships, respect, co-learning, active participation, and shared decision-making in the generation and application of knowledge. All approaches require extensive time and financial investment to develop and maintain true partnerships. CONCLUSIONS: This qualitative study is the first to systematically synthesise experts' perspectives and experiences in a comparison of collaborative research approaches. This work contributes to developing a shared understanding of collaborative research approaches to facilitate conceptual clarity in use, reporting, indexing and communication among researchers, trainees, knowledge users and stakeholders to advance IKT and implementation science.

The provision of midwife-led care in low-and middle-income countries: An integrative review.

BACKGROUND: The provision of midwife-led care, the model of care in which midwives are the lead professionals for women and newborn infants across the continuum, has been shown to be effective in improving outcomes for women and newborn infants, but predominantly based on research in high-income countries. OBJECTIVE: To explore how midwife-led care is provided in low- and middle-income countries. The specific question was to examine how, where and by whom has midwife-led care been provided in low-and-middle-income countries? DESIGN: An integrative literature review was undertaken and included studies using a range of methods. DATA SOURCES: A systematic search was conducted in Pubmed, EMBASE (Ovid), Web of Science, Scopus, Google Scholar, The Cochrane Library and hand-searching of relevant journals and website of International Organizations and relevant grey-literature. REVIEW METHODS: After applying inclusion criteria, systematic sifting and quality assessment processes, data were extracted from relevant studies. The software program NVivo was used to initially extract the findings and results of the studies. Coded data from primary data sources were iteratively compared, using patterns and themes as per the conceptual framework of the WHO on skilled health personnel providing care for childbearing women and newborn infants, including an analysis of the competent provider, standards of practice and the enabling environment. FINDINGS: Of a total of 3324 articles retrieved, 31 studies were included. There were 18 qualitative, nine quantitative and four mixed method studies with different levels of quality from five of six global regions published between 1997 and 2017. In these studies, midwife-led care was not found to be a standardised model in low- and middle-income countries (LMIC) and there was limited evidence on the effectiveness of midwife-led care in these countries. Care provided across the continuum was however described in most studies. Standards of practice in education, regulation and training varied widely as did the enabling environment in which midwife-led care took place. CONCLUSION AND IMPLICATION FOR PRACTICE AND RESEARCH: Midwife-led care is provided across low- and middle-income countries but lack of enabling factors limits the quality of care that midwives can provide. Further research about this model of care is needed to understand the ingredients of successful implementation, their effectiveness and sustainability.

Exploring determinants of, and interventions for, delayed presentation of women with breast symptoms: A systematic review.

PURPOSE: Behaviour change interventions are more likely to be effective if they are sensitive to contextual determinants of behaviour. Delayed presentation of women with breast symptoms is a concern for both high-income and low- and medium-income countries. Our aim was to integrate evidence on determinants of time to presentation of women with breast symptoms with complementary evidence on interventions for promoting early presentation. METHODS: A systematic review was conducted according to PRISMA guidelines. Ten electronic databases were searched for relevant articles published between 1985 to May 2019. Pre-defined selection criteria were applied to retrieved records. Evidence on interventions, and on determinants were integrated through sequential explanatory synthesis design. RESULTS: Of the 4185 documents retrieved, 11 intervention studies and 10 determinants studies were included in the synthesis. Overall, evidence on interventions is of low quality, while that on determinants is of medium quality. Intervention studies were mostly individual-level with almost exclusive focus on breast cancer awareness among postmenopausal women in high-income countries. Synthesis of evidence on determinants resulted in 10 domains. Juxtaposing the evidence on determinants of time to presentation of women with breast symptoms with that of the interventions to promote early presentation shows a mismatch between them. CONCLUSIONS: Whilst there is strong evidence that women with breast symptoms face multi-level influences to presentation, current interventions have focused almost exclusively on breast cancer awareness in high-income countries. High quality multi-level interventions are required to promote early presentation of symptomatic women in different socio-cultural and economic settings.

Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis.

