Stakeholder perspectives on public-private partnership in health service delivery in Sindh province of Pakistan: a qualitative study

Objective: The objective of this study was to explore the perspectives of stakeholders on public-private partnership (PPP) in healthcare service delivery in Sindh province of Pakistan including the reasons for adopting such policies and the barriers for its implementation. Study design: This was a qualitative primary study. Methods: Semistructured in-depth interviews were conducted with 13 stakeholders, including officials from provincial government and district administration (legislators, district managers, deputy commissioners and assistant commissioners) and representatives from private sector organisations with direct or indirect role in implementation of PPP policy, selected using purposive sampling methods. Data were analysed using a thematic approach. Results: Participants had very limited in-depth understanding about the concept of PPP. They considered multifaceted corruption in the health system and the success of existing PPP initiatives as the main reasons for the PPP policy adoption. Resistance from healthcare staff was perceived as the main barrier for implementation of PPP. There was a common perception that better monitoring capacity in the private sector management can be a cause of concern for public sector employees who may have become used to less efficient working. A common theme found in the narratives was the possible apprehensions from healthcare staff about the loss of their jobs. Conclusion: Our findings indicated lack of effective engagement with key stakeholders and the resistance from healthcare staff as the key barriers for PPP implementation in Sindh, Pakistan. These findings provide useful insights for the successful implementation of such initiatives in Pakistan as well as in other similar settings

A retrospective analysis of variations in antenatal care initiation in an ethnically diverse maternal population in the UK with high levels of area deprivation

Background: Research has indicated differential utilisation of antenatal care among ethnic minority mothers in the UK.  However, links between ethnicity, area deprivation and the timing of antenatal care initiation remain poorly understood.   This study investigates variations in antenatal care initiation among mothers residing in an ethnically diverse area in the UK with high levels of area deprivation.  Methods:  Data were derived from an on-going  retrospective cohort study using routinely collected anonymous data of live singleton  births over a 9 year period from 2007-2016 in a maternity unit catering to an ethnically diverse population. Logistic regression and Geographical Information Systems (GIS) were used to examine the associations between antenatal care initiation and ethnicity with and without adjustment for area deprivation. Preliminary results:  Among 45695 births recorded on the Ciconia Maternity information System, great  majority (80%) of mothers lived in neighbourhoods that are in the three most deprived area quintiles and 34.4% belonged to one of the ethnic minority groups. One fifth (20.8%)  of mothers initiated antenatal care late after 12 weeks of gestation. Late initiation was the highest among Black African (34.2%) and Black Caribbean (29.0%) groups who were more than twice as likely than the White British group to initiate antenatal care late (Odds ratio [OR]= 2.65 and 2.08 respectively). The risk appeared to remain after adjustment for area deprivation. Conclusions:  Ethnic minority mothers from some groups are at substantially higher risk of initiating antenatal care late compared to White British mothers regardless of the level of area deprivation. Main messages: Mothers from some ethnic minority groups are at  substantially higher risk of initiating antenatal care after 12 weeks of gestation compared to White British mothers.  Area level deprivation has very little effect on ethnic variations in antenatal care initiation

Prevalence of antenatal depression in South Asia: a systematic review and meta-analysis

