Improving services for disadvantaged childbearing women

Experiences of childbirth care among immigrant and non-immigrant women: a cross-sectional questionnaire study from a hospital in Norway

BACKGROUND

Immigrant women have higher risks for poor pregnancy outcomes and unsatisfactory birth experiences than the general population. The mechanisms behind these associations remain largely unknown, but they may result from differential care provided to immigrant women or unsatisfactory interactions with health providers. This study aimed to investigate immigrant and non-immigrant women's experiences of health care during childbirth, particularly assessing two dimensions: perceived general quality of care and attainment of health care needs during childbirth.

METHODS

This was a cross-sectional study carried out over 15 months in 2020 and 2021, and data were collected from a self-completed questionnaire. The labour and birth subscale from the Experience of Maternity Care questionnaire was used to assess the primary outcome of care experiences. A total of 680 women completed the questionnaire approximately within two days after birth (mean 2.1 days) at a hospital in Trondheim, in central Norway. The questionnaire was provided in eight languages.

RESULTS

The 680 respondents were classified as immigrants (n = 153) and non-immigrants (n = 527). Most women rated their quality of care during childbirth as high (91.5%). However, one-quarter of the women (26.6%) reported unmet health care needs during childbirth. Multiparous immigrant women were more likely than multiparous non-immigrant women to report that their health care needs were unmet during childbirth (OR: 3.31, 95% CI: 1.91-5.72, p < 0.001, aOR: 2.83, 95% CI: 1.53-5.18, p = 0.001). No other significant differences between immigrant versus non-immigrant women were found in subjective ratings of childbirth care experiences. Having a Norwegian-born partner and a high level of Norwegian language skills did not influence the immigrant women's experience of childbirth care.

CONCLUSIONS

Our findings indicate that many women feel they receive high-quality health care during childbirth, but a considerable number still report not having their health care needs met. Also, multiparous immigrant women report significantly more unmet health care needs than non-immigrants. Further research is required to assess immigrant women's childbirth experiences and for health care providers to give optimal care, which may need to be tailored to a woman's cultural background and individual expectations.

Interventions to improve the mental health or mental well-being of migrants and ethnic minority groups in Europe: A scoping review

In Europe, migrants and ethnic minority groups are at greater risk for mental disorders compared to the general population. However, little is known about which interventions improve their mental health and well-being and about their underlying mechanisms that reduce existing mental health inequities. To fill this gap, the aim of this scoping review was to synthesise the available evidence on health promotion, prevention, and non-medical treatment interventions targeting migrants and ethnic minority populations. By mapping and synthesising the findings, including facilitators and barriers for intervention uptake, this scoping review provides valuable insights for developing future interventions. We used the PICo strategy and PRISMA guidelines to select peer-reviewed articles assessing studies on interventions. In total, we included 27 studies and synthesised the results based on the type of intervention, intervention mechanisms and outcomes, and barriers and facilitators to intervention uptake. We found that the selected studies implemented tailored interventions to reach these specific populations who are at risk due to structural inequities such as discrimination and racism, stigma associated with mental health, language barriers, and problems in accessing health care. The majority of interventions showed a positive effect on participants' mental health, indicating the importance of using a tailored approach. We identified three main successful mechanisms for intervention development and implementation: a sound theory-base, systematic adaption to make interventions culturally sensitive and participatory approaches. Moreover, this review indicates the need to holistically address social determinants of health through intersectoral programming to promote and improve mental health among migrants and ethnic minority populations. We identified current shortcomings and knowledge gaps within this field: rigorous intervention studies were scarce, there was a large diversity regarding migrant population groups and few studies evaluated the interventions' (cost-)effectiveness.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions.  OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness.

SEARCH METHODS

We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews.  MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.

Exploring ethnic minority women's experiences of maternity care during the SARS-CoV-2 pandemic: a qualitative study

OBJECTIVE

To explore the experiences of pregnancy, childbirth, antenatal and postnatal care in women belonging to ethnic minorities and to identify any specific challenges that these women faced during the SARS-CoV-2 pandemic.

DESIGN

This was a qualitative study using semistructured interviews of pregnant women or those who were 6 weeks postnatal from Black, Asian and minority ethnic backgrounds. The study included 16 women in a predominantly urban Scottish health board area.

