Utility of the three-delays model and its potential for supporting a solution-based approach to accessing intrapartum care in low- and middle-income countries. A qualitative evidence synthesis

Background: The 3-Delays Model has helped in the identification of access barriers to obstetric care in low and middle-income countries by highlighting the responsibilities at household, community and health system levels. Critiques of the Model include its one dimensionality and its limited utility in triggering preventative interventions. Such limitations have prompted a review of the evidence to establish the usefulness of the Model in optimising timely access to intrapartum care. Objective: To determine the current utility of the 3-Delays Model and its potential for supporting a solution-based approach to accessing intrapartum care. Methods: We conducted a qualitative evidence synthesis across several databases and included qualitative findings from stand-alone studies, mixed-methods research and literature reviews using the Model to present their findings. Papers published between 1994 and 2019 were included with no language restrictions. Twenty-seven studies were quality appraised. Qualitative accounts were analysed using the ‘best-fit framework approach’. Results: This synthesis included twenty-five studies conducted in Africa, Asia, Latin America and the Caribbean. Five studies adhered to the original 3-Delays Model’s structure by identifying the same factors responsible for the delays. The remaining studies proposed modifications to the Model including alterations of the delay’s definition, adding of new factors, and inclusion of a fourth delay. Only two studies reported women’s individual contributions to the delays. All studies applied the Model retrospectively, thus adopting a problem-identification approach. Conclusion: This synthesis unveils the need for an individual perspective, for prospective identification of potential issues. This has resulted in the development of a new framework, the Women’s Health Empowerment Model, incorporating the 3 delays. As a basis for discussion at every pregnancy, this framework promotes a solution-based approach to childbirth, which could prevent delays and support women’s empowerment during pregnancy and childbirth

Adolescent experiences of pregnancy in low-and middle-income countries: a meta-synthesis of qualitative studies

Background: Fertility rates among adolescents have fallen globally, yet the greatest incidence remains in low-and middle-income countries (LMICs). Gaining insight into adolescents needs and experiences of pregnancy will help identify if context specific services meet their needs and how to optimise pregnancy experiences. A meta-synthesis of qualitative studies considering adolescent experiences of pregnancy in LMICs has not yet been published. Aim: To synthesise available qualitative evidence to provide greater understanding of the needs and experiences of adolescents who become pregnant in low-and middle-income countries. Methods: An extensive search utilised six databases and citations searching. Studies were included if they were of a qualitative or mixed methods design. Participants lived in LMICs and were adolescents who were pregnant, had experienced pregnancy during adolescence or were an adolescent male partner. Relevant studies were assessed for quality to determine suitability for inclusion. A meta-ethnography approach was used to generate themes and a final line of argument. Results: After screening and quality assessment 21 studies were included. The meta-ethnography generated four themes, A wealth of emotions, I am not ready, Impactful relationships and Respectful and disrespectful care. Unplanned, unwanted and unacceptable pregnancies were a source of shame, with subsequent challenging personal relationships and frequently a lack of needed support. Even when pregnancy was wanted, adolescents faced the internal conflict of their desires not always aligning with socio-cultural, religious and family expectations. Access, utilisation and experiences of care were significantly impacted by adolescents’ relationships with others, the level of respectful care experienced, and engagement with adolescent friendly services. Conclusions: Adolescents who experience pregnancy in LMICs deserve support to meet their personal and pregnancy needs; efforts are needed to tailor the support provided. A lack of a health care provider knowledge and skills is an obstacle to optimal support, with more and better training integral to increasing the availability of adolescent friendly and respectful care. Adolescents should be involved in the planning of health care services and supported to make decisions about their care. The diversity across countries mean policy makers and other stakeholders need to consider how these implications can be realised in each context

An integrative review of parent-partnerships within neonatal care facilities in low- and lower-middle-income countries

