Primigravid Women's Views of Being Approached to Participate in a Hypothetical Term Cephalic Trial of Planned Vaginal Birth versus Planned Cesarean Birth

Background: Several papers have called for a trial of planned cesarean section versus planned vaginal birth for low-risk women—a recommendation that is fiercely debated. Although proponents of a trial have voiced their support, evidence suggests that in the United Kingdom few midwives and obstetricians believe such a trial to be feasible, and no studies reporting women's views on the prospect of such a trial have been published. The purpose of this study is to explore women's views of participation in a trial of planned cesarean birth versus planned vaginal birth. Methods: A qualitative study was conducted using in-depth interviews in a large maternity hospital in the United Kingdom. Sixty-four women were interviewed 12 months after giving birth. Women were asked “How do you think you would have felt if you had been approached to take part in such a trial during your first pregnancy?” Data were analyzed thematically. Results: Only 3 of the 64 women stated that they would have participated in a trial of planned vaginal birth versus planned cesarean section, had they been asked. However, five other women said that they would have consented to participate if they had been asked during pregnancy, but with hindsight, would have regretted that decision. The remainder of women would not have participated, unless a preference arm was offered. Three main themes were identified: “feeling cheated,”“let nature take its course, ” and “just another trauma that you don't need.” Conclusions: Few women supported a trial and most suggested that it was intuitively wrong. Given the strong views voiced by women, it is unlikely that a trial of planned vaginal delivery versus planned cesarean delivery would be feasible

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

The association between psychological factors and breastfeeding behaviour in women with a body mass index (BMI) ≥30 kg m-2: a systematic review

Breastfeeding can play a key role in the reduction of obesity, but initiation and maintenance rates in women with a body mass index (BMI) of ≥30 kg m−2 are low. Psychological factors influence breastfeeding behaviours in the general population, but their role is not yet understood in women with a BMI ≥30 kg m−2. Therefore, this review aimed to systematically search and synthesize the literature, which has investigated the association between any psychological factor and breastfeeding behaviour in women with a BMI ≥30 kg m−2. The search identified 20 eligible papers, reporting 16 psychological factors. Five psychological factors were associated with breastfeeding behaviours: intentions to breastfeed, belief in breast milk's nutritional adequacy and sufficiency, belief about other's infant feeding preferences, body image and social knowledge. It is therefore recommended that current care should encourage women to plan to breastfeed, provide corrective information for particular beliefs and address their body image and social knowledge. Recommendations for future research include further exploration of several psychological factors (i.e. expecting that breastfeeding will enhance weight loss, depression, anxiety and stress) and evidence and theory‐based intervention development

The Perceptions And Experiences Of Women With A Body Mass Index ≥ 30 kg m2 Who Breastfeed: A Meta-synthesis

Breastfeeding has copious health benefits for both mother and child, but rates of initiation and maintenance amongst women with a BMI ≥30kg/m2 are low. Few interventions aiming to increase these rates have been successful, suggesting that breastfeeding behaviour in this group is not fully understood. Therefore, this review aimed to systematically identify and synthesise the qualitative literature which explored the perceptions and experiences of women with a BMI ≥30kg/m2 who breastfed. The search identified five eligible papers, and a meta-ethnographic approach was taken to synthesise the findings. One theme was identified: ‘weight amplifies breastfeeding difficulties’, revealing that women with a BMI ≥30kg/m2 experience common breastfeeding difficulties to a greater degree. In particular, women with a BMI ≥30kg/m2 struggle with the impact of medical intervention, doubt their ability to breastfeed, and need additional support. These findings can inform understanding of breastfeeding models, future research directions, intervention development and antenatal and postnatal care for women with a BMI ≥30kg/m2

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

Facilitators and barriers to retention in care under universal antiretroviral therapy (Option B+) for the Prevention of Mother to Child Transmission of HIV (PMTCT): A narrative review

