1
|
Shankar M, Hazfiarini A, Zahroh RI, Vogel JP, McDougall ARA, Condron P, Goudar SS, Pujar YV, Somannavar MS, Charantimath U, Ammerdorffer A, Rushwan S, Gülmezoglu AM, Bohren MA. Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review. PLoS Med 2024; 21:e1004405. [PMID: 38814991 PMCID: PMC11139290 DOI: 10.1371/journal.pmed.1004405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/19/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Poor representation of pregnant and lactating women and people in clinical trials has marginalised their health concerns and denied the maternal-fetal/infant dyad benefits of innovation in therapeutic research and development. This mixed-methods systematic review synthesised factors affecting the participation of pregnant and lactating women in clinical trials, across all levels of the research ecosystem. METHODS AND FINDINGS We searched 8 databases from inception to 14 February 2024 to identify qualitative, quantitative, and mixed-methods studies that described factors affecting participation of pregnant and lactating women in vaccine and therapeutic clinical trials in any setting. We used thematic synthesis to analyse the qualitative literature and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. We compared quantitative data against the thematic synthesis findings to assess areas of convergence or divergence. We mapped review findings to the Theoretical Domains Framework (TDF) and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to inform future development of behaviour change strategies. We included 60 papers from 27 countries. We grouped 24 review findings under 5 overarching themes: (a) interplay between perceived risks and benefits of participation in women's decision-making; (b) engagement between women and the medical and research ecosystems; (c) gender norms and decision-making autonomy; (d) factors affecting clinical trial recruitment; and (e) upstream factors in the research ecosystem. Women's willingness to participate in trials was affected by: perceived risk of the health condition weighed against an intervention's risks and benefits, therapeutic optimism, intervention acceptability, expectations of receiving higher quality care in a trial, altruistic motivations, intimate relationship dynamics, and power and trust in medicine and research. Health workers supported women's participation in trials when they perceived clinical equipoise, had hope for novel therapeutic applications, and were convinced an intervention was safe. For research staff, developing reciprocal relationships with health workers, having access to resources for trial implementation, ensuring the trial was visible to potential participants and health workers, implementing a woman-centred approach when communicating with potential participants, and emotional orientations towards the trial were factors perceived to affect recruitment. For study investigators and ethics committees, the complexities and subjectivities in risk assessments and trial design, and limited funding of such trials contributed to their reluctance in leading and approving such trials. All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people. CONCLUSIONS This systematic review highlights diverse factors across multiple levels and stakeholders affecting the participation of pregnant and lactating women in clinical trials. By linking identified factors to frameworks of behaviour change, we have developed theoretically informed strategies that can help optimise pregnant and lactating women's engagement, participation, and trust in such trials.
Collapse
Affiliation(s)
- Mridula Shankar
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Alya Hazfiarini
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Rana Islamiah Zahroh
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Annie R. A. McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Patrick Condron
- University Library, University of Melbourne, Carlton, Victoria, Australia
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Yeshita V. Pujar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Manjunath S. Somannavar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Umesh Charantimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Sara Rushwan
- Concept Foundation, Geneva, Switzerland/Bangkok, Thailand
| | | | - Meghan A. Bohren
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| |
Collapse
|
2
|
van der Weijden BM, van der Weide MC, Plötz FB, Achten NB. Evaluating safety and effectiveness of the early-onset sepsis calculator to reduce antibiotic exposure in Dutch at-risk newborns: a protocol for a cluster randomised controlled trial. BMJ Open 2023; 13:e069253. [PMID: 36787971 PMCID: PMC9930557 DOI: 10.1136/bmjopen-2022-069253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Newborns are at risk for early-onset sepsis (EOS). In the Netherlands, EOS affects less than 0.2% of newborns, but approximately 5% are treated with empirical antibiotics. These numbers form an example of overtreatment in countries using risk-factor based guidelines for administrating antibiotics. An alternative to these guidelines is the EOS calculator, a tool that calculates an individual EOS risk and provides management recommendation. However, validation outside the North-American setting is limited, especially for safety outcomes. We aim to investigate whether EOS calculator use can safely reduce antibiotic exposure in newborns with suspected EOS compared with the Dutch guideline. METHODS AND ANALYSIS This protocol describes a cluster randomised controlled trial assessing whether EOS calculator use is non-inferior regarding safety, and superior regarding limiting overtreatment, compared with the Dutch guideline. We will include newborns born at ≥34 weeks' gestation, with at least one risk factor consistent with EOS within 24 hours after birth. After 1:1 randomisation, the 10 participating Dutch hospitals will use either the Dutch guideline or the EOS calculator as standard of care for all newborns at risk for EOS. In total, 1830 newborns will be recruited. The coprimary non-inferiority outcome will be the presence of at least one of four predefined safety criteria. The coprimary superiority outcome will be the proportion of participants starting antibiotic therapy for suspected and, or proven EOS within 24 hours after birth. Secondary outcomes will be the total duration of antibiotic therapy, the percentage of antibiotic therapy started between 24 and 72 hours after birth, and parent-reported quality of life. Analyses will be performed both as intention to treat and per protocol. ETHICS AND DISSEMINATION This trial has been approved by the Medical Ethics Committee of the Amsterdam UMC (NL78203.018.21). Results will be presented in peer-reviewed journals and at international conferences. TRIAL REGISTRATION NUMBER NCT05274776.