RESULTS

The finding are presented in four themes: 'communication', 'interactions with healthcare professionals', 'racism' and 'the pandemic effect'. Each theme had relevant subthemes. 'Communication' encompassed respect, accent bias, language barrier and cultural dissonance; 'interactions with healthcare professionals': continuity of care, empathy, informed decision making and dissonance with other healthcare systems; 'racism' was deemed to be institutional, interpersonal or internalised; and 'the pandemic effect' consisted of isolation, psychological impact and barriers to access of care.

CONCLUSIONS

This study provides insight into the specific challenges faced by ethnic minority women in pregnancy, which intersect with the unique problems posed by the ongoing SARS-CoV-2 pandemic to potentially widen existing ethnic disparities in maternal outcomes and experiences of maternity care.

Women's vulnerability within the childbearing continuum: A scoping review

INTRODUCTION

The aim of this scoping review is to explore the concept of ‘vulnerability’ affecting pregnant women and to identify an appropriate definition of this term.

METHODS

Five stages were adopted for conducting the scoping review. A literature search was undertaken between 1 October 2017 and 5 January 2018, using three databases. Relevant publications were appraised, and semantic content analysis was performed to identify emergent themes and four determinants of the vulnerability concept. This involved combining items that seem to address the same issue.

RESULTS

Eleven publications were considered, and eight definitions of vulnerability were identified, and from these four themes emerged: poor health outcome or status; exposure to risk; complex social needs; and lack of resources. Further analysis of evidence found examples of groups of people considered to be vulnerable; they were reported into six matrices, mainly with social and psychological difficulties. From these, eleven themes arose. Following a semantic and content analysis of all themes, thirteen final themes were identified. They represent the characteristics associated with women considered to be vulnerable and are called indices of vulnerability. Semantic and content analysis allowed addressing the thirteen indices of vulnerability into four categories called determinants of the vulnerability concept: deficiency, need, risk exposure, and barriers.

CONCLUSIONS

The vulnerability could be defined as a lack of health, related to the presence of at least one of the four determinants. Midwives are the key to identify vulnerable women, offering appropriate care.

Long-term mortality in mothers of infants with neonatal abstinence syndrome: A population-based parallel-cohort study in England and Ontario, Canada

BACKGROUND

Opioid addiction is a major public health threat to healthy life expectancy; however, little is known of long-term mortality for mothers with opioid use in pregnancy. Pregnancy and delivery care are opportunities to improve access to addiction and supportive services. Treating neonatal abstinence syndrome (NAS) as a marker of opioid use during pregnancy, this study reports long-term maternal mortality among mothers with a birth affected by NAS in relation to that of mothers without a NAS-affected birth in 2 high-prevalence jurisdictions, England and Ontario, Canada.

METHODS AND FINDINGS

We conducted a population-based study using linked administrative health data to develop parallel cohorts of mother-infant dyads in England and Ontario between 2002 and 2012. The study population comprised 13,577 and 4,966 mothers of infants with NAS and 4,205,675 and 929,985 control mothers in England and Ontario, respectively. Death records captured all-cause maternal mortality after delivery through March 31, 2016, and cause-specific maternal mortality to December 31, 2014. The primary exposure was a live birth of an infant with NAS, and the main outcome was all deaths among mothers following their date of delivery. We modelled the association between NAS and all-cause maternal mortality using Cox regression, and the cumulative incidence of cause-specific mortality within a competing risks framework. All-cause mortality rates, 10-year cumulative incidence risk of death, and crude and age-adjusted hazard ratios were calculated. Estimated crude 10-year mortality based on Kaplan-Meier curves in mothers of infants with NAS was 5.1% (95% CI 4.7%-5.6%) in England and 4.6% (95% CI 3.8%-5.5%) in Ontario versus 0.4% (95% CI 0.41%-0.42%) in England and 0.4% (95% CI 0.38%-0.41%) in Ontario for controls (p < 0.001 for all comparisons). Survival curves showed no clear inflection point or period of heightened risk. The crude hazard ratio for all-cause mortality was 12.1 (95% 11.1-13.2; p < 0.001) in England and 11.4 (9.7-13.4; p < 0.001) in Ontario; age adjustment did not reduce the hazard ratios. The cumulative incidence of death was higher among NAS mothers than controls for almost all causes of death. The majority of deaths were by avoidable causes, defined as those that are preventable, amenable to care, or both. Limitations included lack of direct measures of maternal opioid use, other substance misuse, and treatments or supports received.

