International Human Rights and the Mistreatment of Women During Childbirth

International human rights bodies have played a critical role in codifying, setting standards, and monitoring human rights violations in the context of sexual and reproductive health and rights. In recent years, these institutions have developed and applied human rights standards in the more particular context of maternal mortality and morbidity, and have increasingly recognized a critical human rights issue in the provision and experience of care during and after pregnancy, including during childbirth. However, the international human rights standards on mistreatment during facility-based childbirth remain, in an early stage of development, focused largely on a discrete subset of experiences, such as forced sterilization and lack of access to emergency obstetric care. As a consequence, the range of mistreatment that women may experience has not been adequately addressed or analyzed under international human rights law. Identifying human rights norms and standards related to the full range of documented mistreatment is thus a first step towards addressing violations of human rights during facility-based childbirth, ensuring respectful and humane treatment, and developing a program of work to improve the overall quality of maternal care. This article reviews international human rights standards related to the mistreatment of women during childbirth in facility settings under regional and international human rights law and lays out an agenda for further research and action

Interventions targeting healthcare providers to optimise use of caesarean section: a qualitative comparative analysis to identify important intervention features

BACKGROUND: Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population-level have limited benefits for women and babies. Many interventions targeting healthcare providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting healthcare providers.  METHODS: We used Qualitative Comparative Analysis (QCA) to identify if certain combination of important intervention features (e.g. type of intervention, contextual characteristics, and how the intervention was delivered) are associated with a successful intervention as reflected in a reduction of CS. We included 21 intervention studies targeting healthcare providers to reduce CS, comprising of 34 papers reporting on these interventions. To develop potential theories driving intervention success, we used existing published qualitative evidence syntheses on healthcare providers' perspectives and experiences of interventions targeted at them to reduce CS. RESULTS: We identified five important components that trigger successful interventions targeting healthcare providers: 1) training to improve providers' knowledge and skills, 2) active dissemination of CS indications, 3) actionable recommendations, 4) multidisciplinary collaboration, and 5) providers' willingness to change. Importantly, when one or more of these components are absent, dictated nature of intervention, where providers are enforced to adhere to the intervention, is needed to prompt successful interventions. Unsuccessful interventions were characterised by the absence of these components. CONCLUSION: We identified five important intervention components and combinations of intervention components which can lead to successful interventions targeting healthcare providers to optimise CS use. Health facility managers, researchers, and policy-makers aiming to improve providers' clinical decision making and reduce CS may consider including the identified components to optimise benefits

Educational interventions targeting pregnant women to optimise the use of caesarean section: What are the essential elements? A qualitative comparative analysis

BACKGROUND: Caesarean section (CS) rates are increasing globally, posing risks to women and babies. To reduce CS, educational interventions targeting pregnant women have been implemented globally, however, their effectiveness is varied. To optimise benefits of these interventions, it is important to understand which intervention components influence success. In this study, we aimed to identify essential intervention components that lead to successful implementation of interventions focusing on pregnant women to optimise CS use. METHODS: We re-analysed existing systematic reviews that were used to develop and update WHO guidelines on non-clinical interventions to optimise CS. To identify if certain combinations of intervention components (e.g., how the intervention was delivered, and contextual characteristics) are associated with successful implementation, we conducted a Qualitative Comparative Analysis (QCA). We defined successful interventions as interventions that were able to reduce CS rates. We included 36 papers, comprising 17 CS intervention studies and an additional 19 sibling studies (e.g., secondary analyses, process evaluations) reporting on these interventions to identify intervention components. We conducted QCA in six stages: 1) Identifying conditions and calibrating the data; 2) Constructing truth tables, 3) Checking quality of truth tables; 4) Identifying parsimonious configurations through Boolean minimization; 5) Checking quality of the solution; 6) Interpretation of solutions. We used existing published qualitative evidence synthesis to develop potential theories driving intervention success. RESULTS: We found successful interventions were those that leveraged social or peer support through group-based intervention delivery, provided communication materials to women, encouraged emotional support by partner or family participation, and gave women opportunities to interact with health providers. Unsuccessful interventions were characterised by the absence of at least two of these components. CONCLUSION: We identified four key essential intervention components which can lead to successful interventions targeting women to reduce CS. These four components are 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. Maternal health services and hospitals aiming to better prepare women for vaginal birth and reduce CS can consider including the identified components to optimise health and well-being benefits for the woman and baby

Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences

Background: Caesarean sections (CS) continue to increase worldwide. Multiple and complex factors are contributing to the increase, including non-clinical factors related to individual women, families and their interactions with health providers. This global qualitative evidence synthesis explores women’s preferences for mode of birth and factors underlying preferences for CS. Methods: Systematic database searches (MEDLINE, EMBASE, CINAHL, PsycINFO) were conducted in December 2016 and updated in May 2019 and February 2021. Studies conducted across all resource settings were eligible for inclusion, except those from China and Taiwan which have been reported in a companion publication. Phenomena of interest were opinions, views and perspectives of women regarding preferences for mode of birth, attributes of CS, societal and cultural beliefs about modes of birth, and right to choose mode of birth. Thematic synthesis of data was conducted. Confidence in findings was assessed using GRADE-CERQual. Results: We included 52 studies, from 28 countries, encompassing the views and perspectives of pregnant women, non-pregnant women, women with previous CS, postpartum women, and women’s partners. Most of the studies were conducted in high-income countries and published between 2011 and 2021. Factors underlying women preferences for CS had to do mainly with strong fear of pain and injuries to the mother and child during labour or birth (High confidence), uncertainty regarding vaginal birth (High confidence), and positive views or perceived advantages of CS (High confidence). Women who preferred CS expressed resoluteness about it, but there were also many women who had a clear preference for vaginal birth and those who even developed strategies to keep their birth plans in environments that were not supportive of vaginal births (High confidence). The findings also identified that social, cultural and personal factors as well as attributes related to health systems impact on the reasons underlying women preferences for various modes of birth (High confidence). Conclusions: A wide variety of factors underlie women’s preferences for CS in the absence of medical indications. Major factors contributing to perceptions of CS as preferable include fear of pain, uncertainty with vaginal birth and positive views on CS. Interventions need to address these factors to reduce unnecessary CS

Factors influencing the implementation of labour companionship: formative qualitative research in Thailand.

INTRODUCTION: WHO recommends that all women have the option to have a companion of their choice throughout labour and childbirth. Despite clear benefits of labour companionship, including better birth experiences and reduced caesarean section, labour companionship is not universally implemented. In Thailand, there are no policies for public hospitals to support companionship. This study aims to understand factors affecting implementation of labour companionship in Thailand. METHODS: This is formative qualitative research to inform the 'Appropriate use of caesarean section through QUALIty DECision-making by women and providers' (QUALI-DEC) study, to design, adapt and implement a strategy to optimise use of caesarean section. We use in-depth interviews and readiness assessments to explore perceptions of healthcare providers, women and potential companions about labour companionship in eight Thai public hospitals. Qualitative data were analysed using thematic analysis, and narrative summaries of the readiness assessment were generated. Factors potentially affecting implementation were mapped to the Capability, Opportunity, and Motivation behaviour change model (COM-B). RESULTS: 127 qualitative interviews and eight readiness assessments are included in this analysis. The qualitative findings were grouped in four themes: benefits of labour companions, roles of labour companions, training for labour companions and factors affecting implementation. The findings showed that healthcare providers, women and their relatives all had positive attitudes towards having labour companions. The readiness assessment highlighted implementation challenges related to training the companion, physical space constraints, overcrowding and facility policies, reiterated by the qualitative reports. DISCUSSION: If labour companions are well-trained on how to best support women, help them to manage pain and engage with healthcare teams, it may be a feasible intervention to implement in Thailand. However, key barriers to introducing labour companionship must be addressed to maximise the likelihood of success mainly related to training and space. These findings will be integrated into the QUALI-DEC implementation strategies

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period:moving from rhetoric to action

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs

Prevalence of and reasons for women’s, family members’, and health professionals’ preferences for cesarean section in Iran: a mixed-methods systematic review

