Contributions to the literature
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Aligning healthcare with evidence-based practice can be challenging—what clinicians do, how they do it, when they do it, and who they do it with, is shaped by myriad factors and processes.
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Implementation science in maternity care was helped or hindered by: organisational factors (culture, communication, coordination, stakeholder engagement and implementation planning); personal factors (motivation, perceived value, knowledge and skill development) and contextual factors (adaptation of the intervention and/or its implementation, the capacity to accommodate change and infrastructure).
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Although theory can clarify how different practices are introduced, operationalised and sustained, only 6 of 158 publications explicitly referred to a theory.
Background
the scientific study of methods to promote the systematic uptake of evidence-based interventions into practice and policy and hence improve health. In this context, it includes the study of influences on professional, patient and organisational behaviour in healthcare, community or population contexts.
About 810 women die from pregnancy- or childbirth-related complications every day. 94% of all maternal deaths occur in low and lower middle-income countries ([31], emphasis added).
Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the estimated global maternal deaths in 2017. Sub-Saharan Africa alone accounted for roughly two-thirds (196 000) of maternal deaths, while Southern Asia accounted for nearly one-fifth (58 000)… [However] Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known ([32], emphasis added).
Methods
Searches
Inclusion criteria
Data extraction, data synthesis and study quality assessment
Results
Review statistics
Characteristic | N° | Publications |
---|---|---|
Study design | ||
Qualitative | ||
Cross-sectional survey | 72 | |
Mixed-methods | 27 | |
Case study | 12 | |
Pre-post study | 8 | |
Ethnography | 6 | |
Cohort study | 4 | |
Pilot-test | 8 | |
Longitudinal survey | 2 | |
Quasi-experimental | 1 | [179] |
Randomised controlled trial | 2 | |
Retrospective medical record and document analysis | 2 | |
Region | ||
Africa | 42 | |
Europe | 36 | |
Australia and/or New Zealand | 26 | |
United States and/or Canada | 14 | |
Asia | 13 | |
Multiple continents | 7 | |
South and Central America | 6 | |
National income level | ||
High | 83 | |
Lower-middle | 24 | |
Upper-middle | 17 | |
Low | 16 | |
Multiple nations with a high-, low- and middle-income classification | 2 | |
Multiple nations with a low- and lower-middle-income classification | 2 | |
Participants | ||
Maternity care clinicians and/or pregnant women | 129 | |
Parents, health administrators, policymakers, project staff, maternity care clinicians, community outreach workers, and/or community members | 10 | |
Policymakers | 3 | |
Nil—secondary data sourced from case-notes, patient records, and/or guidelines | 2 | |
Context | ||
Hospital wards | 107 | |
Community and hospital | 24 | |
Community | 12 | |
General practices | 1 | [135] |
Research methods | ||
Mixed-methods | 53 | |
Questionnaire or survey | 35 | |
Interviews | 31 | |
Interviews and Focus groups | 10 | |
Focus groups | 9 | |
Case study | 4 | |
Observation | 2 | |
Focus | ||
Stakeholder perceptions and attitudes re implementation, and/or the associated helpers and hindrances | ||
Qualitative study | 64 | |
Quantitative and qualitative study | 25 | |
Quantitative study | 20 | |
Create an implementation theory, model, and/or framework | ||
Qualitative study | 1 | [112] |
Feasibility testing and/or assess organisational readiness | ||
Qualitative study | 6 | |
Quantitative and qualitative study | 6 | |
Quantitative study | 1 | [67] |
Use evidence on helpers and hindrances to guide implementation of an intervention | ||
Quantitative and qualitative study | 3 | |
Qualitative study | 2 | |
Implement and/or pilot–test an intervention | ||
Quantitative and qualitative study | 10 | |
Qualitative study | 5 | |
Quantitative study | 1 | [181] |
Author-identified limitations | ||
Methodological issues, including: small sample; recall bias; self-report reliance; and/or limited generalisability | 107 | |
Nil noted | 37 |
Theories, models and frameworks: absent
Factor | Demonstrations | Publications suggesting it helps when present | Publications suggesting it hinders when absent |
---|---|---|---|
Organisational | Healthy organisational culture, including: limited tension between disciplines/professions; clearly defined professional roles and responsibilities; interprofessional respect; limited tension between traditional and western medicine; and limited cultural taboos, social stigma, and discrimination against service users | ||
Effective communication between and among managers, multidisciplinary service providers, and service users | |||
Effective multilevel coordination, support, management, and/or leadership | |||
Stakeholder engagement, including: community engagement; rapport building; local leadership; community awareness initiatives; welcoming community comment; service user involvement in care; and interorganisational networking | |||
Service provider involvement in the design, development, or use of an intervention, and implementation strategy, the evaluation of the intervention, and/or the dissemination of information about the project | |||
Implementation planning, including its stages, pilot–testing, evaluation, and/or sustainability | |||
Personal | Motivation to change among service providers | ||
Perceived value of the intervention among service providers | |||
Knowledge, training, education, and/or feedback to or from service providers or service users | |||
Contextual | Adaptation of the intervention and/or its implementation | ||
Individual capacity to accommodate change, including: resources; time; working arrangements that align with personal needs; pay incentives to upskill or implement different care models of care; reasonable travel times; and individual wellbeing and work–life balance | |||
Organisational capacity to accommodate change, including: workforce capacity; and resources (e.g. medical equipment, administrative equipment, health education materials, time) | |||
Infrastructure, including: transport; technology; structurally safe and accessible services; adequate physical space in buildings and wards; and reliable water and electricity |
Theories, models and frameworks: present
Category | Publication | Nation | Aim | Design and/or method | Participants | Theory, model or framework | Use |
