Search

Background: The COVID-19 pandemic has resulted in profound and far-reaching impacts on maternal and newborn care and outcomes. As part of the ASPIRE COVID-19 project, we describe processes and outcome measures relating to safe and personalised maternity care in England which we map against a pre-developed ASPIRE framework to establish the potential impact of the COVID-19 pandemic for two UK trusts. Methods: We undertook a mixed-methods system-wide case study using quantitative routinely collected data and qualitative data from two Trusts and their service users from 2019 to 2021 (start and completion dates varied by available data). We mapped findings to our prior ASPIRE conceptual framework that explains pathways for the impact of COVID-19 on safe and personalised care. Results: The ASPIRE framework enabled us to develop a comprehensive, systems-level understanding of the impact of the pandemic on service delivery, user experience and staff wellbeing, and place it within the context of pre-existing challenges. Maternity services experienced some impacts on core service coverage, though not on Trust level clinical health outcomes (with the possible exception of readmissions in one Trust). Both users and staff found some pandemic-driven changes challenging such as remote or reduced antenatal and community postnatal contacts, and restrictions on companionship. Other key changes included an increased need for mental health support, changes in the availability and uptake of home birth services and changes in induction procedures. Many emergency adaptations persisted at the end of data collection. Differences between the trusts indicate complex change pathways. Staff reported some removal of bureaucracy, which allowed greater flexibility. During the first wave of COVID-19 staffing numbers increased, resolving some pre-pandemic shortages: however, by October 2021 they declined markedly. Trying to maintain the quality and availability of services had marked negative consequences for personnel. Timely routine clinical and staffing data were not always available and personalised care and user and staff experiences were poorly captured. Conclusions: The COVID-19 crisis magnified pre-pandemic problems and in particular, poor staffing levels. Maintaining services took a significant toll on staff wellbeing. There is some evidence that these pressures are continuing. There was marked variation in Trust responses. Lack of accessible and timely data at Trust and national levels hampered rapid insights. The ASPIRE COVID-19 framework could be useful for modelling the impact of future crises on routine care.

Previous research suggests that a mismatch between parents’ birth expectations and experiences is associated with lower levels of birth satisfaction and an increased risk for childbirth-related posttraumatic stress disorder (CB-PTSD; Webb et al., 2021). However, there is a lack of prospective studies and studies investigating expectations and experiences of birth companions. The current study aims to examine whether a mismatch between birth expectations during pregnancy and experiences at two weeks postpartum predicts CB-PTSD symptoms at six weeks postpartum. This will be investigated individually for mothers and birth companions, as well as within dyads of mothers and their birth companions. Webb, R., Ayers, S., Bogaerts, A., Jeličić, L., Pawlicka, P., Van Haeken, S., ... & Kolesnikova, N. (2021). When birth is not as expected: a systematic review of the impact of a mismatch between expectations and experiences. BMC pregnancy and childbirth, 21(1), 1-14.

