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Background: Uptake of postnatal care (PNC) is low and inequitable in many countries, and immigrant women may experience additional challenges to access and effective use. As part of a larger study examining the views of women, partners, and families on routine PNC, we analysed a subset of data on the specific experiences of immigrant women and families. Methods: This is a subanalysis of a larger qualitative evidence synthesis. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews and grey literature for studies published until December 2019 with extractable qualitative data with no language restrictions. For this analysis, we focused on papers related to immigrant women and families. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and quality assessment were carried out using a study-specific extraction form and established quality assessment tools. Study findings were identified using thematic analysis. Findings are presented by confidence in the finding, applying the GRADE-CERQual approach. Findings: We included 44 papers, out of 602 full-texts, representing 11 countries where women and families sought PNC after immigrating. All but one included immigrants to high-income countries. Four themes were identified: resources and access, differences from home country, support needs, and experiences of care. High confidence study findings included: language and communication challenges; uncertainty about navigating system supports including transportation; high mental health, emotional, and informational needs; the impact of personal resources and social support; and the quality of interaction with healthcare providers. These findings highlight the importance of care experiences beyond clinical care. More research is also needed on the experiences of families migrating between low-income countries. Conclusions: Immigrant families experience many challenges in getting routine PNC, especially related to language, cult

Background Adolescent pregnancy is associated with increased risk of maternal and child morbidity and mortality globally. Access to safe, appropriate and affordable antenatal, childbirth and postnatal care (PNC) is essential in mitigating this risk. PNC is an often undervalued, underused, and understudied component of the continuum of maternal health services; however, it provides an important opportunity for adolescent girls to have access to health information and resources as they navigate the transition to motherhood and/or recovery from childbirth. This qualitative evidence synthesis seeks to highlight the experiences and perspectives of adolescent girls and their partners in accessing and using routine PNC. Methods Papers were selected from a primary review on PNC where a global search of databases was conducted to identify studies with qualitative data focused on PNC utilisation. Within this primary review, a subset of studies focused on adolescents was tagged for subanalysis. A data extraction form drawing on an a priori framework was used to extract data from each study. Review findings were grouped across studies and mapped onto relevant themes, which were then adapted, as appropriate, to best reflect emergent themes from included studies. Results Of 662 papers identified for full text review, 15 were included in this review on adolescents’ experiences. Fourteen review findings were mapped onto four themes including: resources and access, social norms, experiences of care, and tailored support needs. Conclusion Improving uptake of PNC by adolescent girls requires multipronged approaches in improving availability of and access to adolescent-sensitive maternal health services and reducing feelings of shame and stigma in the postpartum period. Much should be done to address structural barriers to access, but tangible steps to improving the quality and responsiveness of available services can be taken immediately.

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 intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for ‘othered’ groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence agains

Background Postnatal care (PNC) is a key component of maternity provision and presents opportunities for healthcare providers to optimise the health and well-being of women and newborns. However, PNC is often undervalued by parents, family members and healthcare providers. As part of a larger qualitative review exploring the factors that influence PNC uptake by relevant stakeholders, we examined a subset of studies highlighting the views of fathers, partners and family members of postpartum women. Methods We undertook a qualitative evidence synthesis using a framework synthesis approach. We searched multiple databases and included studies with extractable qualitative data focusing on PNC utilisation. We identified and labelled a subset of articles reflecting the views of fathers, partners and other family members. Data abstraction and quality assessment were carried out using a bespoke data extraction form and established quality assessment tools. The framework was developed a priori based on previous research on the topic and adapted accordingly. Findings were assessed for confidence using the GRADE-CERQual approach and are presented by country income group. Results Of 12 678 papers identified from the original search, 109 were tagged as ‘family members views’ and, of these, 30 were eligible for this review. Twenty-nine incorporated fathers’ views, 7 included the views of grandmothers or mothers-in-law, 4 incorporated other family member views and 1 included comothers. Four themes emerged: access and availability; adapting to fatherhood; sociocultural influences and experiences of care. These findings highlight the significant role played by fathers and family members on the uptake of PNC by women as well as the distinct concerns and needs of fathers during the early postnatal period. Conclusion To optimise access to postnatal care, health providers should adopt a more inclusive approach incorporating flexible contact opportunities, the availability of more ‘family

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. 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. 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 a

