BACKGROUND AND OBJECTIVES: Respectful maternity care promotes practices that acknowledge women's preferences and women and newborns' needs. It is an individual-centered strategy founded on ethical and human rights principles. The objective of this systematic review is to identify the impact of income on maternal care and respectful maternity care in low- and middle-income countries. MATERIALS AND METHODS: Data were searched from Google Scholar, PubMed, Web of Science, NCBI, CINAHL, National Library of Medicine, ResearchGate, MEDLINE, EMBASE database, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Maternity and Infant Care database. This review followed PRISMA guidelines. The initial search for publications comparing low- and middle-income countries with respectful maternity care yielded 6000 papers, from which 700 were selected. The review articles were further analyzed to ensure they were pertinent to the comparative impact of income on maternal care. A total of 24 articles were included, with preference given to those published from 2010 to 2023 during the last fourteen years. RESULTS: Considering this study's findings, respectful maternity care is a crucial component of high-quality care and human rights. It can be estimated that there is a direct association between income and maternity care in LMICs, and maternity care is substandard compared to high-income countries. Moreover, it is determined that the evidence for medical tools that can enhance respectful maternity care is sparse. CONCLUSIONS: This review highlights the significance of improving maternal care experiences, emphasizing the importance of promoting respectful practices and addressing disparities in low- and middle-income countries.

Antenatal care (ANC) is essential in maternal and child health since it provides care to pregnant women from conception through to labour in order to ensure a safe pregnancy and childbirth. In recent years, mobile health (mHealth) interventions have emerged as a promising solution to improve maternal and child health outcomes in low- and middle-income countries (LMICs). The present study aimed to conduct a systematic review and meta-analysis of trials to evaluate the effectiveness of mHealth interventions to monitor prenatal care among pregnant women in LMICs. A systematic literature review was conducted using the databases CINHAL, Embase, MEDLINE, and PsycINFO on the effectiveness of mHealth interventions in monitoring the antenatal care of pregnant women. The study selection, data extraction of the included articles, and quality appraisal were assessed. Our study included six studies considering 7886 participants. All articles were from low- and middle-income countries (LMICs). Antenatal mothers who used a mobile health intervention were more likely (RR = 1.66, 95%CI = 1.07-2.58, I(2) = 98%) to attend ANC check-ups when compared with the women who did not use any mobile health applications or did not receive any short message services. mHealth technologies are being utilised more and more to increase care accessibility and improve maternal and fetal health. Policymakers should prioritise the integration of mHealth interventions into maternal healthcare services in LMICs, ensuring that they are cost- effective, accessible, and sustainable and that healthcare workers are trained to deliver these interventions effectively.

OBJECTIVE: To compare benefits and harms of televisits and in-person visits in people receiving routine antenatal care. DATA SOURCES: A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries. METHODS OF STUDY SELECTION: Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher. TABULATION, INTEGRATION, AND RESULTS: Two randomized controlled trials, four nonrandomized comparative studies, and one survey compared visit types between 2004 and 2020, three of which were conducted during the coronavirus disease 2019 (COVID-19) pandemic. Number, timing, and mode of televisits and who provided care varied across studies. Low-strength evidence from studies comparing hybrid (televisits and in-person visits) and all in-person visits did not indicate differences in rates of neonatal intensive care unit admission of the newborn (summary odds ratio [OR] 1.02, 95% CI 0.82–1.28) or preterm births (summary OR 0.93, 95% CI 0.84–1.03). However, the studies with stronger, although still statistically nonsignificant, associations between use of hybrid visits and preterm birth compared the COVID-19 pandemic and prepandemic eras, confounding the association. There is low-strength evidence that satisfaction with overall antenatal care was greater in people who were pregnant and receiving hybrid visits. Other outcomes were sparsely reported. CONCLUSION: People who are pregnant may prefer hybrid televisits and in-person visits. Although there is no evidence of differences in clinical outcomes between hybrid visits and in-person visits, the evidence is insufficient to evaluate most outcomes.