Abstract: Background: Cesarean section (CS) rates have been increasing globally. Iran has one of the highest CS rates in the world (47.9%). This review was conducted to assess the prevalence of and reasons for women’s, family members’, and health professionals’ preferences for CS in Iran. Methods and findings: In this mixed-methods systematic review, we searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, Google scholar; as well as Iranian scientific databases including SID, and Magiran from 1 January 1990 to 8th October 2019. Primary quantitative, qualitative, and mixed-methods studies that had been conducted in Iran with Persian or English languages were included. Meta-analysis of quantitative studies was conducted by extracting data from 65 cross-sectional, longitudinal, and baseline measurements of interventional studies. For meta-synthesis, we used 26 qualitative studies with designs such as ethnography, phenomenology, case studies, and grounded theory. The Review Manager Version 5.3 and the Comprehensive Meta-Analysis (CMA) software were used for meta-analysis and meta-regression analysis. Results showed that 5.46% of nulliparous women (95% CI 5.38–5.50%; χ2 = 1117.39; df = 28 [p < 0.00001]; I2 = 97%) preferred a CS mode of delivery. Results of subgroup analysis based on the time of pregnancy showed that proportions of preference for CS reported by women were 5.94% (95% CI 5.86–5.99%) in early and middle pregnancy, and 3.81% (95% CI 3.74–3.83%), in late pregnancy. The heterogeneity was high in this review. Most women were pregnant, regardless of their parity; the risk level of participants were unknown, and some Persian publications were appraised as low in quality. A combined inductive and deductive approach was used to synthesis the qualitative data, and CERQual was used to assess confidence in the findings. Meta-synthesis generated 10 emerging themes and three final themes: ‘Women’s factors’, ‘Health professional factors’, andex ‘Health organization, facility, or system factors’. Conclusion: Despite low preference for CS among women, CS rates are still so high. This implies the role of factors beyond the individual will. We identified a multiple individual, health facility, and health system factors which affected the preference for CS in Iran. Numerous attempts were made in recent years to design, test and implement interventions to decrease unnecessary CS in Iran, such as mother-friendly hospitals, standard protocols for labor and birth, preparation classes for women, midwives, and gynaecologists, and workshops for specialists and midwives through the “health sector evolution policy”. Although these programs were effective, high rates of CS persist and more efforts are needed to optimize the use of CS

Cochrane Effective Practice and Organisation of Care (EPOC) Qualitative Evidence Syntheses, Differences From Reviews of Intervention Effectiveness and Implications for Guidance

Systematic reviews of qualitative research (‘qualitative evidence syntheses’) are increasingly popular and represent a potentially important source of information about people’s views, needs and experiences. Since 2013, Cochrane has published qualitative evidence syntheses, and the Cochrane Effective Practice and Organisation of Care group has been involved in the majority of these reviews. But more guidance is needed on how to prepare these reviews in an environment that is more familiar with reviews of quantitative research. In this paper, we describe and reflect on how Cochrane qualitative evidence syntheses differ from reviews of intervention effectiveness and how these differences have influenced the guidance developed by the EPOC group. In particular, we discuss how it has been important to display to end users, firstly, that qualitative evidence syntheses are carried out with rigour and transparency, and secondly, that these quality standards need to reflect qualitative research traditions. We also discuss lessons that reviews of effectiveness might learn from qualitative research

Qualitative Evidence Syntheses Within Cochrane Effective Practice and Organisation of Care: Developing a Template and Guidance

A growing number of researchers are preparing systematic reviews of qualitative evidence, often referred to as ‘qualitative evidence syntheses’. Cochrane published its first qualitative evidence synthesis in 2013 and published 27 such syntheses and protocols by August 2020. Most of these syntheses have explored how people experience or value different health conditions, treatments and outcomes. Several have been used by guideline producers and others to identify the topics that matter to people, consider the acceptability and feasibility of different healthcare options and identify implementation considerations, thereby complementing systematic reviews of intervention effectiveness.Guidance on how to conduct and report qualitative evidence syntheses exists. However, methods are evolving, and we still have more to learn about how to translate and integrate existing methodological guidance into practice. Cochrane’s Effective Practice and Organisation of Care (EPOC) (www.epoc.org) has been involved in many of Cochrane’s qualitative evidence syntheses through the provision of editorial guidance and support and through co-authorship. In this article, we describe the development of a template and guidance for EPOC’s qualitative evidence syntheses and reflect on this process