CONCLUSIONS

In this study, we found that approximately 1 in 20 mothers of infants with NAS died within 10 years of delivery in both England and Canada-a mortality risk 11-12 times higher than for control mothers. Risk of death was not limited to the early postpartum period targeted by most public health programs. Policy responses to the current opioid epidemic require effective strategies for long-term support to improve the health and welfare of opioid-using mothers and their children.

Influence of past trauma and health interactions on homeless women's views of perinatal care: a qualitative study

Background

Homeless women are twice as likely to become pregnant and are less likely to receive antenatal care than women who are not homeless. Prevalent biopsychosocial complexity and comorbidities, including substance use and mental illness, increase the risk of obstetric complications, postnatal depression, and child loss to social services.

Aim

To explore the perspectives of women who have experienced pregnancy and homelessness to ascertain how to improve perinatal care.

Design and setting

A qualitative study with a purposive sample of women who had experienced pregnancy and homelessness, recruited from three community settings.

Method

Semi-structured interviews continued to data saturation and were recorded, transcribed, and analysed thematically using a self-conscious approach, with independent verification of emergent themes.

Results

Eleven women, diverse in age (18–40 years) and parity (one to five children), participated. Most women had experienced childhood trauma, grief, mental illness, and substance use. Overarching themes of ‘mistrust‘ and ‘fear of child loss to social services’ (CLSS) influenced their interactions with practitioners. The women experienced stigma from practitioners, and lacked effective support networks. Women who mistrusted practitioners attended appointments but concealed their needs, preventing necessary care. Further themes were being seen to do ‘the best for the baby’; pregnancy-enabled access to necessary holistic biopsychosocial care; and lack of postnatal support for CLSS or parenting.

Conclusion

Pregnancy offered a pivotal opportunity for homeless women to engage with care for their complex needs and improve self-care, despite mistrust of practitioners. Poor postnatal support and the distress of CLSS reinforced an ongoing cycle of grief, mental health crises, substance use relapse, and homelessness.

Recency of migration, region of origin and women's experience of maternity care in England: Evidence from a large cross-sectional survey

Background

In the UK, changes to legislation in 2003 regarding the free movement of people in the European Union resulted in an increase in immigration from countries that joined the EU since 2004, the Accession countries.

Objective

To describe and compare the maternity experiences of recent migrant mothers to those who had been resident in the UK for longer, and to UK-born women, while taking into account their region of origin.

Design

Cross-sectional national survey.

Setting

England, 2009.

Participants

Random sample of postpartum women.

Measurements

Questionnaires asked about demographic characteristics, care during pregnancy, labour, birth and postnatally, about country of origin and, if not born in the UK, when they came to the UK. Country of origin was grouped into UK, Accession countries, and rest of the world. Recency of migration was grouped into recent arrivals (0–3 years), and earlier arrivals (4 or more years since arrival). Descriptive statistics and binary logistic regression were used to explore women's experiences of care. Stratified analyses were used to account for the strong correlation between recency of migration and region of origin.

Findings

Overall, 5332 women responded to the survey (a usable response rate of 54%). Seventy-nine percent of women were UK-born. Of the 21% born outside the UK, a third were born in Accession countries. All migrants reported a poorer experience of care than UK-born women. In particular, recent migrants from the Accession countries were significantly less likely to feel that they were spoken to so they could understand and treated with kindness and respect.

Conclusions

Given the rising population of non-UK-born women of childbearing age resident in the UK and the relatively high proportion from Accession countries, it is important that staff are able to communicate effectively, through interpreters if necessary.

Implications for practice

The differences in clinical practice between women's home countries and the UK should be discussed so that women's expectations of care are informed about the options available to them.

A multisite audit to assess how women with complex social factors access and engage with maternity services

OBJECTIVE

to audit women with socially complex lives' documented access to and engagement with antenatal care provided by three inner city, UK maternity services in relation to birth and neonatal outcomes, and referral processes.

BACKGROUND

women living socially complex lives, including young mothers, recently arrived immigrants, non-English speaking, and those experiencing domestic violence, poor mental health, drug and alcohol abuse, and poverty experience high rates of morbidity, mortality and poor birth outcomes. This is associated with late access to and poor engagement with antenatal care.

METHOD

data was collected from three separate NHS trusts data management systems for a total of 182 women living socially complex lives, between January and December 2015. Data was presented by individual trust and compared to standards derived from NICE guidelines, local trust policy and national statistic using Excel and SPSS Version 22. Tests of correlation were carried out to minimise risks of confounding factors in characteristic differences.

