AUTHORS Authors Ms Bielka Carvajal. Division of Nursing, Midwifery & Social Work, The University of Manchester. Departamento de Promoción de la Salud de la Mujer, Universidad de Chile. Dr Helen White. Division of Nursing, Midwifery & Social Work, The University of Manchester. Dr Jane Brooks. Division of Nursing, Midwifery & Social Work, The University of Manchester. Prof Ann Thomson. Division of Nursing, Midwifery & Social Work, The University of Manchester. Dr Alison Cooke. Division of Nursing, Midwifery & Social Work, The University of Manchester. BACKGROUND The cessation of a pregnancy before the foetus is ready to survive outside the womb can occur due to several causes, including an abnormal embryo, a woman's medical condition or her choice (1,2). Although the result in these three scenarios is the same, there has been a need from the general population and medical staff to differentiate the 'spontaneous' loss from the deliberate act to terminate a pregnancy. Therefore, terms such as spontaneous abortion, medical abortion, medical termination, induced abortion, miscarriage, pregnancy loss, pregnancy termination and others have been used, often inconsistently, to describe these differences (3). While some of these terms could help to diminish women's sorrow after the loss (4), some others are considered to increase discrimination and fear of punishment, especially in contexts where induced abortions are against the law (5). In particular, this review will refer to the active process of ending a gestation before foetal extrauterine viability (6–8) as the termination of pregnancy (TOP). As in any other healthcare policy, the implementation of pregnancy termination services involves law enactment, developing new staff skills, creating new guidelines and protocols, and acquiring equipment (9). Additionally to these, this process is also profoundly affected by what individuals believe to be right and wrong (10,11), which in the case of TOP is grounded in people's beliefs about human life and women's rights (12). Healthcare providers are an essential factor when implementing any policy; moreover, they are considered de facto policymakers because their actions and attitudes shape policies (13). For example, healthcare professionals could decide to be less compliant with clinical guidelines if they perceive them as a threat to their clinical autonomy (14) or too complicated (15). This autonomy or discretion can also be used against procedures or regulations that providers consider to be immoral, thus affecting the availability of certain services. Healthcare providers are usually allowed to abstain from participation in activities against their moral or religion, known as conscientious objection (16). This permission is generally given in TOP cases, where the abstention could differentiate between causes and include different professionals who are allowed to object (17). Moreover, these differences about what is considered immoral could extend to emergency contraception, which some argue affects the implantation process (18–20). Regarding conscientious objection, balancing the provider's right to object with women's right to choose can be challenging and affect patient referrals, especially in places where the objection rate is high (21–23). Furthermore, the referral process itself must be planned meticulously, or non-objectors could face a heavier workload than those who object (23). Beyond the impact of conscientious objection, providers could set other potential barriers when sexual and reproductive policies are being implemented, affecting access and healthcare provision (12,24–30). Therefore, this review aims to explore the facilitators and barriers affecting healthcare providers when implementing pregnancy termination (including emergency contraception) policies. INTEGRATIVE REVIEW Successful implementation of healthcare policies can be a complex issue; thus, it is best studied using a broad range of research (31–33). Considering the growing volume of evidence in all subjects, reviews stand as a strategy that allows the synthesis of a large portion of evidence while making recommendations or providing an overview of the studied topic. It is possible to identify several types of review that respond to different aims (34,35). Considering this review aims to explore the TOP policy implementation process, an integrative review can be particularly useful as they include findings from quantitative, qualitative and unpublished literature to provide an insight into the studied topic (36–38). In Cronin and George’s (38) words, integrative reviews integrate communities of practice 'who study similar topics using different paradigms, conceptual language, and research traditions, even in their metatheoretical analyses' (p.2). Accomplishing the integration of different evidence types is not exempt from challenges, especially when trying to ensure rigour in the process (38,39). Thus, Whittemore and Knafl (2005) defined five stages that this integrative review will follow to ensure it is being developed correctly and systematically. METHODS AND ANALYSIS Problem Identification As stated in the introduction of this review, healthcare personnel actions and attitudes can affect medical care provision, affecting the implementation of policies and/or guidelines. Therefore, this review aims to explore facilitators and barriers to healthcare personnel's participation in the implementation of pregnancy termination (including emergency contraception) policies. Hence, the research question of this integrative review will be: 'What are providers' experiences and attitudes in implementing emergency contraception and pregnancy termination policies?' Secondary questions for this review will address two different implementation aspects: i) how patient referral is addressed in conscientious objection cases? and ii) how the healthcare team manages conscientious objection? Additionally, in the cases where conscientious objection is not part of these policies, it is expected to explore i) what are the perceptions of this situation