Scoping Review of Intermittent Auscultation

Routine vaginal examinations are undertaken at regular time intervals during labour to assess whether labour is progressing as expected. Unusually slow progress can be due to underlying problems, described as labour dystocia, or can be a normal variation of progress. Evidence suggests that if mother and baby are well, length of labour alone should not be used to decide whether labour is progressing normally. Other methods to assess labour progress include intrapartum ultrasound and monitoring external physical and behavioural cues. Vaginal examinations can be distressing for women, and overdiagnosis of dystocia can result in iatrogenic morbidity due to unnecessary intervention. It is important to establish whether routine vaginal examinations are effective, both as an accurate measure of physiological labour progress and to distinguish true labour dystocia, or whether other methods for assessing labour progress are more effective. This Cochrane Review is an update of a review first published in 2013.To compare the effectiveness, acceptability, and consequences of routine vaginal examinations compared with other methods, or different timings, to assess labour progress at term.For this update, we searched Cochrane Pregnancy and Childbirth Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings) and ClinicalTrials.gov (28 February 2021). We also searched the reference lists of retrieved studies.We included randomised controlled trials (RCTs) of vaginal examinations compared with other methods of assessing labour progress and studies assessing different timings of vaginal examinations. Quasi-RCTs and cluster-RCTs were eligible for inclusion. We excluded cross-over trials and conference abstracts.Two review authors independently assessed all studies identified by the search for inclusion in the review. Four review authors independently extracted data. Two review authors assessed risk of bias and certainty of the evidence using GRADE.We included four studies that randomised a total of 755 women, with data analysed for 744 women and their babies. Interventions used to assess labour progress were routine vaginal examinations, routine ultrasound assessments, routine rectal examinations, routine vaginal examinations at different frequencies, and vaginal examinations as indicated. We were unable to conduct meta-analysis as there was only one study for each comparison. All studies were at high risk of performance bias due to difficulties with blinding. We assessed two studies as high risk of bias and two as low or unclear risk of bias for other domains. The overall certainty of the evidence assessed using GRADE was low or very low. Routine vaginal examinations versus routine ultrasound to assess labour progress (one study, 83 women and babies) Study in Turkey involving multiparous women with spontaneous onset of labour. Routine vaginal examinations may result in a slight increase in pain compared to routine ultrasound (mean difference -1.29, 95% confidence interval (CI) -2.10 to -0.48; one study, 83 women, low certainty evidence) (pain measured using a visual analogue scale (VAS) in reverse: zero indicating 'worst pain', 10 indicating no pain). The study did not assess our other primary outcomes: positive birth experience; augmentation of labour; spontaneous vaginal birth; chorioamnionitis; neonatal infection; admission to neonatal intensive care unit (NICU). Routine vaginal examinations versus routine rectal examinations to assess labour progress (one study, 307 women and babies) Study in Ireland involving women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine rectal examinations, routine vaginal examinations may have little or no effect on: augmentation of labour (risk ratio (RR) 1.03, 95% CI 0.63 to 1.68; one study, 307 women); and spontaneous vaginal birth (RR 0.98, 95% CI 0.90 to 1.06; one study, 307 women). We found insufficient data to fully assess: neonatal infections (RR 0.33, 95% CI 0.01 to 8.07; one study, 307 babies); and admission to NICU (RR 1.32, 95% CI 0.47 to 3.73; one study, 307 babies). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; maternal pain. Routine four-hourly vaginal examinations versus routine two-hourly examinations (one study, 150 women and babies) UK study involving primiparous women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine two-hourly vaginal examinations, routine four-hourly vaginal examinations may have little or no effect, with data compatible with both benefit and harm, on: augmentation of labour (RR 0.97, 95% CI 0.60 to 1.57; one study, 109 women); and spontaneous vaginal birth (RR 1.02, 95% CI 0.83 to 1.26; one study, 150 women). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; neonatal infection; admission to NICU; maternal pain. Routine vaginal examinations versus vaginal examinations as indicated (one study, 204 women and babies) Study in Malaysia involving primiparous women being induced at term. We assessed the certainty of the evidence as low. Compared with vaginal examinations as indicated, routine four-hourly vaginal examinations may result in more women having their labour augmented (RR 2.55, 95% CI 1.03 to 6.31; one study, 204 women). There may be little or no effect on: • spontaneous vaginal birth (RR 1.08, 95% CI 0.73 to 1.59; one study, 204 women); • chorioamnionitis (RR 3.06, 95% CI 0.13 to 74.21; one study, 204 women); • neonatal infection (RR 4.08, 95% CI 0.46 to 35.87; one study, 204 babies); • admission to NICU (RR 2.04, 95% CI 0.63 to 6.56; one study, 204 babies). The study did not assess our other primary outcomes of positive birth experience or maternal pain.Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Further large-scale RCT trials are required. These should include essential clinical and experiential outcomes. This may be facilitated through the development of a tool to measure positive birth experiences. Data from qualitative studies are also needed to fully assess whether methods to evaluate labour progress meet women's needs for a safe and positive labour and birth, and if not, to develop an approach that does.

More women and neonates die each year in India than in almost every other country of the world. Since 1947, India has in principle provided free medical maternal health care to all pregnant and childbearing women. Although rates of maternal and neonatal deaths have fallen since the 1990s, major inequalities remain. Some Indian States have very high rates of interventions, (e.g., cesarean section), while others have intervention and care rates that are too low. Disrespectful treatment of women in labor and lack of evidence-based practice have also been reported. The World Health Organization and others have strongly recommended that professional midwives (trained in a woman-centered philosophy and to international standards) have a key role for reducing mortality and morbidity, minimizing unnecessary interventions in pregnancy and labor, and improving maternal care quality in low- and medium-income countries. This paper provides a community case-report of the first professional midwifery programme in India designed to international standards, implemented in 2011 in Hyderabad. We describe the design and implementation in the programme's first eleven years, as a basis for further scale-up and testing in India, and in other low- or medium-income countries. The ultimate aim is to improve maternal care quality, choice and outcomes in India and in similar socio-economic and cultural settings.