FINDINGS

non-English speaking women were much less likely to have accessed care within the recommended timeframes, with over 70% of the sample not booked for maternity care by 12 weeks gestation. On average 89% primiparous women across all samples had less than the recommended number of antenatal appointments. No sample met the audit criteria in terms of number of antenatal appointments attended. Data held on the perinatal data management systems for a number of outcomes and processes was largely incomplete and appeared unreliable.

CONCLUSION

this data forms a baseline against which to assess the impact of future service developments aimed at improving access and engagement with services for women living with complex social factors. The audit identified issues with the completeness and reliability of data on the perinatal data management system.

Deprivation and poor psychosocial support are key determinants of late antenatal presentation and poor fetal outcomes--a combined retrospective and prospective study

BACKGROUND

Published guidelines emphasise the need for early antenatal care to promote maternal and neonatal health. Inadequate engagement with antenatal care is associated with adverse pregnancy outcomes including maternal death. The factors that influence the uptake and utilisation of maternity care services are poorly understood. We retrospectively explore a large maternity database of births in a large referral UK hospital to capture the socio-demographic factors that influence late pregnancy booking, and then prospectively compare the stress and social support status of consenting early and late-booking women.

METHODS

Retrospective socio-demographic and clinical outcome data on 59,487 women were collected from the maternity database record of births between 2002 and 2010 at the Jessop Wing Hospital, Sheffield UK. In a follow-on prospective survey between October 2012 and May 2013 a convenience cohort of early and late bookers for antenatal care were then studied using validated scales for fetomaternal attachment, stress and anxiety, and social support.

RESULTS

In our retrospective study, pregnancy during the teenage years, higher parity, non-white ethnic background, unemployment and smoking were significantly associated with late access to antenatal services and poor fetal outcomes (P < 0.001). However, late booking per se did not predict adverse fetal outcomes, when socio-demographic factors were accounted for. A high index of multiple deprivation (IMD) score remained independently associated with late booking when confounding factors such as ethnicity and employment status were controlled for in the model (P = 0.03). Our prospective data demonstrated that women who book late were more likely to be unmarried (OR: 3.571, 95 % CI: 1.464-8.196, p =  .005), of high parity (OR: 1.759, 95 % CI: 1.154-2.684, P = 0.009), and have lower social support than early bookers (P = 0.047).

CONCLUSIONS

Of the many complex sociocultural factors that influence the timing of maternal engagement with antenatal care, multiple deprivation and poor social support remain key factors. Improving access to prenatal care requires in-depth exploration of the relationship between maternal psychosocial health indices, social support mechanisms and engagement with antenatal care. Findings from these studies should inform interventions aimed at improving access to care.

Immigrant women's experiences of maternity-care services in Canada: a systematic review using a narrative synthesis

BACKGROUND

Canada's diverse society and its statutory commitment to multiculturalism means that a synthesis of knowledge related to the healthcare experiences of immigrants is essential to realise the health potential for future Canadians. Although concerns about the maternity experiences of immigrants in Canada are relatively new, recent national guidelines explicitly call for the tailoring of services to user needs. We therefore assessed the experiences of immigrant women accessing maternity-care services in Canada. In particular, we investigated the experiences of immigrant women in Canada in accessing and navigating maternity and related healthcare services from conception to 6 months postpartum in Canada. Our focus was on (a) the accessibility and acceptability of maternity-care services for immigrant women and (b) the effects of the perceptions and experiences of these women on their birth and postnatal outcomes.

METHODS

We conducted a systematic review using a systematic search and narrative synthesis of peer-reviewed and non-peer-reviewed reports of empirical research, with the aim of providing stakeholders with perspectives on maternity-care services as experienced by immigrant women. We partnered with key stakeholders ('integrated knowledge users') to ensure the relevancy of topics and to tailor recommendations for effective translation into future policy, practice and programming. Two search phases and a three-stage selection process for published and grey literature were conducted prior to appraisal of literature quality and narrative synthesis of the findings.

RESULTS

Our knowledge synthesis of maternity care among immigrants to Canada provided a coherent evidence base for (a) eliciting a better understanding of the factors that generate disparities in accessibility, acceptability and outcomes during maternity care; and (b) improving culturally based competency in maternity care. Our synthesis also identified pertinent issues in multiple sectors that should be addressed to configure maternity services and programs appropriately.