BACKGROUND: Sustainable Development Goals -3 (SDG - 3) were to ensure healthy live and promote well-being by reducing global maternal and neonatal deaths. These were to be implemented through the concept of continuum of care in maternal health program framework to improve health outcomes. There is a paucity of published evidences; as such, this review is designed to assess the effectiveness of the concept of continuum of care in maternal and neonatal health services on the reduction of maternal and neonatal mortality. METHODS: A search was conducted using the key words; maternal and neonatal, health services, continuum of care, maternal and neonatal mortality. Search focused on PubMed, Cochrane, MEDLINE and Google Scholar. Extractions of articles were done based on predetermine criteria. Data were compiled, and screened, entered and analysis was done using STATA 13 and Rev. Man. software. Effects of the intervention package were determined and the result was interpreted in random effect RR with 95%CI. The publication bias was determined by using funnel plot, Egger and Bagger test, heterogeneity, and sensitivity test. RESULTS: A total of 4685 articles were retrieved of these 20 articles reviewed. Articles on 631,975 live births (LBs) were analyzed. Results showed the distribution as follows; 23,126 newborns died within 28 days resulting [NMR = 35/1000LBs among the intervention group whereas NMR = 39/1000LBs among the control group]. The pooled effect of the intervention was significantly reduced neonatal mortality (RR = 0.84; 95%CI: 0.77-0.91). Similarly, 1268 women died during the pregnancy period up to 42 days after childbirth that resulted [MMR = 330/100,000LBs among the intervention group whereas MMR = 460/100,000LBs among the control group]. The pooled effect of the intervention was not a statistically significant association with maternal mortality (RR = 0.64; 95%CI: 0.41-1.00). CONCLUSION: Adoption of continuum of care concepts in maternal health services reduced maternal and neonatal mortality. We recommend strengthening and effective implementation of a continuum of care in maternal health services to improve maternal and neonatal health care outcomes.

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.

IMPORTANCE: Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. OBJECTIVE: To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum. EVIDENCE REVIEW: Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide. FINDINGS: A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits. CONCLUSIONS AND RELEVANCE: The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

BACKGROUND: Positive health behavior changes before pregnancy can optimize perinatal outcomes for mothers, babies, and future generations. Women are often motivated to positively change their behavior in preparation for pregnancy to enhance their health and well-being. Mobile phone apps may provide an opportunity to deliver public health interventions during the preconception period. OBJECTIVE: This review aimed to synthesize the evidence of the effectiveness of mobile phone apps in promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods), which may improve future outcomes for mothers and babies. METHODS: Five databases were searched in February 2022 for studies exploring mobile phone apps as a prepregnancy intervention to promote positive behavior change. The identified studies were retrieved and exported to EndNote (Thomson Reuters). Using Covidence (Veritas Health Innovation), a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) study flow diagram was generated to map the number of records identified, included, and excluded. Three independent reviewers assessed the risk of bias and conducted data extraction using the Review Manager software (version 5.4, The Cochrane Collaboration), and the data were then pooled using a random-effects model. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess the certainty of the evidence. RESULTS: Of the 2973 publications identified, 7 (0.24%) were included. The total number of participants across the 7 trials was 3161. Of the 7 studies, 4 (57%) included participants in the interconception period, and 3 (43%) included women in the preconception period. Of the 7 studies, 5 (71%) studies focused on weight reduction, assessing the outcomes of reductions in adiposity and weight. Of the 7 studies, nutrition and dietary outcomes were evaluated in 2 (29%) studies, blood pressure outcomes were compared in 4 (57%) studies, and biochemical and marker outcomes associated with managing disease symptoms were included in 4 (57%) studies. Analysis showed that there were no statistically significant differences in energy intake; weight loss; body fat; and biomarkers such as glycated hemoglobin, total cholesterol, fasting lipid profiles, or blood pressure when compared with standard care. CONCLUSIONS: Owing to the limited number of studies and low certainty of the evidence, no firm conclusions can be drawn on the effects of mobile phone app interventions on promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods).