Background Mother to child transmission (MTCT) is the most significant sources of Human Immune Deficiency Virus (HIV) in children. The risk of HIV transmission from the mother to the child, during pregnancy, birthing and breastfeeding, ranges from 15 to 45% (World Health Organisation [WHO] 2018), but with prevention of mother to child transmission (PMTCT) services the risk of transmission can be reduced to 5% (WHO, 2017). In 2011, Malawi became the first country to use Option B+ in 2011 which later became the WHO recommendation for the prevention of mother to child transmission of HIV (PMTCT) in Low and Middle-income countries (WHO, 2013). With Option B+, all HIV positive pregnant and lactating women are initiated on lifelong antiretroviral therapy (ART) regardless of their clinical and immunological status (WHO, 2013). Furthermore, all babies born or lactating from such mothers are said to be HIV exposed and are enrolled in an early infant diagnosis (EID) programme where they are followed up until they are two years old. Some of the reasons for adopting these recommendations were to increase access to ART, reduce MTCT, prolong the life and sustain the health of the mother, and reduce HIV transmission to the spouse or sexual partner. Evidence suggests that the use of ART by pregnant and lactating mothers prevents MTCT and improves maternal health (Shapiro et al., 2010; Granich et al., 2010). This is true because ARTs suppress HIV viral replication thereby drastically lowering the HIV viral load in infected persons stopping the progression of HIV disease; consequently, HIV becomes untransmissible (Bunnell et al., 2006, Granich et al., 2010. Following the adoption of Option B+, there was substantial progress in pregnant mothers receiving ART. The UNAIDS (2017a), reported that 80% of pregnant mothers living with HIV were on ART in 2017, compared with 51% who had access in 2010. Furthermore, results from the implementation of Option B+ accounted for a significant reduction of MTCT (Haas et al., 2017; Miller, Muyindike, Matthews, Kanyesigye, & Siedner, 2017; Ng'ambi et al., 2016; Ngemu et al., 2014; Phiri et al., 2017). For instance, a retrospective cohort study utilising routinely collected HIV exposed infant data from 2012-2014 at a large HIV centre in Lilongwe, Malawi found an MTCT rate of 6.2% for infants at 24 months (Ng'ambi et al., 2016). Similarly, another retrospective study found that only 5.3% of infants from 21 large health facilities in two regions of Malawi were HIV infected at the age of 30 months (Haas et al., 2017). Additionally, UNAIDS (2017a) reported that due to the implementation of sound PMTCT services, around 1.4 million HIV infections among children were prevented between 2010 and 2018. Such progress provides evidence that ART interrupts HIV transmission. For this reason, the need for providing universal lifelong ART to all HIV pregnant and breastfeeding mothers is undisputed. However, although the above studies show a significant decrease in the MTCT risks, these studies did not capture the risks of MTCT at different time points within the PMTCT programme. A more recent Malawi national-level analysis study found that overall, the risk of MTCT was as low as 4.7% with higher rates of 11.4% if mothers miss maternal ART, infant prophylaxis ARTs and infant testing (van Lettow et al., 2018). It can be argued, therefore, that the MTCT rate can only decrease if the mothers comply with all the steps in the PMTCT cascade. Nevertheless, lost to follow up (LTFU) has been the greatest challenge in the implementation of the Option B+ programme (Haas et al., 2016; Keehn & Karfakis, 2014; Nachega et al., 2016; Tenthani et al., 2015), leaving many infants undiagnosed, significantly putting their lives at risk of dying. According to the UNAIDS (2014) gap report, only 42% of exposed infants get tested for HIV in the first two months of life. Moreover, despite getting tested, some do not receive their results, as such, they are not promptly treated (Bobrow et al., 2016). Several studies have been conducted on LTFU from PMTCT (Bwirire et al., 2008; Kinuthia et al., 2011; Muchedzi et al., 2010; Nachega et al., 2012), but reasons for non-retention in the era of universal ART for PMTCT have not been comprehensively synthesised. For instance, a systematic review that assessed the reasons for low rates of access, initiation, and adherence to ARV drugs by mothers and HIV exposed infants in sub-Saharan Africa, identified and grouped facilitators and barriers to PMTCT as individual, partner, community and health care factors (Gourlay et al., 2015). However, this review included studies that were published between the year 2000 to 2012, (Gourlay et al., 2015) a period before the universal test and treat ART recommendation. Similarly, another systematic review examined health system barriers to and enablers of initiation, retention, and adherence of pregnant and postpartum women from 42 studies globally (Colvin et al., 2014). However, although this review was conducted in the era of Option B+, most of the studies that were included considered barriers and enablers under option A and B (Options where women were only started on lifelong ART if their CD4 count was below 350cells/mm3) and included only two papers on option B+ (Colvin et al., 2014). Recently, a mixed method review synthesised data on retention in care and identified factors associated with retention in care in the era of Option B+ (Knettel et al., 2017). The review included 22 papers on retention rates and 25 papers for factors associated with retention. The review identified younger age, initiating ART during pregnancy versus breastfeeding and initiating late in pregnancy as risk factors associated with retention (Knettel et al., 2017). They further reported that retention was compromised by stigma, fear of disclosure and lack of social support (Knettel et al., 2017). However, despite providing explicit data on Option B+ retention rates, the facilitators and barriers to option B+ uptake were not explicitly synthesised. While existing studies and reviews have considered LTFU under universal life-long ART for the PMTCT, the evidence has not been comprehensively synthesised. Therefore, a narrative synthesis of evidence surrounding retention in care under the universal life-long ART for the PMTCT was conducted to build on the above literature