BACKGROUND: Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low, and lower-middle income countries (LMIC) and needs to be underpinned by effective education. There is considerable variation in the quality of midwifery education provided globally. OBJECTIVE: To determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care. DESIGN: Rapid Systematic Evidence Review METHODS: A systematic search of the following databases was conducted: Medline, CINAHL, LILACs, PsycInfo, ERIC, and MIDIRs. Studies that evaluated the effects of pre-service and in-service education that were specifically designed to train, educate or upskill care providers in order to provide quality maternal and newborn care were included. Data was extracted and presented narratively. FINDINGS: Nineteen studies were included in the review. Of these seven were evaluations of pre-service education programmes and 12 were evaluations of in-service education programmes. Whilst studies demonstrated positive effects on knowledge and skills, there was a lack of information on whether this translated into behaviour change and positive effects for women and babies. Moreover, the level of the evidence was low and studies often lacked an educational framework and theoretical basis. Mapping the skills taught in each of the programmes to the Quality Maternal and Newborn Care framework (Renfrew et al., 2014) identified that interventions focused on very specific or individual clinical skills and not on the broader scope of midwifery. KEY CONCLUSIONS: There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs; this is at odds with the importance of the topic to survival, health and well-being. There is a preponderance of studies which focus on training for specific emergencies during labour and birth. None of the in-service programmes considered the education of midwives to international standards with the full scope of competencies needed. There is an urgent need for the development of theoretically informed pre-service and in-service midwifery education programmes, and well-conducted evaluations of such programmes. Upscaling quality midwifery care for all women and newborn infants is of critical importance to accelerate progress towards Sustainable Development Goal 3. Quality midwifery education is an essential pre-requisite for quality care. To deliver SDG 3, the startling underinvestment in midwifery education identified in this review must be reversed.

Motivating Change: a grounded theory of how to achieve large-scale, sustained change, co-created with improvement organisations across the UK.

Background: Various theories provide guidance on implementing, sustaining and evaluating innovations within healthcare. There has been less attention given, however, to personal theories drawn from practice and the expertise of managers and front-line staff is a largely untapped resource. In this paper, we share learning from experienced improvement organisations to provide a conceptual level explanation of the conditions necessary to facilitate and sustain improvement at scale. Methods: Staff (n=42) from three leading change organisations in the UK, spanning health, education and social care, took part in three consultation meetings with the aim of sharing knowledge about sustaining large-scale change. This included one government organisation, one National Health Service Board and one large charity organisation. Using a participatory grounded theory approach, the workshops resulted in a co-created theory. Results: The theory of Motivating Change describes the psychosocial-structural conditions for large-scale, sustained change from the perspectives of front-line staff. The theory posits that change is more likely to be sustained at scale if there is synergy between staff's perceived need and desire for improvement, and the extrinsic motivators for change. Witnessing effective change is motivating for staff and positive outcomes provide a convincing argument for the need to sustain improvement activity. As such, evidence of change becomes evidence for change. This is only possible when there is a flow of trust within organisations that capitalises on positive peer pressure and suppresses infectious negativity. When these conditions are in place, organisations can generate self-proliferating improvement. Conclusions: The theory of Motivating Change has been co-created with staff and offers a useful explanation and guide for others involved in change work that capitalises on front-line expertise.

Understanding the experiences of married Southern African women in protecting themselves from HIV/AIDS: a systematic review and meta-synthesis.

Background: Whilst marriage has been repeatedly identified in the literature as an HIV risk factor amongst Southern African women, not much is known about women's perception of their role, experiences and strategies used to address HIV risks in the context of a marriage. Aims: The aim of the study was to synthesise perceptions, experiences and strategies of married Southern African women in the prevention of HIV. Methods: A systematic review of qualitative studies was conducted. Three electronic databases (Medline, Cinahl and PsycINFO) were systematically searched to identify relevant literature. The meta-synthesis process followed Sandelowski and Barroso's [2007. Handbook for Synthesizing Qualitative Research. Springer Publishing Company] recommendations. Results: Of 7 609 papers, 15 were included in the review. The quality of the included studies was variable. In the final synthesis stage, three broad analytic themes emerged: contextual background, cues to preventive behaviour, and HIV prevention strategies. Implications: Findings were used to develop a conceptual framework for studying HIV/AIDS prevention experiences of married Southern African women.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child.

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents "different research questions" drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on "right care," which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Routinely collected infant feeding data: Time for global action.

The importance of breastfeeding is clear. However, global action to support breastfeeding is hindered by the lack of reliable standard data, which continues to impede progress. Routinely collected data can monitor the effectiveness of health policy, evaluate interventions, and enhance international research collaboration and comparisons. Use of routine data to support effective public health initiatives such as smoking cessation has been demonstrated. However, the data collected about infant feeding practices worldwide is inconsistent in timing, methods, definitions, detail, storage, and consistency. Improvements to the reach and quality of routinely collected data about infant feeding are needed to strengthen the global evidence and policy base. An international collaborative effort is called for to progress this.