BACKGROUND: Preterm Birth (PTB) is one of the leading causes of infant morbidity and mortality. Prenatal care is an effective way to improve pregnancy outcomes but there is limited evidence of effective interventions to improve perinatal outcomes in disadvantaged pregnant women. This review was conducted with the aim to assess the effectiveness of prenatal care programs in reducing PTB in socioeconomically disadvantaged women. MATERIALS AND METHODS: We searched the Scopus, PubMed, Web of Science, and Cochrane Library databases from January 1, 1990 to August 31, 2021. The inclusion criteria included clinical trials and cohort studies focusing on prenatal care in deprived women with the primary outcome of PTB (< 37 weeks). Risk of bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias and the Newcastle-Ottawa Scale. Heterogeneity was evaluated using the Q test and I2 statistics. The pooled odds ratio was calculated using random-effects models. RESULTS: In total, 14 articles covering 22,526 women were included in the meta-analysis. Interventions/exposures included group prenatal care, home visits, psychosomatic programs, integrated intervention on socio-behavioral risk factors, and behavioral intervention through education, social support, joint management, and multidisciplinary care. The pooled results showed that all types of interventions/exposure were associated with a reduction in the risk of PTB [OR = 0.86; 95% confidence interval: (0.64, 1.16); I2 = 79.42%]. CONCLUSIONS: Alternative models of prenatal care reduce PTB in socioeconomically disadvantaged women compared with standard care. The limited number of studies may affect the power of this study.

BACKGROUND: Telehealth can reduce the gap between developmental concern and diagnosis. Evaluation of telehealth methods is needed for providers to make decisions about using telediagnostic assessments. AIM: This systematic review examined telehealth in facilitating a diagnosis for children with developmental concerns and assessed 1) study characteristics and type of diagnostic evaluation; 2) comparison of telehealth technologies to in-person diagnostic methods; 3) feasibility and acceptability of telehealth technologies; and 4) methodological quality. METHOD AND PROCEDURES: Peer-reviewed studies from PsycINFO, CINAHL, Web of Science, PubMed, Embase, and Cochrane published January 2000-July 2021 were searched using "telehealth" AND "developmental concern" AND "diagnosis". Data extraction included study characteristics, diagnostic evaluation, technology, diagnostic accuracy, feasibility, and acceptability. Methodological quality was assessed using NHLBI tools. OUTCOMES AND RESULTS: Nine studies met inclusion. Children with suspected FAS, social-emotional concerns, suspected genetic conditions, and failed hearing screenings received a telediagnosis. Evaluations included dysmorphology, feeding, neurological, developmental, audiological, and psychiatric. Seven studies used videoconferencing in real-time and two used Store-and-Forward methods. High diagnostic agreement occurred between face-to-face and remote methods. Stakeholders reported high satisfaction and feasibility. Many of the studies were rated as fair quality. CONCLUSIONS AND IMPLICATIONS: Findings underscore partnership models between local providers and remote specialists. Rigorous study designs with larger samples covering a wider range of developmental domains are needed to provide a stronger empirical base for providers.

BACKGROUND: The birth plan was introduced in the 1980s to facilitate communication between maternity care providers and women and increase agency for childbearing women in the face of medicalised birth. Forty years on, the birth plan is a heterogeneous document with uncertainty surrounding its purpose, process, and impact. The aim of this review was to synthesise the evidence and improve understanding of the purpose, process and impact of the birth plan on childbearing women's experiences and outcomes. METHODS: This systematic review followed the PRISMA guidelines. A comprehensive search strategy was designed and applied to electronic databases CINAHL, MEDLINE, PsychINFO, Cochrane Library, Scopus, and ClinicalTrials.gov. Articles were appraised using the Crowe Critical Appraisal Tool and a five-step integrative approach to analysis followed. FINDINGS: Eleven articles were identified, all quantitative in nature. It is clear that the general purpose of birth plans is communication, with decision making a key factor. Even though the processes of birth planning were varied, having a birth plan was associated with generally positive birth outcomes. CONCLUSIONS: Despite the heterogeneity of birth plans, birth plans were associated with positive outcomes for childbearing women when developed in collaboration with care providers. The act of collaboratively creating a birth plan may improve obstetric outcomes, aid realistic expectations, and improve satisfaction and the sense of control.

Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.

AIMS: Black, Asian and minority ethnic women are at higher risk of dying during pregnancy, childbirth and postnatally and of experiencing premature birth, stillbirth or neonatal death compared with their White counterparts. Discrimination against women from ethnic minorities is known to negatively impact women's ability to speak up, be heard and their experiences of care. This evidence synthesis analysed Black, Asian and minority ethnic women's experiences of UK maternity services in light of these outcomes. DESIGN: We conducted a systematic review and qualitative evidence synthesis using the method of Thomas and Harden. DATA SOURCES: A comprehensive search in AMED, Cinahl, Embase, Medline, PubMed and PsycINFO, alongside research reports from UK maternity charities, was undertaken from 2000 until May 2021. Eligible studies included qualitative research about antenatal, intrapartum and postnatal care, with ethnic minority women in maternity settings of the UK NHS. REVIEW METHODS: Study quality was graded using the Critical Appraisal Skills Programme tool. RESULTS: Twenty-four studies met the inclusion criteria. Our synthesis highlights how discriminatory practices and communication failures in UK NHS maternity services are failing ethnic minority women. CONCLUSION: This synthesis finds evidence of mistreatment and poor care for ethnic minority women in the UK maternity system that may contribute to the poor outcomes reported by MBRRACE. Woman-centred midwifery care is reported as positive for all women but is often experienced as an exception by ethnic minority women in the technocratic birthing system. IMPACT: Ethnic minority women report positive experiences when in receipt of woman-centred midwifery care. Woman-centred midwifery care is often the exception in the overstretched technocratic UK birthing system. Mistreatment and poor care reported by many ethnic minority women in the UK could inform the inequalities of outcomes identified in the MBRRACE report.

BACKGROUND: Despite the existence of global recommendations, postnatal care provided following childbirth is variable and often fails to address a woman's concerns about herself and the parents' concerns about their baby. Discharge from a facility after birth is a key moment to ensure the woman, parents and newborn receive support for the transition to care in the home. We mapped the current policies, guidance and literature on discharge preparation and readiness to identify key concepts and evidence and inform recommendations to be considered in a World Health Organization (WHO) guidance on postnatal care. METHODS: We were guided by the Johanna Briggs Institute approach, and developed inclusion criteria based on existing defintions of discharge preparation and readiness, and criteria for discharge readiness compiled by international professional organisaitons. To identify guidelines and policies we searched websites and archives of guideline organisations, and contacted individuals and professional societies working on postnatal care. We searched 14 electronic databases to locate published research and other literature on discharge preparation and readiness. For documents that met the inclusion criteria we extracted key characteristics, summarised discharge readiness criteria and components and discharge preparation steps, and characterised interventions to improve discharge preparation. RESULTS: The review provides a systematic map of criteria for discharge that are in use and the common steps healthcare providers take in preparing women and newborns for the transition home. The mapping also identified interventions used to strengthen discharge preparation, theories and models that conceptualise discharge preparation, scales for measuring discharge readiness and qualitative studies on the perspectives of women, men and healthcare providers on postnatal discharge. CONCLUSIONS: The findings highlight contrasts between the research literature and policy documents. They indicate potential gaps in current discharge policies, and point to the need for more comprehensive discharge assessment and education to better identify and meet the needs of women, parents/caregivers and families prior to discharge and identify those who may require additional support.