OBJECTIVE To estimate the prevalence of antenatal depression in South Asia and to examine variations by country and study characteristics to inform policy, practice and future research.  METHODS We conducted a comprehensive search of 13 data bases including international data bases and databases covering scientific literature from South Asian countries in addition to Google Scholar and grey sources from 1·1·2007 to 31·5·2018. Studies reporting prevalence estimates of antenatal depression using a validated diagnostic/ screening tool were identified, screened, selected, and appraised.  Primary outcome was proportion (%) of pregnant women identified as having antenatal depression. RESULTS Thirty-three studies involving 13,087 pregnant women were included in the meta-analysis. Twelve studies were rated as of high quality and 21 studies were of moderate quality. Overall pooled prevalence of antenatal depression was 24·57% (95% CI: 19·34, 30·69). Studies showed a high degree of heterogeneity (I2=97·55%) and evidence of publication bias (p=0·722). Prevalence rates for India (17·74%, 95% CI: 11·19, 26·96) and Sri Lanka (15·87%, 95% CI: 14·04, 17·88) were lower compared to the overall prevalence whereas prevalence rates for Pakistan (32·2%, 95% CI: 23·11, 42·87) and Nepal (50%, 95% CI: 35·64,64·36) were higher. CONCLUSIONS While robust prevalence studies are sparse in most South Asian countries, available data suggests one in four pregnant women is likely to experience antenatal depression in the region. Findings highlight the need for recognition of the issue in health policy and practice and for resource allocation for capacity building at regional and national levels for prevention, diagnosis and treatment

Development, acceptability and feasibility of a community-based intervention to increase timely initiation of antenatal care in an area of high ethnic diversity and low socio-economic status in the UK

BACKGROUND: Antenatal care plays an important role in preventing adverse maternal and new-born outcomes. Women from ethnic minority backgrounds and of low socio-economic status are at greater risk of initiating antenatal care later than the recommended 10 weeks. There is a paucity of research exploring the development and evaluation of community-based interventions to increase the timely initiation of antenatal care. OBJECTIVE: To develop and evaluate the acceptability and feasibility of a co-produced community-based intervention to increase uptake of antenatal care in an area with high ethnic diversity and low socio-economic status. DESIGN: The intervention was developed using co-production workshops and conversations with 20 local service users and 14 stakeholders, underpinned by the theory of Diffusion of Innovation. The intervention was evaluated, on the domains of acceptability, adoption, appropriateness, and feasibility. Questionnaires (n=36), interviews (n=10), and focus groups (n=13) were conducted among those who received the intervention. Observations (n=13) of intervention sessions were conducted to assess intervention fidelity. Quantitative and qualitative data were analysed using SPSS and NVivo software respectively. RESULTS: Over 91% of respondents positively ranked the intervention. Qualitative findings with respect to ‘acceptability’ included four subthemes: how the intervention was communicated, the characteristics of the person delivering the intervention and their knowledge, and the reassurance offered by the intervention. The ‘adoption’ theme included three sub-themes: being informed helps women to engage with antenatal care, the intervention provides information for future use, and onwards conveyance of the intervention information. The ‘appropriateness’ theme included three sub-themes: existing gap in information, nature of information given as part of the intervention, and talking about pregnancy in public. The ‘feasibility’ theme included two sub-themes: value of delivering the intervention in areas of high footfall and relational aspect of receiving the intervention. Observations showed intervention fidelity of 100%. CONCLUSION: The community-based intervention, coproduced with women and maternity care stakeholders, was positively evaluated, and offered an innovative and promising approach to engage and educate women about the timely initiation of antenatal care in an ethnically diverse and socio-economically deprived community

Ethnic minority women’s experiences of accessing antenatal care in high income European countries: a systematic review

Background: Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women’s experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women’s perspectives. Methods: We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a ‘best fit’ framework, based on an existing theoretical model of health care access. Results: A total of 30 studies were included in this review. Women’s experiences covered two overarching themes: ‘provision of antenatal care’ and ‘women's uptake of antenatal care’. The ‘provision of antenatal care’ theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The ‘women's uptake of antenatal care’ theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes. Conclusion: The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women’s ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care

Effectiveness of nutrition interventions in low and middle income countries: an evidence summary

This is an independent report commissioned under the DFID Systematic Review Programme for SouthAsia. This material has been funded by South Asia Research Hub, Research and Evidence Division,Department for International Development,Government of UK. The views expressed do not necessarilyreflect the UK Government’s official policies

Ethnic variations in risk of preterm birth in an ethnically dense socially disadvantaged area in the UK: a retrospective cross-sectional study