INTRODUCTION: Stillbirth is associated with significant physical, psychosocial and economic consequences for parents, families, wider society and the healthcare system. There is emerging momentum to design and evaluate interventions for care after stillbirth and in subsequent pregnancies. However, there is insufficient evidence to inform clinical practice compounded by inconsistent outcome reporting in research studies. To address this paucity of evidence, we plan to develop a core outcome set for stillbirth care research, through an international consensus process with key stakeholders including parents, healthcare professionals and researchers. METHODS AND ANALYSIS: The development of this core outcome set will be divided into five distinct phases: (1) Identifying potential outcomes from a mixed-methods systematic review and analysis of interviews with parents who have experienced stillbirth; (2) Creating a comprehensive outcome long-list and piloting of a Delphi questionnaire using think-aloud interviews; (3) Choosing the most important outcomes by conducting an international two-round Delphi survey including high-income, middle-income and low-income countries; (4) Deciding the core outcome set by consensus meetings with key stakeholders and (5) Dissemination and promotion of the core outcome set. A parent and public involvement panel and international steering committee has been convened to coproduce every stage of the development of this core outcome set. ETHICS AND DISSEMINATION: Ethical approval for the qualitative interviews has been approved by Berkshire Ethics Committee REC Reference 12/SC/0495. Ethical approval for the think-aloud interviews, Delphi survey and consensus meetings has been awarded from the University of Bristol Faculty of Health Sciences Research Ethics Committee (Reference number: 116535). The dissemination strategy is being developed with the parent and public involvement panel and steering committee. Results will be published in peer-reviewed specialty journals, shared at national and international conferences and promoted through parent organisations and charities. PROSPERO REGISTRATION NUMBER: CRD42018087748., National Institute of Health Research

In this chapter, the relation of salutogenesis to maternity care is discussed by giving a critical overview of studies in perinatal care, primarily measuring and promoting parental sense of coherence (SOC) and well-being.An overview is given on salutogenic approaches to neonatal and infant service provision. Important aspects of and salutogenic interventions for parent–child attachment in the first year of a child’s life are examined. Parents’ and caregivers’ relationship with their infants and newborns plays a critical role in shaping the emotional, cognitive, and social development of their child. Different interventions of early support to optimize parenting capacity and their impact are also discussed.Although the chapter focuses only on examples of salutogenic approaches based on reasonable evidence, there is a growing awareness of the value of salutogenic approaches to the provision of maternity care, and to facilities and services to enhance parenting and well-being in infancy and early childhood. Research gaps are identified, and suggestions for the direction of future research are outlined.

Background The COVID-19 pandemic had a severe impact on women’s birth experiences. To date, there are no studies that use both quantitative and qualitative data to compare women’s birth experiences before and during the pandemic, across more than one country. Aim To examine women’s birth experiences during the COVID-19 pandemic and to compare the experiences of women who gave birth in the United Kingdom (UK) or the Netherlands (NL) either before or during the pandemic. Method This study is based on analyses of quantitative and qualitative data from the online Babies Born Better survey. Responses recorded by women giving birth in the UK and the NL between June and December 2020 have been used, encompassing women who gave birth between 2017 and 2020. Quantitative data were analysed descriptively, and chi-squared tests were performed to compare women who gave birth pre- versus during pandemic and separately by country. Qualitative data was analysed by inductive thematic analysis. Findings Respondents in both the UK and the NL who gave birth during the pandemic were as likely, or, if they had a self-reported above average standard of life, more likely to rate their labour and birth experience positively when compared to women who gave birth pre-pandemic. This was despite the fact that those labouring in the pandemic reported a lack of support and limits placed on freedom of choice. Two potential explanatory themes were identified in the qualitative data: respondents had lower expectations of care during the pandemic, and they appreciated the efforts of staff to give individualised care, despite the rules. Conclusion Our study implies that many women labouring during the COVID-19 pandemic experienced restrictions, but their experience was mitigated by staff actions. However, personalised care should not be maintained by the good will of care providers, but should be a priority in maternity care policy to benefit all service users equitably.

This is the first article in a series reflecting on the role of research midwives in the ASPIRE (Achieving Safe and Personalised maternity care In Response to Epidemics) study. In this article we introduce ASPIRE and provide an overview of the study. We also reflect on what makes ASPIRE uniquely midwifery-led within the National Institute for Health Research (NIHR) Portfolio and the role of research midwives within recruitment sites. We hope this article, and those that follow in the series, written by ASPIRE research midwives, will serve as a roadmap to inspire the next chapter of midwifery research in England.

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 consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach. Findings Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women’s desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care. Conclusions Factors that influence women’s utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings. Registration This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.