Background: Neonatal deaths in low-income countries account for a disproportionate percentage of all-mortality rates of children under 5. Parental-participation in neonatal care has been proven to improve outcomes for key developmental factors that influence morbidity and mortality of infants. Objectives: This review aims to explore the current models of parent-partnership used in neonatal care facilities and identify factors that influence effective utilisation in low-resource nations. Methods: This Integrative Review was performed by searching the databases of CINAHL, Medline and Global Health. The search was conducted using key-terms relating to Neonatology, Kangaroo Mother Care and Parent-Partnerships. Papers published between 2011 and 2021, from lower- and lower-middle-income countries, were included. Results: The search identified 336 publications. Following screening and full-text review, 24 studies were identified that satisfied the inclusion criteria. Data were quality-appraised using the Mixed-Methods Appraisal Tool and extracted utilising the framework described by Whittemore and Knafl. The analysis produced nine key themes – KMC as the predominant model of parent-partnership; the positive impact parent-partnerships have upon infants; the positive impact for parents; positive impact for nursing staff; enabling and limiting factors that influence implementation; pre-existing social and cultural barriers; task-sharing between staff and family; and how education influences perceptions. Conclusions: Economic, social and cultural factors have been identified that strongly influence and inhibit the widespread use of parent-partnerships in neonatal care facilities. KMC is the predominant model of parent-partnership. A future or adapted form of healthcare in these facilities should include a structured approach of education, empowerment, enhanced male and community involvement that simultaneously accommodates to the psychosocial needs of the family unit

Emergency Verbal Consent for Intrapartum Research: A Grounded Theory Study

Objective To understand the experiences of women, birth partners and health professionals of verbal followed by retrospective written consent in a prospective cohort study of a device to manage postpartum haemorrhage (PPH). Design Grounded Theory. Setting Tertiary facility in North-West England, UK. Sample We used purposive and theoretical sampling to recruit 51 participants; 12 women, 12 birth partners, 16 obstetricians and 11 midwives. Methods Semi-structured interviews were conducted, using a topic guide for focus, until data saturation was achieved. Data were analysed using framework analysis technique. Results Most women wanted sufficient information to make a decision at the time of the event, rather than in advance, and preferred not to be overwhelmed with detail. A key factor in making the decision to participate was a positive and trusting relationship with the attending obstetrician. Obtaining consent for research in emergencies was viewed by obstetricians as requiring a different approach and more challenging than consent for standard procedures in an emergency. Conclusions This is one of the first studies to explore verbal followed by retrospective written consent processes with women, clinicians and observers. This was acceptable to all, however information needs to be appropriate, and those discussing consent require adequate training (199/200)

Journey of vulnerability: a mixed-methods study to understand intrapartum transfers in Tanzania and Zambia

From Springer Nature via Jisc Publications RouterHistory: received 2020-01-13, accepted 2020-05-06, registration 2020-05-07, pub-electronic 2020-05-14, online 2020-05-14, collection 2020-12Publication status: PublishedFunder: National Institute for Health Research; doi: http://dx.doi.org/10.13039/501100000272; Grant(s): 16/137/53Abstract: Background: Timely intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. We explored the complexities around referrals to gain understanding of the characteristics, experiences and outcomes of those being transferred. Methods: We used a mixed-method parallel convergent design, in Tanzania and Zambia. Quantitative data were collected from a consecutive, retrospective case-note review (target, n = 2000); intrapartum transfers and stillbirths were the outcomes of interest. A grounded theory approach was adopted for the qualitative element; data were collected from semi-structured interviews (n = 85) with women, partners and health providers. Observations (n = 33) of transfer were also conducted. Quantitative data were analysed descriptively, followed by binary logistic regression models, with multiple imputation for missing data. Qualitative data were analysed using Strauss’s constant comparative approach. Results: Intrapartum transfer rates were 11% (111/998; 2 unknown) in Tanzania and 37% (373/996; 1 unknown) in Zambia. Main reasons for transfer were prolonged/obstructed labour and pre-eclampsia/eclampsia. Women most likely to be transferred were from Zambia (as opposed to Tanzania), HIV positive, attended antenatal clinic 30 min away from the referral hospital. Differences were observed between countries. Of those transferred, delays in care were common and an increase in poor outcomes was observed. Qualitative findings identified three categories: social threats to successful transfer, barriers to timely intrapartum care and reparative interventions which were linked to a core category: journey of vulnerability. Conclusion: Although intrapartum transfers are inevitable, modifiable factors exist with the potential to improve the experience and outcomes for women. Effective transfers rely on adequate resources, effective transport infrastructures, social support and appropriate decision-making. However, women’s (and families) vulnerability can be reduced by empathic communication, timely assessment and a positive birth outcome; this can improve women’s resilience and influence positive decision-making, for the index and future pregnancy