Background: Frailty is associated with adverse health outcomes in people with chronic kidney disease (CKD). Evidence supporting targeted interventions is needed. This pilot randomised controlled trial (RCT) aimed to inform the design of a definitive RCT evaluating the effectiveness of a home-based exercise intervention for pre-frail and frail older adults with CKD. Methods: Participants were recruited from nephrology outpatient clinics to this two-arm parallel group mixed-methods pilot RCT. Inclusion criteria were: ≥65 years old; CKD G3b-5; and Clinical Frailty Scale score ≥4. Participants categorised as pre-frail or frail using the Frailty Phenotype were randomised to a 12-week progressive multi-component home-based exercise programme or usual care. Primary outcome measures included eligibility, recruitment, adherence, outcome measure completion and participant attrition rate. Semi-structured interviews were conducted with participants to explore trial and intervention acceptability. Results: Six hundred and sixty-five patients had an eligibility assessment with 217 (33%; 95% CI 29, 36) eligible. Thirty-five (16%; 95% CI 12, 22) participants were recruited. Six were categorised as robust and withdrawn prior to randomisation. Fifteen participants were randomised to exercise and 14 to usual care. Eleven (73%; 95% CI 45, 91) participants completed ≥2 exercise sessions/week. Retained participants completed all outcome measures (n = 21; 100%; 95% CI 81, 100). Eight (28%; 95% CI 13, 47) participants were withdrawn. Fifteen participated in interviews. Decision to participate/withdraw was influenced by perceived risk of exercise worsening symptoms. Participant perceived benefits included improved fitness, balance, strength, well-being, energy levels and confidence. Conclusions: This pilot RCT demonstrates that progression to definitive RCT is possible provided recruitment and retention challenges are addressed. It has also provided preliminary evidence that home-based exer

Purpose: Frailty is highly prevalent in adults with chronic kidney disease (CKD) and is associated with adverse health outcomes. However, exercise training may improve physical function leading to associated improvements in outcomes. The EX-FRAIL CKD trial (ISRCTN87708989) aimed to inform the design of a randomised controlled trial (RCT) that investigates the efficacy of a progressive home-based exercise programme in pre-frail and frail older adults with CKD.

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 MEDLINE, 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. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings.

Background: Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and severe morbidity globally. When PPH cannot be controlled using standard medical treatments, uterine balloon tamponade (UBT) may be used to arrest bleeding. While UBT is used by healthcare providers in hospital settings internationally, their views and experiences have not been systematically explored. The aim of this review is to identify, appraise and synthesize available evidence about the views and experiences of healthcare providers using UBT to treat PPH. Methods: Using a pre-determined search strategy, we searched MEDLINE, CINAHL, PsycINFO, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996–2019, reporting qualitative data on the views and experiences of health professionals using UBT to treat PPH. Author findings were extracted and synthesised using techniques derived from thematic synthesis and confidence in the findings was assessed using GRADE-CERQual. Results: Out of 89 studies we identified 5 that met our inclusion criteria. The studies were conducted in five low- and middle-income countries (LMICs) in Africa and reported on the use of simple UBT devices for the treatment of PPH. A variety of cadres (including midwives, medical officers and clinical officers) had experience with using UBTs and found them to be effective, convenient, easy to assemble and relatively inexpensive. Providers also suggested regular, hands-on training was necessary to maintain skills and highlighted the importance of community engagement in successful implementation. Conclusions: Providers felt that administration of a simple UBT device offered a practical and cost-effective approach to the treatment of uncontrolled PPH, especially in contexts where uterotonics were ineffective or unavailable or where access to surgery was not possible. The findings are limited by the relatively small number of studies contributing to the review and further research in other contexts

Background Frailty is associated with adverse health outcomes in people with chronic kidney disease (CKD). Evidence supporting targeted interventions is needed. This pilot randomised controlled trial (RCT) aimed to inform the design of a definitive RCT evaluating the effectiveness of a home-based exercise intervention for pre-frail and frail older adults with CKD. Methods Participants were recruited from nephrology outpatient clinics to this two-arm parallel group mixed-methods pilot RCT. Inclusion criteria were: ≥65 years old; CKD G3b-5; and Clinical Frailty Scale score ≥4. Participants categorised as pre-frail or frail using the Frailty Phenotype were randomised to a 12-week progressive multi-component home-based exercise programme or usual care. Primary outcome measures included eligibility, recruitment, adherence, outcome measure completion and participant attrition rate. Semi-structured interviews were conducted with participants to explore trial and intervention acceptability. Results Six hundred and sixty-five patients had an eligibility assessment with 217 (33%; 95% CI 29, 36) eligible. Thirty-five (16%; 95% CI 12, 22) participants were recruited. Six were categorised as robust and withdrawn prior to randomisation. Fifteen participants were randomised to exercise and 14 to usual care. Eleven (73%; 95% CI 45, 91) participants completed ≥2 exercise sessions/week. Retained participants completed all outcome measures (n = 21; 100%; 95% CI 81, 100). Eight (28%; 95% CI 13, 47) participants were withdrawn. Fifteen participated in interviews. Decision to participate/withdraw was influenced by perceived risk of exercise worsening symptoms. Participant perceived benefits included improved fitness, balance, strength, well-being, energy levels and confidence. Conclusions This pilot RCT demonstrates that progression to definitive RCT is possible provided recruitment and retention challenges are addressed. It has also provided preliminary evidence that home-based exercise