Introduction Women can face opposition when exerting autonomous decision-making regarding their birth choices, particularly when the decisions involve going against medical advice and/or outside of national guidelines. Termed ‘unconventional birth choices’, some research has explored women’s reasons and experiences of making such choices, but less is known about the midwives caring for them. Objectives To synthesize existing qualitative literature on the views, attitudes, and experiences of midwives caring for women who make unconventional birth choices. Methods A systematic search and meta-ethnography informed by Noblit and Hare and Schutz was undertaken. Eight databases were searched using predetermined search terms, alongside author, reference, citation chasing, and hand searching. Searches were conducted in July 2016 and updated in October 2017. Qualitative studies published since 1993 in English were included. Included studies were subjected to quality appraisal, conducted independently by two reviewers. Analysis was informed by the interpretative meta-ethnography methods. Main results Five studies met the inclusion criteria. Eight subthemes emerged. These resulted in three higher level interpretative themes emerged: perceptions of women’s decision making, conflicting tensions as caregivers, ways of working with-woman. Conclusions Midwives can play a pivotal role in ensuring that respectful maternity care includes supporting women in their birthing decisions. Whilst limited research has been undertaken in this area, available insights suggest that midwives’ views in this area are situated along a spectrum from ‘willingly facilitative’ to ‘reluctantly accepting’. Views were influenced by context, as well as prior philosophies and values. While further research is needed, this study offers insights into the challenges women can face in seeking unconventional birth choices if they require support from midwives to do so.

Additional file 1: Table S1. Example search-MEDLINE.

Additional file of Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

Additional file 1: Topic guide for 6month postnatal follow up.

Additional file 2: Intervention fidelity monitoring checklist.

Additional file of Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

Additional file of Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

Supplemental Material, sj-pdf-1-tva-10.1177_15248380211060808 for Effectiveness of Psychological Interventions to Improve the Mental Well-Being of Parents Who Have Experienced Traumatic Childbirth: A Systematic Review and Meta-Analysis by Shefaly Shorey, Soo Downe, Joelle Yan Xin Chua, Sofia O. Byrne, Maaike Fobelets and Joan Lalor in Trauma, Violence, & Abuse

Additional file of Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

Supplemental Material, sj-pdf-2-tva-10.1177_15248380211060808 for Effectiveness of Psychological Interventions to Improve the Mental Well-Being of Parents Who Have Experienced Traumatic Childbirth: A Systematic Review and Meta-Analysis by Shefaly Shorey, Soo Downe, Joelle Yan Xin Chua, Sofia O. Byrne, Maaike Fobelets and Joan Lalor in Trauma, Violence, & Abuse

Additional file of Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

Introduction Rates 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 analysis Population: 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 mindset) and support their ability to birth without pain relief using evidence-based tools (tools and techniques). The intervention could occur in a hospital-based or community setting. Comparator: standard care alone in hospital-based maternity units. Outcomes Primary: CS. Secondary: epidural analgesia, mode of birth, perineal trauma, postpartum haemorrhage, newborn resuscitation, psychosocial well-being. Subgroup analysis: parity, model of care, maternal risk status, maternal education, maternal socio-economic status, intervention components. Study design An individual participant data (IPD) prospective meta-analysis (PMA) of randomised controlled trials, including cluster design. Each trial is conducted independently but share core protocol elements to contribute data to the PMA. Participating trials are deemed eligible for the PMA if their results are not yet known outside their Data Monitoring Committees. Ethics and dissemination Participants in the individual trials will consent to participation, with respective trials receiving ethical approval by their local Human Research Ethics Committees. Individual datasets remain the property of trialists, and can be published prior to the publication of final PMA results. The overall data for meta-analysis will be held, analysed and published by the collaborative group, led by the Cochrane PMA group.

Additional file 1. Search strategy Ovid medline.

Additional file 13. Qualitative module 9: Equalising physician pay for vaginal and caesarean birth.

Additional file 15. Qualitative module 11: Setting a goal for caesarean section rate at a facility-level.

Additional file 9. Qualitative module 5: Public dissemination of caesarean section rates at a facility-level.

Additional file 5. Qualitative module 1: Prenatal education and support.

Additional file 6. Qualitative module 2: Decision-aids for mode of birth.

Additional file 7. Qualitative module 3: Psychosocial support for women with fear of childbirth.

Additional file 14. Qualitative module 10: Opinion leader education.

Additional file 8. Qualitative module 4: Labour companionship.

Additional file 4. Qualitative module 0: Background and understanding context of preferences for mode of delivery.

Additional file 10. Qualitative module 6: Audit and feedback including external review of labour and delivery records and use of Robson classification as a feedback too.