Promoting respectful maternal and newborn care using the Dignity game: A quasi-experimental study

Aim This study assessed a) the impact of playing the Dignity board game on participants’ understanding of respectful maternal and newborn care and b) participants’ perceptions of how the game influenced their subsequent practice in Malawi and Zambia. Background Nurse-midwives’ poor understanding of respectful maternal and newborn care can lead to substandard practice; thus, effective education is pivotal. Used in several disciplines, game-based learning can facilitate skills acquisition and retention of knowledge. Design a quasi-experimental study, using mixed-methods of data collection. Methods Data were collected between January and November 2020. Nurse-midwives (N = 122) and students (N = 115) were recruited from public hospitals and nursing schools. Completion of paper-based questionnaires, before and after game-playing, assessed knowledge of respectful care principles and perceptions around behaviours and practice. Face-to-face interviews (n = 18) explored perceived impact of engaging with the game in clinical practice. Paired and unpaired t-test were used to compare scores. Qualitative data were analysed and reported thematically. Results The study was completed by 215 (90.7 %) participants. Post-test scores improved significantly for both groups combined; from 25.91 (SD 3.73) pre-test to 28.07 (SD 3.46) post-test (paired t = 8.67, 95 % confidence interval 1.67–2.65), indicating an increased knowledge of respectful care principles. Nurse-midwives performed better than students, both before and after. In Malawi, the COVID pandemic prevented a third of nurse-midwives’ from completing post-game questionnaires. Qualitative findings indicate the game functioned as a refresher course and helped nurse-midwives to translate principles of respectful care into practice. It was also useful for self-reflection. Conclusions The Dignity board game has the potential to enhance understanding and practice of respectful maternal and newborn care principles in low-resource settings. Integration into nursing and midwifery curricula and in-service training for students and healthcare workers should be considered

Respectful care an added extra: a grounded theory study exploring intrapartum experiences in Zambia and Tanzania

Background Quality of maternal and newborn care is integral to positive clinical, social and psychological outcomes. Respectful care is an important component of this but is suboptimum in many low-income settings. A renewed energy among health professionals and academics is driving an international agenda to eradicate disrespectful health facility care around the globe. However, few studies have explored respectful care from different vantage points. Methods We used Strauss and Corbin’s grounded theory methodology to explore intrapartum experiences in Tanzania and Zambia. In-depth interviews were conducted with 98 participants (48 women, 18 partners, 21 health-providers and 11 key stakeholders), resulting in data saturation. Analysis involved constant comparison, comprising three stages of coding: open, axial and selective. The process involved application of memos, reflexivity and positionality. Results Findings demonstrated that direct and indirect social discrimination led to inequity of care. Health-providers were believed to display manipulative behaviours to orchestrate situations for their own or the woman’s benefit, and were often caring against the odds, in challenging environments. Emergent categories were related to the core category: respectful care, an added extra, which reflects the notion that women did not always expect or receive respectful care, and tolerated poor experiences to obtain services believed to benefit them or their babies. Respectful care was not seen as a component of good quality care, but a luxury that only some receive. Conclusion Both quality of care and respectful care were valued but were not viewed as mutually inclusive. Good quality treatment (transactional care) was often juxtaposed with disrespectful care; with relational care having a lower status among women and healthcare providers. To readdress the balance, respectful care should be a predominant theme in training programmes, policies and audits. Women’s and health-provider voices are pivotal to the development of such interventions