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Determinant frameworks | [192] | Morocco | ‘understand the implementation process by identifying the characteristics of this intervention and the dimensions of the three systems which could act as barriers to/facilitators of the implementation process’ | Case study (document analysis, focus groups, interviews, observation of educational sessions) | • Administrators (medical administration officers, administrative nurse cadres, health programmer), clinicians (consultant, midwives, nurses, obstetricians, physicians), managers (academic directors, medical directors nurse managers, midwifery managers and representatives), students, women (n = 107) | Consolidated framework for implementation research | Analyse qualitative data |
[191] | Australia | ‘explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines’ | Interviews | • Managers (obstetric, midwifery = 8), clinicians (midwives, obstetricians = 19; total = 27) | Theoretical domains framework | Identify implementation barriers | |
[190] | Kenya | ‘describes and analyses the implementation process, its strengths and challenges, and the lessons gained’ | Mixed-methods (case narratives, document analysis, focus groups, interviews) | • Clinicians (community health workers, doctors, matrons, nurses), managers (district health program managers, coordinators), policymakers, professional association representatives (medical, nursing), women who delivered at the service in the last 6 months (interviews: n = 122) • Community leaders, community members, women who delivered at the service in the last 6 months (focus groups: n = 98) • Women who delivered at the service in the last 6 months (case narratives: n = 65) | Consolidated framework for implementation research | Analyse qualitative data | |
[193] | Australia | ‘describes the perceptions that midwives and nurses have about the BFHI [Baby Friendly Health Initiative] and examines factors that may facilitate or hinder the implementation process’ | Focus groups | • Clinicians (child and family nurses, midwives, neonatal nurses), managers (clinical consultants, midwifery and child and family health nursing managers), student midwives (n = 132) | Diffusion of innovations model | Analyse qualitative data | |
[189] | Australia | ‘systematically assess evidence-practice gap in the multidisciplinary management of overweight and obesity… in pregnancy to inform an intervention to facilitate translating obesity guidelines into practice in a tertiary maternity service’ | Survey | • Clinicians (dieticians, midwives, obstetricians, physiotherapists; n = 84) | Theoretical domains framework | Analyse qualitative data | |
Implementation theories | [195] | Australia | ‘discuss how theory can be used to explore, understand and interpret implementation strategies and the impact of organisational context when evaluating new models of health service delivery’ | Case studies | • RCT one: midwives (n = 8), women (n = 1000) • RCT two: midwives (n = 12), women (n = 2314) | Normalisation process model | Analyse qualitative data |
[186] | United Kingdom | ‘develop an intervention to improve the quality and content of place of birth discussions between midwives and low-risk women and to evaluate this intervention in practice’ | Mixed-methods (focus groups, interviews, questionnaires, midwife feedback visits, workshops) | • Stage 1: midwives (n = 38) • Stage 2: midwives (n = 58) • Stage 3: midwives (n = 66) | Capability, opportunity, motivation and behaviour (COM-B) | Guide intervention design | |
[196] | United Kingdom | Gauge the ‘acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention’ | Process evaluation (interviews, observation) | • Maternity staff (n = 60), staff who deliver smoking cessation services (n = 39), staff of other organisations (n = 4; total = 103) | Normalisation process theory | Analyse qualitative data | |
[194] | United Kingdom | ‘explore the benefits, barriers and disadvantages of implementing an electronic record system (ERS). The extent that the system has become ‘normalised’ into routine practice was also explored’ | Interviews | • Healthcare staff (doctors, healthcare assistants, midwives; total = 19) | Normalisation process theory | Analyse qualitative data | |
Classic theories | [198] | Spain | ‘develop an instrument to measure variables that influence health care professionals’ behaviour with regard to the protection, promotion, and support of breastfeeding, especially one that related to the Baby-Friendly Hospital Initiative (BFHI), and to conduct a psychometric assessment’ | Cross-sectional using a questionnaire | • Multidisciplinary working group that developed the questionnaire included (preventive medicine and public health physicians = 2; psychologists = 2; midwife=1; nurse = 1; paediatrician n = 1) • Expert groups that reviewed the questionnaire (clinicians=20; psychologists = 12; nurses = 6; paediatricians = 5; midwives = 3; general practitioners = 2) • Maternity and primary care clinicians who completed the questionnaire, including midwives, nurses, nursing assistants, physicians (n = 201) | Theory of reasoned action | Inform questionnaire development |
[197] | Australia | ‘understand clinician factors that may influence the up- take, acceptance and use of the NLBB [Normal Labour and Birth Bundle]’ | Mixed-methods (two focus groups, survey) | • Maternity care clinicians (midwives, consultant obstetricians, residents and registrars; n = 74) | Theory of planned behaviour | Analyse qualitative data | |
Evaluation framework | [199] | Zambia | ‘explore perspectives, roles, achievements and challenges of the Safe Motherhood Action Groups (SMAG) programme in Kalomo, Zambia’ | Interviews | • Action group members (n = 22), community leaders (n = 5), husbands (n = 3), manager (n = 1), mothers (n = 10), nurses (n = 5; total = 46) | PRECEDE-PROCEED | Analyse qualitative data |
Process model | [200] | United States | ‘set forth a new patient-centred implementation model informed by a qualitative study that explored women’s decisions, perceptions, and experiences of elective induction of labour’ | Interviews | • Pregnant women (n = 29) | Ottawa model of research use (OMRU) framework | Analyse qualitative data |
Additional framework | [201] | United Kingdom | Gauge the feasibility of implementing a maternity care intervention | Case study (pre-implementation survey, development and deployment of an implementation plan) | • Postnatal women (n = 250) | Stages of implementation framework | Describe and guide the translation of research into practice |