Objective To investigate ethnic variations in risk of preterm birth (PTB), including extreme preterm birth (EPTB) and moderately preterm birth (MPTB), among mothers in an ethnically dense, socially disadvantaged area, and to examine whether any variations were dependent of area deprivation and maternal biological and behavioural factors. Design Retrospective cross-sectional study using routinely collected data. Setting A large UK National Health Service maternity unit. Participants 46 307 women who gave singleton births between April 2007 and March 2016. Outcome measures PTB defined as <37 weeks of gestation and further classified into EPTB (<28 weeks of gestation) and MPTB (28 to <37 weeks of gestation). Results Overall prevalence of PTB was higher (8.3%) compared with the national average (7.8%). Black Caribbean (2.2%) and black African (2.0%) mothers had higher absolute risk of EPTB than white British mothers (1.3%), particularly black Caribbean mothers whose relative risk ratio (RRR) was nearly twice after adjustment for all covariates (RRR=1.93[1.20 to 3.10]). Excess relative risk of EPTB among black African mothers became non-significant after adjustment for prenatal behavioural factors (RRR=1.41[0.99 to 2.01]). Bangladeshi mothers had the lowest absolute risk of EPTB (0.6%), substantially lower than white British mothers (1.3%); the difference in relative risk remained significant after adjustment for area deprivation (RRR=0.59[0.36 to 0.96]), but became non-significant after adjustment for maternal biological factors. Changes were evident in the relative risk of EPTB and MPTB among some ethnic groups compared with the white British on adjustment for different covariates. Conclusions Higher than national rates of PTB point to the need for evidence-based antenatal and neonatal care programmes to support preterm babies and their families in ethnically dense socially disadvantaged areas. Differential impact of area deprivation and the role of modifiable behavioural factors highlight the need for targeted preventive interventions for groups at risk

Development, acceptability and feasibility of a community-based intervention to increase timely initiation of antenatal care in an area of high ethnic diversity and low socio-economic status in the UK

BACKGROUND: Antenatal care plays an important role in preventing adverse maternal and new-born outcomes. Women from ethnic minority backgrounds and of low socio-economic status are at greater risk of initiating antenatal care later than the recommended 10 weeks. There is a paucity of research exploring the development and evaluation of community-based interventions to increase the timely initiation of antenatal care. OBJECTIVE: To develop and evaluate the acceptability and feasibility of a co-produced community-based intervention to increase uptake of antenatal care in an area with high ethnic diversity and low socio-economic status. DESIGN: The intervention was developed using co-production workshops and conversations with 20 local service users and 14 stakeholders, underpinned by the theory of Diffusion of Innovation. The intervention was evaluated, on the domains of acceptability, adoption, appropriateness, and feasibility. Questionnaires (n=36), interviews (n=10), and focus groups (n=13) were conducted among those who received the intervention. Observations (n=13) of intervention sessions were conducted to assess intervention fidelity. Quantitative and qualitative data were analysed using SPSS and NVivo software respectively. RESULTS: Over 91% of respondents positively ranked the intervention. Qualitative findings with respect to ‘acceptability’ included four subthemes: how the intervention was communicated, the characteristics of the person delivering the intervention and their knowledge, and the reassurance offered by the intervention. The ‘adoption’ theme included three sub-themes: being informed helps women to engage with antenatal care, the intervention provides information for future use, and onwards conveyance of the intervention information. The ‘appropriateness’ theme included three sub-themes: existing gap in information, nature of information given as part of the intervention, and talking about pregnancy in public. The ‘feasibility’ theme included two sub-themes: value of delivering the intervention in areas of high footfall and relational aspect of receiving the intervention. Observations showed intervention fidelity of 100%. CONCLUSION: The community-based intervention, coproduced with women and maternity care stakeholders, was positively evaluated, and offered an innovative and promising approach to engage and educate women about the timely initiation of antenatal care in an ethnically diverse and socio-economically deprived community