CONCLUSIONS

Although immigrant women in Canada are generally given the opportunity to obtain necessary services, they face many barriers in accessing and utilising these services. These barriers include lack of information about or awareness of the services, insufficient supports to access these services and discordant expectations between the women and their service providers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42012002185 .

Maternal deaths among rural-urban migrants in China: a case-control study

BACKGROUND

Disparity in maternal mortality exists between rural-urban migrant and urban resident women in China, but little research has provided evidence for related policy development. The objective of this study was to identify associations with and risks for maternal death among rural-urban migrant women in order to improve health services for migrant women and reduce maternal mortality in China.

METHODS

We conducted a prospective case-control study in urban areas of Guangdong, Zhejiang and Fujian provinces and Beijing municipality. In each, migrant women who died between July 1, 2010 and October 1, 2011 were identified through reports from China's Maternal and Child Mortality Surveillance System. For each, four matched controls were selected from migrant women who delivered in local hospitals during the same period. We compared socio-demographic characteristics, health status and health service variables between cases and controls, and used bivariate and multivariate conditional logistic regression analyses to determine associations with and risk factors for maternal death.

RESULTS

109 cases and 436 controls were assessed. Family income <2000 yuan per month (OR = 4.5; 95% CI 1.7-11.7) and lack of health insurance (OR = 1.3; 95% CI 1.1-1.6) were more common amongst women who died, as were lack of antenatal care (ANC) (OR = 22.3; 95% CI 4.3-116.0) and attending ANC only 1-4 times (OR = 5.0; 95% CI 1.6-15.5). Knowledge of danger signs during delivery was less common in this group (OR = 0.3; 95% CI 0.1-0.8).

CONCLUSION

Differences existed between migrant women who died in pregnancy and surviving controls. The identified risk factors suggest strategies for health sector and community action on reducing maternal mortality among migrant women in China. A systematic approach to maternity care for rural-urban migrant women is recommended.

Experiencing maternity care: the care received and perceptions of women from different ethnic groups

BACKGROUND

According to the Office for National Statistics, approximately a quarter of women giving birth in England and Wales are from minority ethnic groups. Previous work has indicated that these women have poorer pregnancy outcomes than White women and poorer experience of maternity care, sometimes encountering stereotyping and racism. The aims of this study were to examine service use and perceptions of care in ethnic minority women from different groups compared to White women.

METHODS

Secondary analysis of data from a survey of women in 2010 was undertaken. The questionnaire asked about women's experience of care during pregnancy, labour and birth, and the postnatal period, as well as demographic factors. Ethnicity was grouped into eight categories: White, Mixed, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African, and Other ethnicity.

RESULTS

A total of 24,319 women completed the survey. Compared to White women, women from minority ethnic groups were more likely to be younger, multiparous and without a partner. They tended to access antenatal care later in pregnancy, have fewer antenatal checks, fewer ultrasound scans and less screening. They were less likely to receive pain relief in labour and, Black African women in particular, were more likely to deliver by emergency caesarean section. Postnatally, women from minority ethnic groups had longer lengths of hospital stay and were more likely to breastfeed but they had fewer home visits from midwives. Throughout their maternity care, women from minority ethnic groups were less likely to feel spoken to so they could understand, to be treated with kindness, to be sufficiently involved in decisions and to have confidence and trust in the staff.

CONCLUSION

Women in all minority ethnic groups had a poorer experience of maternity services than White women. That this was still the case following publication of a number of national policy documents and local initiatives is a cause for concern.

Migration and maternity: insights of context, health policy, and research evidence on experiences and outcomes from a three country preliminary study across Germany, Canada, and the United kingdom

A group from Germany, Canada, and the United Kingdom undertook country-specific scoping reviews and stakeholder consultations before joining to holistically compare migration and maternity in all three countries. We examined four interlinking dimensions to understand how international migrant/minority maternal health might be improved upon using transnational research: (a) wider sociopolitical context, (b) health policy arena, (c) constellation, outcomes, and experiences of maternity services, and (d) existing research contexts. There was clear evidence that the constellation and delivery of services may undermine good experiences and outcomes. Interventions to improve access and quality of care remain small scale, short term, and lacking in rigorous evaluation.

Caseload midwifery in a multi-ethnic community: the women's experiences

OBJECTIVE

to evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area.

DESIGN AND SETTING

semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery.

FINDINGS

key themes from previous work fitted well with the themes that emerged from this study. Themes included 'knowing and being known', 'person-centred care', 'social support', 'gaining trust and confidence', 'quality and sensitivity of care' and 'communication'.