Collapse
Affiliation(s)
- Bo M van der Weijden
- Department of Paediatrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Paediatrics, Tergooi MC, Blaricum, The Netherlands
| | - Marijke C van der Weide
- Department of Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, The Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Paediatrics, Tergooi MC, Blaricum, The Netherlands
| | - Niek B Achten
- Sophia Children's Hospital, Department of Paediatrics, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
3
|
Ayebare E, Hanson C, Nankunda J, Hjelmstedt A, Nantanda R, Jonas W, Tumwine JK, Ndeezi G. Factors associated with birth asphyxia among term singleton births at two referral hospitals in Northern Uganda: a cross sectional study. BMC Pregnancy Childbirth 2022; 22:767. [PMID: 36224532 PMCID: PMC9559004 DOI: 10.1186/s12884-022-05095-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/04/2022] [Indexed: 11/28/2022] Open
Abstract
Background Birth asphyxia is one of the leading causes of neonatal mortality worldwide. In Uganda, it accounts for 28.9% of all neonatal deaths. With a view to inform policy and practice interventions to reduce adverse neonatal outcomes, we aimed to determine the prevalence and factors associated with birth asphyxia at two referral hospitals in Northern Uganda. Methods This was a cross-sectional study, involving women who gave birth at two referral hospitals. Women in labour were consecutively enrolled by the research assistants, who also attended the births and determined Apgar scores. Data on socio-demographic characteristics, pregnancy history and care during labour, were obtained using a structured questionnaire. Participants were tested for; i) malaria (peripheral and placental blood samples), ii) syphilis, iii) white blood cell counts (WBC), and iv) haemoglobin levels. The prevalence of birth asphyxia was determined as the number of newborns with Apgar scores < 7 at 5 min out of the total population of study participants. Factors independently associated with birth asphyxia were determined using multivariable logistic regression analysis and a p-value < 0.05 was considered statistically significant. Results A total of 2,930 mother-newborn pairs were included, and the prevalence of birth asphyxia was 154 [5.3% (95% confidence interval: 4.5- 6.1)]. Factors associated with birth asphyxia were; maternal age ≤ 19 years [adjusted odds ratio (aOR) 1.92 (1.27–2.91)], syphilis infection [aOR 2.45(1.08–5.57)], and a high white blood cell count [aOR 2.26 (1.26–4.06)], while employment [aOR 0.43 (0.22–0.83)] was protective. Additionally, referral [aOR1.75 (1.10–2.79)], induction/augmentation of labour [aOR 2.70 (1.62–4.50)], prolonged labour [aOR 1.88 (1.25–2.83)], obstructed labour [aOR 3.40 (1.70–6.83)], malpresentation/ malposition [aOR 3.00 (1.44–6.27)] and assisted vaginal delivery [aOR 5.54 (2.30–13.30)] were associated with birth asphyxia. Male newborns [aOR 1.92 (1.28–2.88)] and those with a low birth weight [aOR 2.20 (1.07–4.50)], were also more likely to develop birth asphyxia. Conclusion The prevalence of birth asphyxia was 5.3%. In addition to the known intrapartum complications, teenage motherhood, syphilis and a raised white blood cell count were associated with birth asphyxia. This indicates that for sustained reduction of birth asphyxia, appropriate management of maternal infections and improved intrapartum quality of care are essential.