among the healthcare team? ii) how do healthcare personnel who consider themselves objectors deal with the situation? iii) how does the healthcare team balance 'protection' of the objector's position while providing care? Literature Search A good literature search strategy in a review should ensure that all relevant studies/documents are retrieved. Furthermore, when the search fails to do so, the chances of bias increase and the results become less trustworthy (40). In this review, the eligibility criteria to select the literature will be the following: Inclusion Criteria Participants For studies to be eligible in this review, they must include healthcare providers as research participants. The concept 'healthcare providers' will be understood as the personnel directly involved in the prescription or provision of emergency contraception or those who perform pregnancy terminations or provide medical care before, during or after this procedure. Type of studies This review will include quantitative, qualitative and mixed-method primary research focused on exploring healthcare providers' experiences. Therefore, the three types of studies will be eligible for inclusion providing that they are focused on providers' experiences while implementing emergency contraception and pregnancy termination policies. No literature will be excluded based on the study's subtype (quasi-experimental, non-experimental, and others), methodology (phenomenology, grounded theory and others), gender or ethnicity of the participants, the country of origin of the publication, or when the article was published. Unpublished articles will also be eligible in this review (such as congress abstracts). In these cases, attempts will be made to contact the authors to retrieve more information about the study. Policy reports aimed to describe TOP or emergency contraception policies will also be included in this review. Phenomenon of Interest The phenomenon of interest in this review is the implementation of pregnancy termination policies. Although emergency contraception is not abortive, some providers recognise it as an action against 'human' life; hence, it will be studied as part of the pregnancy termination phenomenon. Exclusion Criteria A flow diagram using the recommendations made by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) will be created describing the reasons for excluding articles in this review (41). The exclusion criteria for this review will be: i) Studies not focused on providers' experiences when implementing policies or where their experiences/attitudes could not be isolated from the article ii) Studies where providers were not included as participants iii) Articles focused on miscarriages, ectopic pregnancy, pregnancy loss or any other unprovoked pregnancy termination iv) Personal opinions, such as commentaries and editorials v) Articles where the full text version cannot be accessed by the research team (attempts will be made to obtain these from the authors) vi) Articles where the full text is in a language different from English or Spanish Search Strategy This review will use a three-step search strategy to maximise the retrieval of literature. The first step will be focused on searching electronic databases using PICO (Population, Intervention, Comparator, Outcome) (42) and SPIDER (Sample, Phenomenon of Interest, Design, Evaluation and Research type) (43) strategies. Considering that PICO is more focused towards quantitative literature and SPIDER is more specific to qualitative studies, it is expected that by using both most of the existing literature in both paradigms is retrieved (43,44). The second step will be a hand search of the references mentioned in international reports related to the topic and a hand search using the reference lists of all selected articles. Finally, the third step will be to contact authors who are prolific in the topic area to identify any unpublished 'grey' literature. Electronic Searches The search of the literature will be conducted in the following medical and social science databases: The Cumulative Index of Nursing and Allied Health Literature (CINAHL) Plus, the British Nursing Index, Medical Literature Analysis and Retrieval System Online (Medline), the Psychological Information Database (PsycINFO), the Applied Social Sciences Index Abstracts (ASSIA), the Social Science database. Furthermore, to ensure retrieving literature from low and middle-income Spanish speaking countries the search will also be conducted in the Scientific Electronic Library Online (SciELO), and the Latin American and Caribbean Health Sciences Literature (LILACS). These databases include literature related to healthcare from Latin American countries and hold the largest volume of literature available in the subject area. The searches will use the keywords described in Appendix 1. The research team will agree on the final search strategy to ensure that the process is rigorous. The final search strategy will be published in detail, along with the results of the review. Other searches The hand search of relevant literature will be conducted using the list of references of international and congress reports related to the studied subject made by the United Nations Fund for Population Activities (UNFPA), the Guttmacher Institute, the American College of Obstetricians and Gynecologists (ACOG), the International Confederation of Midwives (ICM), the International Council of Nurses (ICN), the International Federation of Gynaecology and Obstetrics (FIGO), the International Pharmaceutical Federation (FIP) and the World Health Organization (WHO). The reference lists from selected articles will also be screened to identify any study not retrieved in the electronic searches. A list of authors will be created, and prolific authors in the topic area will be approached to enquire about any unpublished evidence related to the topic. DATA EVALUATION Selection of Studies The selection of eligible studies will be conducted in two consecutive steps: i) reviewing titles and abstracts retrieved, and ii) reviewing the