KEY CONCLUSIONS AND IMPLICATIONS

women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety.

Immigrant women's experiences of maternity-care services in Canada: a protocol for systematic review using a narrative synthesis

BACKGROUND

Canada's diverse society and statutory commitment to multiculturalism means that the synthesis of knowledge related to the health care experiences of immigrants is essential to realize the health potential for future Canadians. Although concerns about the maternity experiences of immigrants in Canada are relatively new, recent national guidelines explicitly call for tailoring of services to user needs. We are therefore assessing the experiences of immigrant women in Canada accessing maternity-care services. We are focusing on: 1) accessibility and acceptability (as an important dimension of access) to maternity-care services as perceived and experienced by immigrant women, and 2) the birth and postnatal outcomes of these women.

METHODS

The aim of this study is to use a narrative synthesis, incorporating both a systematic review using narrative synthesis of reports of empirical research (qualitative, quantitative, and mixed-method designs), and a literature review of non-empirically based reports, both of which include 'grey' literature. The study aims to provide stakeholders with perspectives on maternity-care services as experienced by immigrant women. To achieve this, we are using integrated knowledge translation, partnering with key stakeholders to ensure topic relevancy and to tailor recommendations for effective translation into future policy and practice/programming. Two search phases and a three-stage selection process are being conducted (database search retrieved 1487 hits excluding duplicates) to provide evidence to contribute jointly to both the narrative synthesis and the non-empirical literature review. The narrative synthesis will be informed by the previous framework published in 2006 by Popay et al., using identified tools for each of its four elements. The non-empirical literature review will build upon the narrative-synthesis findings and/or identify omissions or gaps in the empirical research literature. The integrated knowledge translation plan will ensure that key messages are delivered in an audience-specific manner to optimize their effect on policy and practice change throughout the health service, and the public health, immigration and community sectors.

DISCUSSION

Narrative-synthesis methods of systematic review facilitate understanding and acknowledgement of the broader influences of theoretical and contextual variables, such as race, gender, socioeconomic status, and geographical location. They also enable understanding of the shaping of differences between reported outcomes and study designs related to childbearing populations, and the development and implementation of maternity services and health interventions across diverse settings.

PROSPERO REGISTRATION

Number 2185.

Evaluation of Lay Support in Pregnant women with Social risk (ELSIPS): a randomised controlled trial

BACKGROUND

Maternal, neonatal and child health outcomes are worse in families from black and ethnic minority groups and disadvantaged backgrounds. There is little evidence on whether lay support improves maternal and infant outcomes among women with complex social needs within a disadvantaged multi-ethnic population in the United Kingdom (UK).

METHOD/DESIGN

The aim of this study is to evaluate a lay Pregnancy Outreach Worker (POW) service for nulliparous women identified as having social risk within a maternity service that is systematically assessing social risks alongside the usual obstetric and medical risks. The study design is a randomised controlled trial (RCT) in nulliparous women assessed as having social risk comparing standard maternity care with the addition of referral to the POW support service. The POWs work alongside community midwifery teams and offer individualised support to women to encourage engagement with services (health and social care) from randomisation (before 28 weeks gestation) until 6 weeks after birth. The primary outcomes have been chosen on the basis that they are linked to maternal and infant health. The two primary outcomes are engagement with antenatal care, assessed by the number of antenatal visits; and maternal depression, assessed using the Edinburgh Postnatal Depression Scale at 8-12 weeks after birth. Secondary outcomes include maternal and neonatal morbidity and mortality, routine child health assessments, including immunisation uptake and breastfeeding at 6 weeks. Other psychological outcomes (self efficacy) and mother-to-infant bonding will also be collected using validated tools.A sample size of 1316 will provide 90% power (at the 5% significance level) to detect increased engagement with antenatal services of 1.5 visits and a reduction of 1.5 in the average EPDS score for women with two or more social risk factors, with power in excess of this for women with any social risk factor. Analysis will be by intention to treat. Qualitative research will explore the POWs' daily work in context. This will complement the findings of the RCT through a triangulation of quantitative and qualitative data on the process of the intervention, and identify other contextual factors that affect the implementation of the intervention.

DISCUSSION

The trial will provide high quality evidence as to whether or not lay support (POW) offered to women identified with social risk factors improves engagement with maternity services and reduces numbers of women with depression. MREC NUMBER: 10/H1207/23

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN35027323.