OBJECTIVE: To systematically review the literature related to the effectiveness of parents' active involvement during painful interventions for their preterm infants. DATA SOURCES: We performed a systematic search of PubMed, EMBASE/Ovid, CINAHL, Livivio, and PsycInfo using the keywords "preterm infants," "pain," and "parents." STUDY SELECTION: Articles were eligible for inclusion if they were published between 2000 and 2021 and reported randomized controlled trials (RCTs) in which preterm infants underwent painful interventions, and parents were present and actively involved in pain-reducing measures. DATA EXTRACTION: We used the Consolidated Standards of Reporting Trials (CONSORT) checklist for RCTs for data extraction. We assessed methodologic quality using critical appraisal for RCTs according to the Joanna Briggs Institute. DATA SYNTHESIS: In total, 22 articles met the inclusion criteria. These articles reported 18 studies focused on kangaroo/skin-to-skin care, one focused on breastfeeding, and two focused on facilitated tucking. The methods used to evaluate pain in the infant varied substantially. Overall, kangaroo/skin-to-skin care and facilitated tucking resulted in clinically and statistically significant decreases in pain. For breastfeeding, effectiveness was linked to a more mature sucking pattern of the preterm infant. CONCLUSION: The current evidence suggests that involving parents in pain-reducing measures during painful interventions for their preterm infants is beneficial. However, more research is needed for the different methods of involving parents in pain-reducing measures.

AIM: We conducted an integrative review of the global-free maternity (FM) policies and evaluated the quality of care (QoC) and cost and cost implications to provide lessons for universal health coverage (UHC). METHODOLOGY: Using integrative review methods proposed by Whittemore and Knafl (2005), we searched through EBSCO Host, ArticleFirst, Cochrane Central Registry of Controlled Trials, Emerald Insight, JSTOR, PubMed, Springer Link, Electronic collections online, and Google Scholar databases guided by the preferred reporting item for systematic review and meta-analysis protocol (PRISMA) guideline. Only empirical studies that described FM policies with components of quality and cost were included. There were 43 papers included, and the data were analysed thematically. RESULTS: Forty-three studies that met the criteria were all from developing countries and had implemented different approaches of FM policy. Review findings demonstrated that some of the quality issues hindering the policies were poor management of complications, worsened referral systems, overburdening of staff because of increased utilisation, lack of transport, and low supply of stock. There were some quality improvements on monitoring vital signs by nurses and some procedures met the recommended standards. Equally, mothers still bear the burden of some costs such as the purchase of drugs, transport, informal payments despite policies being 'free'. CONCLUSIONS: FM policies can reduce the financial burden on the households if well implemented and sustainably funded. Besides, they may also contribute to a decline in inequity between the rich and poor though not independently. In order to achieve the SDG goal of UHC by 2030, there is a need to promote awareness of the policy to the poor and disadvantaged women in rural areas to help narrow the inequality gap on utilisation and provide a sustainable form of transport through collaboration with partners to help reduce impoverishment of households. Also, there is a need to address elements such as cultural barriers and the role of traditional birth attendants which hinder women from seeking skilled care even when they are freely available.