Search strategy, 6th October 2015. (DOCX 38 kb)

Additional file 1. Interventions that may reduce the rate of unnecessary caesarean sections. Twelve potential interventions that may influence use of caesarean section were identified through the WHO guideline development. This file provides a description of each intervention, theory of change, and supporting evidence for each potential intervention.

Additional file 16. Qualitative module 12: Policies limiting legal liability and malpractice lawsuits.

Additional file 3. Data collection form: readiness form assessment.

Additional file 11. Qualitative module 7: Mandatory second opinion before conducting a caesarean section.

Additional file 2. Data collection form: document review.

Background or context refugee and asylum seekers are over represented in maternal death data. Many asylum seeking and refugee women access maternity care infrequently, or not at all. Little is known about the role of voluntary sector workers in supporting pregnant refugees and asylum seekers. Objective to explore the experiences of voluntary sector workers supporting asylum seeking and refugee women during pregnancy and early motherhood. Design a qualitative descriptive study. Setting and participants individual and focus group interviews in three large urban centres in North West England, United Kingdom. Findings two main themes emerged. ‘Literally through hell and back' reflected the experiences of suffering, abuse and loss recounted to the volunteers by many of the women they work with. ׳Bridging the unacknowledged gap' related to the invisible processes undertaken by the workers as they enable the women they work with to over come their marginalised position. This included the difficulties of transience, and lack of enculturation, and to support them in accessing maternity care. Conclusion voluntary sector workers supporting asylum seeking and refugee women strongly identified with the extreme suffering experienced by many of the women they work with. Through this contact, they become acutely aware of the gaps in provision for such women, and developed unique and innovative approaches to bridge this gap. These findings highlight the need for maternity health system to actively collaborate with, and learn from, voluntary agencies working in this field to improve the support offered to asylum seeking and refugee women.

Table S1. Themes, emergent themes, initial concepts and supporting quotes. (DOCX 35 kb)

Table S2. CERQual Summary of evidence profile table. (DOCX 33 kb)

Box S1. Summary of qualitative synthesis process. (DOCX 26 kb)

Appendix S0. PRISMA checklist. (DOCX 32 kb)

Appendix S1. Search strategy. (DOCX 32 kb)

Background Several qualitative studies have described disrespectful, abusive, and neglectful treatment of women\ud during facility-based childbirth, but few studies document the extent of person-centred maternity care (PCMC)—ie,\ud responsive and respectful maternity care—in low-income and middle-income countries. In this Article, we present\ud descriptive statistics on PCMC in four settings across three low-income and middle-income countries, and we\ud examine key factors associated with PCMC in each setting.\ud \ud Methods We examined data from four cross-sectional surveys with 3625 women aged 15–49 years who had recently\ud given birth in Kenya, Ghana, and India (surveys were done from August, 2016, to October, 2017). The Kenya data were\ud collected from a rural county (n=877) and from seven health facilities in two urban counties (n=530); the Ghana data\ud were from five rural health facilities in the northern region (n=200); and the India data were from 40 health facilities\ud in Uttar Pradesh (n=2018). The PCMC measure used was a previously validated scale with subscales for dignity and\ud respect, communication and autonomy, and supportive care. We analysed the data using descriptive statistics and\ud bivariate and multivariate regressions to examine predictors of PCMC.\ud \ud Findings The highest mean PCMC score was found in urban Kenya (60·2 [SD 12·3] out of 90), and the lowest in rural\ud Ghana (46·5 [6·9]). Across sites, the lowest scores were in communication and autonomy (from 8·3 [3.3] out of 27 in\ud Ghana to 15·1 [5·9] in urban Kenya). 3280 (90%) of the total 3625 women across all countries reported that providers\ud never introduced themselves, and 2076 (57%) women (1475 [73%] of 1980 in India) reported providers never asked\ud permission before performing medical procedures. 120 (60%) of 200 women in Ghana and 1393 (69%) of 1980 women\ud in India reported that providers did not explain the purpose of examinations or procedures, and 116 (58%) women in\ud Ghana and 1162 (58%) in India reported they did not receive explanations on medications they were given; additionally,\ud 104 (52%) women in Ghana did not feel able to ask questions. Overall, 576 (16%) women across all countries reported\ud verbal abuse, and 108 (3%) reported physical abuse. PCMC varied by socioeconomic status and type of facility in three\ud settings (ie, rural and urban Kenya, and India).\ud \ud Interpretation Regardless of the setting, women are not getting adequate PCMC. Efforts are needed to improve the\ud quality of facility-based maternity care.

Search Strategy. (DOCX 13 kb)

Excluded Research Studies. (DOCX 14 kb)