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

Introduction Frailty is highly prevalent in adults with chronic kidney disease (CKD) and is associated with adverse health outcomes including falls, poorer health-related quality of life (HRQOL), hospitalisation and mortality. Low physical activity and muscle wasting are important contributors to physical frailty in adults with CKD. Exercise training may improve physical function and frailty status leading to associated improvements in health outcomes, including HRQOL. The EX-FRAIL CKD trial aims to inform the design of a definitive randomised controlled trial (RCT) that investigates the effectiveness of a progressive, multi-component home-based exercise programme in pre-frail and frail older adults with CKD. Methods and Analysis The EX-FRAIL CKD trial is a two-arm parallel group pilot RCT. Participants categorised as pre-frail or frail, following Frailty Phenotype assessment, will be randomised to receive exercise or usual care. Participants randomised to the intervention arm will receive a tailored 12-week exercise programme, which includes weekly telephone calls to advise on exercise progression. Primary feasibility outcome measures include rate of recruitment, intervention adherence, outcome measure completion and participant attrition. Semi-structured interviews with a purposively selected group of participants will inform the feasibility of the randomisation procedures, outcome measures and intervention. Secondary outcome measures include physical function (walking speed and Short Physical Performance Battery), frailty status (Frailty Phenotype), fall concern (Falls Efficacy Scale-International tool), activities of daily living (Barthel Index), symptom-burden (Palliative Care Outcome Scale-Symptoms RENAL) and HRQOL (Short Form-12v2). Ethics and Dissemination Ethical approval was granted by a National Health Service (NHS) Regional Ethics Committee and the NHS Health Research Authority. The study team aim to publish findings in a peer-reviewed journal and presen

Background and Aims Frailty is highly prevalent in adults with chronic kidney disease (CKD) and is associated with adverse health outcomes. However, exercise training may improve physical function leading to associated improvements in outcomes. The EX-FRAIL CKD trial (ISRCTN87708989) aimed to inform the design of a randomised controlled trial (RCT) that investigates the efficacy of a progressive home-based exercise programme in pre-frail and frail older adults with CKD. Methods Patients aged ≥65 years with CKD G3b-5 and a Clinical Frailty Scale score ≥4 were eligible for participation. Participants categorised as pre-frail or frail, following Frailty Phenotype (FP) assessment, were randomised to receive a tailored 12-week home-based exercise programme or usual care (UC). Primary outcome measures included recruitment, intervention adherence, outcome measure completion and participant attrition rate. Secondary outcome measures included frailty status (FP), physical function (walking speed, handgrip strength and Short Physical Performance Battery [SPPB]), fall concern (Falls Efficacy Scale-International tool [FESI]), symptom-burden (Palliative Care Outcome Scale-Symptoms RENAL [POS-S RENAL]) and health-related quality of life (Short Form-12v2 [SF-12]). Outcome measures are reported descriptively with 95% confidence intervals (CI) as recommended for pilot trials. Progression criteria to RCT stage were defined as: (1) eligibility: STOP <5%, GO >10%; (2) recruitment: STOP <10%, GO >30%; (3) exercise adherence: STOP: <30%, GO >70%; (4) outcome measure completion: STOP <70%, GO >80%; and (5) loss to follow-up: STOP >50%, GO <25%. Results Six hundred and sixty-five participants had an eligibility assessment with 201 (30% [95% CI 27-34]) patients eligible for enrolment. Thirty-five (17% [95% CI 12-23]) participants were recruited. Six participants were categorised as robust and therefore withdrawn prior to