BACKGROUND: Preterm birth is a serious and common pregnancy complication. The burden is particularly high in low- and middle-income countries where available care is often inadequate to ensure preterm newborn survival. Administration of antenatal corticosteroids (ACS) is recommended as the standard care for the management of women at risk of imminent preterm birth but its coverage varies globally. Efforts to improve preterm newborn survival have largely been focused on optimising the coverage of ACS use. However, the benefits and harms of such strategies are unclear OBJECTIVES: To determine the relative benefits and risks of individual patient protocols, health service policies, educational interventions or other strategies which aim to optimise the use of ACS for anticipated preterm birth. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA: We planned to include randomised controlled trials (RCTs), randomised at individual or cluster level, and quasi-randomised trials that assessed strategies to optimise (either by increasing or restricting) the administration of ACS compared with usual care amongst women at risk of preterm birth. Our primary outcomes were perinatal death and a composite outcome of offspring mortality and early or late neurodevelopmental morbidity. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. All three review authors independently extracted data and assessed risk of bias. We used narrative synthesis to analyse results, as we were unable to pool data from the included studies. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: We included three cluster-RCTs, all assessing the effects of a multifaceted strategy aiming to promote the use of ACS among women at risk of preterm birth. We did not identify any trials assessing strategies to restrict the use of ACS versus usual care. Two of the included trials assessed use of ACS in high-resource hospital settings. The third trial, the Antenatal Corticosteroid Trial (ACT) was a multi-site trial conducted in rural and semi-urban settings of six low- and middle-income countries in South Asia, sub-Saharan Africa and Central and South America. In two trials, promoting the use of ACS resulted in increased use of ACS, whereas one trial did not find a difference in the rate of ACS administration compared to usual care. Whilst we included three studies, we were unable to pool the data in meta-analysis due to outcomes not being reported across all studies, or outcome results being reported in different ways. The main source of data in this review is from the ACT trial. We assessed the ACT trial as high risk for performance and selective reporting bias. In the protocol for this review, we planned to report all settings and subgroup by low-middle versus high-income countries; these planned analyses were not possible in this version of the review, although adding further studies in future updates may allow us to carry out planned subgroup analyses. The ACT trial was conducted in low-resource settings and reported data on appropriate ACS treatment and inappropriate ACS treatment. Although a strategy of promoting the administration of ACS compared to routine care may increase appropriate ACS treatment (RR 4.34, 95%CI 3.59 to 5.25; 1 study; n = 4389; low-certainty evidence), it may also increase inappropriate ACS treatment (RR 9.11 95%CI 8.04 to 10.33, 1 study, n = 89,237; low-certainty evidence). In low-resource settings, a strategy of promoting the administration of ACS probably increases population level perinatal death by 3 per 1000 infants (risk ratio (RR) 1.11, 95% confidence interval (CI) 1.04 to 1.19; 1 study; n = 100,705; moderate-certainty evidence); stillbirth by 2 per 1000 infants (RR 1.11, 95% CI 1.02 to 1.21; 1 study; n = 100,705; moderate-certainty evidence); and neonatal death before 28 days by 2 per 1000 infants (RR 1.12, 95% CI 1.02 to 1.23; 1 study; n = 100,705; moderate-certainty evidence); may increase the risk for 'suspected' maternal infection or inflammation (RR 1.49, 95% CI 1.32 to 1.68; 1 study; n = 99,742; low-certainty evidence); and make little or no difference to the risk of maternal mortality (RR 1.11, 95% CI 0.64 to 1.92; 1 study; n = 99,742; low-certainty evidence) compared to routine care. Included trials did not report on the composite outcomes offspring mortality, early neurodevelopmental morbidity or late neurodevelopmental morbidity; and offspring mortality or severe neonatal morbidity. AUTHORS' CONCLUSIONS: In low-resource settings, a strategy of actively promoting the use of ACS in women at risk of preterm birth may increase ACS use in the target population, but may also carry a substantial risk of unnecessary exposure of ACS to women in whom ACS is not indicated. At the population level, these effects are probably associated with increased risks of stillbirth, perinatal death, neonatal death before 28 days, and maternal infection. The findings of this review support a more conservative approach to clinical protocols and clinical decision-making particularly in low-resource settings, along the lines of the World Health Organization's ACS 2015 recommendations, which take into account both the established clinical efficacy of ACS when used in the correct situation and context, and the possibility of important adverse effects when certain conditions are not met. Given the unanticipated results of the ACT trial, further research on strategies to optimise the use of ACS in low-resource settings is justified.

Task shifting of Caesarean-sections to non-physician clinicians (NPCs) has raised concerns over NPCs' competences and rationale of using them in facilities where medical doctors (MDs) are scarce to provide mentorship. We conducted a scoping review to provide an update on NPCs' contribution to C-sections including barriers and enablers to task shifting. Using the PRISMA Flow Diagram, we identified 15 eligible articles from Google Scholar, PubMed and Africa Index Medicus using specific search terms and a pre-established inclusion criterion. All 15 studies characterised NPCs: their names, training, challenges and enablers to task shifting. NPCs performed 50%-94% C-sections. Outcomes of such C-sections were comparable to those performed by MDs. Enablers included supportive policies, pre-existing human resources for health shortage, well- resourced health facilities and supervision of NPCs. Weak health systems were major barriers. While NPCs make a significant contribution to accessing C-sections services, there is need to address challenges to fully realize benefits.