Collapse
Affiliation(s)
- Elizabeth Ayebare
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. .,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
| | - Jolly Nankunda
- Mulago Specialized Women's & Neonatal Hospital, Kampala, Uganda.,Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Anna Hjelmstedt
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Rebecca Nantanda
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Wibke Jonas
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - James K Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Paediatrics and Child Health, School of Medicine, Kabale University, Kabale, Uganda
| | - Grace Ndeezi
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| |
Collapse
|
4
|
Valente EP, Mariani I, Covi B, Lazzerini M. Quality of Informed Consent Practices around the Time of Childbirth: A Cross-Sectional Study in Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127166. [PMID: 35742415 PMCID: PMC9222941 DOI: 10.3390/ijerph19127166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022]
Abstract
Background: Few studies have explored consent request practices during childbirth. Objective: We explored consent request practices during childbirth in a referral hospital and research centre in Italy, capturing both women and health workers’ perspectives. Methods: Data were collected using self-administrated questionnaires between December 2016 and September 2018. Nine key maternal and newborn procedures were analysed. Associations between consent requests and women characteristics were explored by multiple logistic regression. Results: Among 1244 women, the rate of consent requests varied widely, with caesarean section (CS) showing the highest rate (89.1%) and neonatal conjunctivitis prophylaxis presenting the lowest rate (11.4%). Information provided on “risks/benefits” and “reasons” for procedures by health staff was most often not comprehensive for procedures of interest (range 18.6–87.4%). The lack of informed consent is not specifically linked to any pattern of women characteristics. According to 105 health workers, adequate protocols and standard forms for consent requests were available in 67.6% and 78.1% of cases, respectively, while less than one third (31.4%) reported having received adequate training and supportive supervision on how to deliver informed consent. Conclusions: Study findings align with previous evidence showing that consent request practices during childbirth need to be largely improved. More research is needed to investigate effective strategies for improvement.
Collapse
|
5
|
A comparison of two versus four sterile water injections for the relief of back pain in labour: A multicentre randomised equivalence trial. Women Birth 2022; 35:e556-e562. [DOI: 10.1016/j.wombi.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
|
6
|
Shook LL, Shui JE, Boatin AA, Devane S, Croul N, Yonker LM, Matute JD, Lima RS, Schwinn M, Cvrk D, Gardner L, Azevedo R, Stanton S, Bordt EA, Yockey LJ, Fasano A, Li JZ, Yu XG, Kaimal AJ, Lerou PH, Edlow AG. Rapid establishment of a COVID-19 perinatal biorepository: early lessons from the first 100 women enrolled. BMC Med Res Methodol 2020; 20:215. [PMID: 32842979 PMCID: PMC7447612 DOI: 10.1186/s12874-020-01102-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/13/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Collection of biospecimens is a critical first step to understanding the impact of COVID-19 on pregnant women and newborns - vulnerable populations that are challenging to enroll and at risk of exclusion from research. We describe the establishment of a COVID-19 perinatal biorepository, the unique challenges imposed by the COVID-19 pandemic, and strategies used to overcome them. METHODS A transdisciplinary approach was developed to maximize the enrollment of pregnant women and their newborns into a COVID-19 prospective cohort and tissue biorepository, established on March 19, 2020 at Massachusetts General Hospital (MGH). The first SARS-CoV-2 positive pregnant woman was enrolled on April 2, and enrollment was expanded to SARS-CoV-2 negative controls on April 20. A unified enrollment strategy with a single consent process for pregnant women and newborns was implemented on May 4. SARS-CoV-2 status was determined by viral detection on RT-PCR of a nasopharyngeal swab. Wide-ranging and pregnancy-specific samples were collected from maternal participants during pregnancy and postpartum. Newborn samples were collected during the initial hospitalization. RESULTS Between April 2 and June 9, 100 women and 78 newborns were enrolled in the MGH COVID-19 biorepository. The rate of dyad enrollment and number of samples collected per woman significantly increased after changes to enrollment strategy (from 5 to over 8 dyads/week, P < 0.0001, and from 7 to 9 samples, P < 0.01). The number of samples collected per woman was higher in SARS-CoV-2 negative than positive women (9 vs 7 samples, P = 0.0007). The highest sample yield was for placenta (96%), umbilical cord blood (93%), urine (99%), and maternal blood (91%). The lowest-yield sample types were maternal stool (30%) and breastmilk (22%). Of the 61 delivered women who also enrolled their newborns, fewer women agreed to neonatal blood compared to cord blood (39 vs 58, P < 0.0001). CONCLUSIONS Establishing a COVID-19 perinatal biorepository required patient advocacy, transdisciplinary collaboration and creative solutions to unique challenges. This biorepository is unique in its comprehensive sample collection and the inclusion of a control population. It serves as an important resource for research into the impact of COVID-19 on pregnant women and newborns and provides lessons for future biorepository efforts.
Collapse
Affiliation(s)
- Lydia L Shook
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Jessica E Shui
- Division of Neonatology and Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Adeline A Boatin
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Samantha Devane
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Natalie Croul
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Lael M Yonker
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Juan D Matute
- Division of Neonatology and Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Rosiane S Lima
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Muriel Schwinn
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Dana Cvrk
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Laurel Gardner
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Robin Azevedo
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne Stanton
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Evan A Bordt
- Department of Pediatrics, Lurie Center for Autism, Massachusetts General Hospital, Boston, MA, USA
| | - Laura J Yockey
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Alessio Fasano
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Z Li
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Xu G Yu
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Ragon Institute of the Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard University, Cambridge, MA, USA
| | - Anjali J Kaimal
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Paul H Lerou
- Division of Neonatology and Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Andrea G Edlow
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|