Introduction Frailty is highly prevalent in adults with chronic kidney disease (CKD) and is associated with adverse health outcomes including falls, poorer health-related quality of life (HRQOL), hospitalisation and mortality. Low physical activity and muscle wasting are important contributors to physical frailty in adults with CKD. Exercise training may improve physical function and frailty status leading to associated improvements in health outcomes, including HRQOL. The EX-FRAIL CKD trial aims to inform the design of a definitive randomised controlled trial (RCT) that investigates the effectiveness of a progressive, multi-component home-based exercise programme in pre-frail and frail older adults with CKD. Methods and Analysis The EX-FRAIL CKD trial is a two-arm parallel group pilot RCT. Participants categorised as pre-frail or frail, following Frailty Phenotype assessment, will be randomised to receive exercise or usual care. Participants randomised to the intervention arm will receive a tailored 12-week exercise programme, which includes weekly telephone calls to advise on exercise progression. Primary feasibility outcome measures include rate of recruitment, intervention adherence, outcome measure completion and participant attrition. Semi-structured interviews with a purposively selected group of participants will inform the feasibility of the randomisation procedures, outcome measures and intervention. Secondary outcome measures include physical function (walking speed and Short Physical Performance Battery), frailty status (Frailty Phenotype), fall concern (Falls Efficacy Scale-International tool), activities of daily living (Barthel Index), symptom-burden (Palliative Care Outcome Scale-Symptoms RENAL) and HRQOL (Short Form-12v2). Ethics and Dissemination Ethical approval was granted by a National Health Service (NHS) Regional Ethics Committee and the NHS Health Research Authority. The study team aim to publish findings in a peer-reviewed journal and presen

Introduction: The postnatal period is an underserved aspect of maternity care. Guidelines for postnatal care are not usually informed by what matters to the women who use it. This qualitative systematic review was undertaken to identify what matters to women in the postnatal period, to inform the scope of a new World Health Organization (WHO) postnatal guideline. Methods: We searched MEDLINE, CINAHL, PsycINFO, POPLINE, Global Index Medicus, EMBASE, LILACS, AJOL, and reference lists of eligible studies published January 2000–July 2019, reporting qualitative data on women’s beliefs, expectations, and values relating to the postnatal period. Data collection and analysis: Author findings were extracted, coded and synthesised using techniques derived from thematic synthesis. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting findings was assessed using GRADE-CERQual. Results: We included 36 studies from 15 countries, representing the views of more than 800 women. Confidence in most results was moderate to high. What mattered to women was a positive postnatal experience where they were able to adapt to their new self-identity and develop a sense of confidence and competence as a mother; adjust to changes in their intimate and family relationships, including their relationship to their baby; navigate ordinary physical and emotional challenges; and experience the dynamic achievement of personal growth as they adjust to the ‘new normal’ of motherhood and parenting in their own cultural context. Conclusion: This review provides evidence that what matters to women in the postnatal period is achieving positive motherhood (including maternal self‐esteem, competence, and autonomy), as well as fulfilling adaptation to changed intimate and family relationships, and (re)gaining health and wellbeing for both their baby, and themselves. Where this process is optimal, it also results in joy, self-confidence, and an enhanced capacity to thriv

Background Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Reducing deaths from PPH is a global challenge. The voices of women and healthcare providers have been missing from the debate around best practices for PPH prevention. The aim of this review was to identify, appraise and synthesize available evidence about the views and experiences of women and healthcare providers on interventions to prevent PPH. Methods We searched eight electronic databases and reference lists of eligible studies published between 1996 and 2018, reporting qualitative data on views and experiences of PPH in general, and of any specific preventative intervention(s). Authors’ findings were extracted 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. Results Thirty-five studies from 29 countries met our inclusion criteria. Our results indicate that women and healthcare providers recognise the dangers of severe blood loss in the perinatal and postpartum period, but don’t always share the same beliefs about the causes and consequences of PPH. Skilled birth attendants and traditional birth attendants (TBA’s) want to prevent PPH but may lack the required resources and training. Women generally appreciate PPH prevention strategies, especially where their individual needs, beliefs and values are taken into account. Women and healthcare providers also recognize the value of using uterotonics (medications that contract the uterus) to prevent PPH but highlight safety concerns and potential misuse of the drugs as acceptability and implementation issues. Conclusions Based on stakeholder views and experiences, PPH prevention strategies are more likely to be successful where all stakeholders agree on the causes and consequences of severe postpartum blood loss, especially in the co