BACKGROUND: Pregnancy apps are a booming global industry, with most pregnant women in high-income countries now using them. From the perspective of health care and health information provision, this is both encouraging and unsettling; the demand indicates a clear direction for the development of future resources, but it also underscores the importance of processes ensuring access, reliability, and quality control. OBJECTIVE: This review provides an overview of current literature on pregnancy apps and aims at describing (1) the ways in which apps are used by women, in general, and by those of a culturally and linguistically diverse (CALD) background; (2) the utility and quality of information provided; and (3) areas where more research, development, and oversight are needed. METHODS: We chose a narrative review methodology for the study and performed a structured literature search including studies published between 2012 and 2017. Searches were performed using MEDLINE, EMBASE, and CINAHL databases. Studies were identified for inclusion using two separate search criteria and strategies: (1) studies on pregnancy apps and pregnant women's use of these apps and (2) studies on CALD pregnant women and their use of technology for accessing information on and services for pregnancy. Overall, we selected 38 studies. RESULTS: We found that pregnancy apps were principally used to access pregnancy health and fetal development information. Data storage capability, Web-based features or personalized tools, and social media features were also popular app features sought by women. Lower rates of the pregnancy app uptake were indicated among lower-income and non-English-speaking women. Preliminary evidence indicates that a combination of technological, health literacy, and language issues may result in lower uptake of pregnancy apps by these groups; however, further investigation is required. A marked limitation of the health app industry is lack of regulation in a commercially dominated field, making it difficult for users to assess the reliability of the information being presented. Health professionals and users alike indicate that given the choice, they would prefer using pregnancy apps that are relevant to their local health care context and come from a trusted source. Evidence indicates a need for greater health professional and institutional engagement in the app development, as well as awareness of and guidance for women's use of these resources. CONCLUSIONS: This is the first review of pregnancy app use, types of information provided, and features preferred by pregnant women in general and by those of a CALD background in particular. It indicates the demand for access to accurate information that is relevant to users, their community, and their associated health services. Given the popularity of pregnancy apps, such apps have enormous potential to be used for the provision of accurate, evidence-based health information.

BACKGROUND: Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa. METHODS: Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings. RESULT: The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff. CONCLUSIONS: A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness.

INTRODUCTION: Quality of care is increasingly recognized as a critical aspect of the maternal and newborn health, mainly with respect to care around labor and delivery and in the immediate postnatal period. The aim of this review was to identify the recommended intrapartum care indicators in order to measure the quality of midwifery care. EVIDENCE ACQUISITION: A structured literature search was conducted in August 2017 incorporating English and Italian language studies from 1993 and onwards to identify published articles on quality standards of intrapartum care. Research was performed into the area of enquiry in electronic database (Medline, Cochrane Library, CINAHL, Trip) and in relevant midwifery websites. EVIDENCE SYNTHESIS: We identified 369 quality indicators to measure the intrapartum care. Following a systematic process that allows to classify all indicators in domains and categories, we analyzed 268 outcome and process indicators specifically designated to monitor the intrapartum care in a low risk population. Through the identification of further exclusion criteria and semantic analogies we obtained 80 final quality indicators (39 outcome indicators and 41 process indicators). CONCLUSIONS: We identified 80 indicators that should be used to measure the quality of low risk intrapartum care. Although the majority of indicators we could monitor through hospital databases and the Italian Birth Register-CeDAP are outcome indicators, it is important to give attention also to process indicators that measure the activities performed and whether or not they are evidence-based. For a low risk population they could measure adherence with guidelines that promote and support the normality of the process.