The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review

BACKGROUND

Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated.

METHODS

We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS)) RESULTS: We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered 'promising'.

CONCLUSIONS

There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity has now achieved international political importance with endorsement from the World Health Assembly in 2009.  The failure of systematic reviews to consider effects on health equity is cited by decision-makers as a limitation to their ability to inform policy and program decisions. 

OBJECTIVES

To systematically review methods to assess effects on health equity in systematic reviews of effectiveness.

SEARCH STRATEGY

We searched the following databases up to July 2 2010: MEDLINE, PsychINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Index to Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on October 7 2010.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities.

DATA COLLECTION AND ANALYSIS

Data were extracted using a pre-tested form by two independent reviewers. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews. 

MAIN RESULTS

Thirty-four methodological studies were included.  The methods used by these included studies were: 1) Targeted approaches (n=22); 2) gap approaches (n=12) and gradient approach (n=1).  Gender or sex was assessed in eight out of 34 studies, socioeconomic status in ten studies, race/ethnicity in seven studies, age in seven studies, low and middle income countries in 14 studies, and two studies assessed multiple factors across health inequity may exist.Only three studies provided a definition of health equity. Four methodological approaches to assessing effects on health equity were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (all 34 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (12/34 studies); 3) analytic approaches (10/34 studies); and 4) applicability assessment (11/34 studies). Both analytic and applicability approaches were not reported transparently nor in sufficient detail to judge their credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to assess and report effects on health equity in systematic reviews.

Reliability of self reported smoking status by pregnant women for estimating smoking prevalence: a retrospective, cross sectional study

OBJECTIVE

To determine what impact reliance on self reported smoking status during pregnancy has on both the accuracy of smoking prevalence figures and access to smoking cessation services for pregnant women in Scotland.

DESIGN

Retrospective, cross sectional study of cotinine measurements in stored blood samples.

PARTICIPANTS

Random sample (n=3475) of the 21 029 pregnant women in the West of Scotland who opted for second trimester prenatal screening over a one year period.

MAIN OUTCOME MEASURE

Smoking status validated with cotinine measurement by maternal area deprivation category (Scottish Index of Multiple Deprivation).

RESULTS

Reliance on self reported smoking status underestimated true smoking by 25% (1046/3475 (30%) from cotinine measurement v 839/3475 (24%) from self reporting, z score 8.27, P<0.001). Projected figures suggest that in Scotland more than 2400 pregnant smokers go undetected each year. A greater proportion of smokers in the least deprived areas (deprivation categories 1+2) did not report their smoking (39%) compared with women in the most deprived areas (22% in deprivation categories 4+5), but, because smoking was far more common in the most deprived areas (706 (40%) in deprived areas compared with 142 (14%) in affluent areas), projected figures for Scotland suggest that twice as many women in the most deprived areas are undetected (n=1196) than in the least deprived areas (n=642).

CONCLUSION

Reliance on self reporting to identify pregnant smokers significantly underestimates the number of pregnant smokers in Scotland and results in a failure to detect over 2400 smokers each year who are therefore not offered smoking cessation services.

Acknowledging a persistent truth: domestic violence in pregnancy

Violence against women has a devastating effect on women's sexual and reproductive health, and also affects the health of their children. Such behaviour is rooted in gender inequality, which is sadly persistent, arguably throughout all societies. This phenomenon is a serious health and development concern, in addition to a violation of a woman's human rights. Violence can begin or escalate in pregnancy and has significant consequences for the woman, fetus and child. Questioning pregnant women about the presence of violence and offering referral to a secondary agency can help to break the pattern of abuse.

Applying the Gelberg-Andersen behavioral model for vulnerable populations to health services utilization in homeless women

We applied the Gelberg-Andersen Behavioral Model for Vulnerable Populations to predict health services utilization (HSU) in 875 homeless US women. Structural models assessed the impact of predisposing (demographics, psychological distress, alcohol/drug problems, homelessness severity), enabling (health insurance, source of care, barriers) and need (illness) variables on HSU (preventive care, outpatient visits, hospitalizations). Homelessness severity predicted illness, barriers and less insurance. Distress predicted more barriers, illness and less outpatient HSU. Drug problems predicted hospitalizations. Barriers predicted more illness and less outpatient HSU. Health and homelessness indicators were worse for White women. Better housing, access to care and insurance would encourage appropriate HSU.