full-text version of the articles considered eligible using the inclusion and exclusion criteria. For this, a screening tool developed by the research team following the recommendations of Polanin et al. (45) will be used (see Appendix 2). This tool will be piloted and adapted (if necessary) using 20 articles retrieved in the search to ensure questions are appropriate (45). For this, the first author (BC) will screen articles using the tool to determine if they should be included in the study. After completing this process, the same articles will be read in full, and a decision for its inclusion will be made accordingly. After both processes are completed, the decisions made using both techniques will be contrasted. The whole process will be monitored and reviewed by two other authors in the research team (HW/AC). In the cases where a discrepancy is found, the research team will analyse which aspects of the articles lead to the disagreement and the tool will be edited to ensure this situation is resolved. If the screening tool requires amendment, the revised tool will be piloted using another 3 articles from the search. All references will be managed using EndNote©. Once the electronic search is complete duplicate articles will be removed using this software. After this process, the first author will review all titles and abstracts of articles resulting from the searches using the inclusion and exclusion criteria. This process will be monitored and reviewed by two other authors in the research team (HW/AC). When the article's exclusion raises concerns, the paper will be considered by the research team to reach a consensus on inclusion or exclusion. The full-text version of all articles considered eligible will be downloaded, and the first author (BC) will conduct an assessment for their inclusion. Two other members of the research team (HW/AC) will monitor and review these articles to ensure rigour. When a full-text version cannot be secured, the publication's authors will be contacted to obtain it. Those articles where the full-text version cannot be obtained from the authors will be excluded from the review. Once article selection is complete, their reference list will be screened to ensure all relevant literature is included. The same process will be conducted with reference lists from international reports. The whole research team will approve the final body of literature for review. Data Extraction and Quality Assessment The tool that will be used in this review for the data extraction process (see Appendix 3) is an adaptation of the data collection form for intervention reviews for randomised controlled trials (RCT) and non-RCTs published by the Cochrane Collaboration (46,47). The form will be piloted and adapted (if necessary) using the first 20 articles retrieved in the search to ensure it is appropriate, using the same rigorous process and members of the research team outlined in the ‘Selection of Studies’ section. If a situation raises concern during the data extraction process, the research team will discuss and resolve it. Irrespective of the results of their quality assessment, all studies will undergo data extraction. A quality appraisal will be conducted for each selected article using the Mixed Method Appraisal Tool (MMAT) version 2018 (48). This tool allows assessment of the quality of primary research using qualitative, quantitative (randomised controlled trials, non-randomised and descriptive studies) or mixed-method methodology (Appendix 4). To incorporate the quality appraisal of policy reports and guidelines the research team included a modification in the MMAT tool (see Appendix 4), with consideration to the policy process cycle (49). Part six of this tool includes the dimensions for assessing a report as 'good', which are: a clear aim, have used appropriate evidence to its formulation, addressing cultural differences in the implementation process, including information about the evaluation process of the policy and a conflict of interest statement. The appraisal tool will be piloted using the first 20 policy documents retrieved in the search, using a rigorous process with three members of the research team as outlined in the ‘Selection of Studies’ section. This pilot test will aim to determine if it is possible to answer the questions using the data in the reports, otherwise the questions will be reformulated to obtain information about the dimensions proposed in this tool. A growing number of authors have started to discourage calculating overall quality scores for appraised articles (50–53). Their main arguments for doing so are focused on the insufficient information provided by a 'score number' and the problems of assigning weight (importance) to the criteria used to evaluate quality. Therefore, and following MMAT suggestions (48), no article will be scored nor excluded from this synthesis. The quality appraisal findings will be incorporated in the results section of this review emphasising which dimensions were most likely to be accomplished and missed. DATA ANALYSIS, CONCLUSION DRAWING AND VERIFICATION To be rigorous when managing data extracted from very different types of studies, the data will be analysed following Whittemore and Knafl’s (2005) recommendation for integrative reviews. This process includes data reduction, data display and data comparison (38). For this, each study will be read to extract the results. Results will later be compared within and against the rest of the studies to address differences and similarities. Data will be grouped and described into types of designs and relevant categories related to the studied topic. In each group, literature will be read and re-read to identify common themes and patterns which will later be used to create a conceptual model (54). Once the conceptual model is created, it will be verified against the primary data sources to ensure confirmability (55). Conflicting evidence that cannot be included in the model will be reported as part of the narrative synthesis. 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