Objective To review what is known about the relationship between stillbirth and inequalities from different disciplinary perspectives to inform stillbirth prevention strategies. Design Systematic review using the meta-narrative method. Setting Studies undertaken in the UK. Data sources Scoping 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 selection Any investigation of stillbirth and inequalities with a UK component. Data extraction and synthesis Three 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. Results Fifty-four sources from nine distinctive research traditions were included. The evidence of associations between social inequalities and stillbirth spanned 70 years. Across research traditions, there was recurrent evidence of the social gradient remaining constant or increasing, fuelling repeated calls for action (meta-theme 1: something must be done). There was less evidence of an effective response to these calls. Data pertaining to socioeconomic, area and ethnic disparities were routinely collected, but not consistently recorded, monitored or reported in relation to stillbirth (meta-theme 2: problems of precision). Many studies stressed the interplay of socioeconomic status, deprivation or ethnicity with aggregated factors including heritable, structural, environmental and lifestyle factors (meta-theme 3: moving from associations towards intersectionality and intervention(s)). No intervention studies were identified. Conclusion Research investigating inequalities and stillbirth in the UK is underdeveloped. This is despite repeated evidence of an association betw

Background: WHO has recognised the need to improve its guideline methodology to ensure that guideline decision-making 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 experie

Background Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes. This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future. Objectives To identify, appraise, and synthesise qualitative studies exploring: · Women’s views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women’s accounts; · Healthcare providers’ views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers. Search methods To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase. Selection criteria We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education. Data collectio

Objective To assess whether the multitherapy antenatal education ‘CTLB’ (Complementary Therapies for Labour and Birth) Study programme leads to net cost savings. Design Cost analysis of the CTLB Study, using analysis of outcomes and hospital funding data. Methods We take a payer perspective and use Australian Refined Diagnosis-Related Group (AR-DRG) cost data to estimate the potential savings per woman to the payer (government or private insurer). We consider scenarios in which the intervention cost is either borne by the woman or by the payer. Savings are computed as the difference in total cost between the control group and the study group. Results If the cost of the intervention is not borne by the payer, the average saving to the payer was calculated to be $A808 per woman. If the payer covers the cost of the programme, this figure reduces to $A659 since the average cost of delivering the programme was $A149 per woman. All these findings are significant at the 95% confidence level. Significantly more women in the study group experienced a normal vaginal birth, and significantly fewer women in the study group experienced a caesarean section. The main cost saving resulted from the reduced rate of caesarean section in the study group. Conclusion The CTLB antenatal education programme leads to significant savings to payers that come from reduced use of hospital resources. Depending on which perspective is considered, and who is responsible for covering the cost of the programme, the net savings vary from $A659 to $A808 per woman. Compared with the average cost of birth in the control group, we conclude that the programme could lead to a reduction in birth-related healthcare costs of approximately 9%. Trial registration number ACTRN12611001126909.

Introduction 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. Methods 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. Data collection and analysis 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. Results 35 studies (19 countries) were included in the primary search, and 2 in the update. Confidence in most results was moderate to high. What mattered to most women was a positive experience that fulfilled or exceeded their prior personal and socio-cultural beliefs and expectations. This included giving birth to a healthy baby in a clinically and psychologically safe environment with practical and emotional support from birth companions, and competent, reassuring, kind clinical staff. Most wanted a physiological labour and birth, while acknowledging that birth can be unpredictable and frightening, and that they may need to ‘go with the flow’. If intervention was needed or wanted, women wanted to retain a sense of personal achievement and control through active decision-making. These values and expectations were mediated through womens’ embodied (physical and psychosocial) experience of pregnancy and birth; local familial and sociocultural norms; and encounters with local maternity services and staff. Conclusions Most healthy childbeari

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 were undertaken in Africa (Kenya, Tanzania, Sudan, South Africa), and involved a range of components. Two were cluster RCTs, and three were before/after studies. In total, over 8000 women were included at baseline and over 7500 at the endpoints. Moderate certainty evidence suggested that RMC interventions increases women's experiences of respectful care (one cRCT, approx. 3000 participants; adjusted odds ratio (aOR) 3.44, 95% CI 2.45-4.84); two observational studies also reported positive changes. Reports of good quality care increased. Experiences of disrespectful or abusive care, and, specifically, physical abuse, were reduced. Low certainty evidence indicated fewer accounts of non-dignified care, lack of privacy, verbal abuse, neglect and abandonment with RMC interventions, but no difference in satisfaction rates. Other than low certainty evidence of reduced episiotomy rates, there were no data on the pre-specified clinical outcomes. Multi-component RMC policies appear to reduce women'