The effectiveness of interventions to improve access to and utilization of prenatal care: a systematic review protocol

Abstract

Centers conducting the review University of Manitoba; Queens Joanna Briggs Collaboration for Patient Safety: a Collaborating Center of the Joanna Briggs Institute Review question/objective The quantitative objective is to identify the effectiveness of novel or innovative interventions designed to improve access to and utilization of prenatal care. More specifically, the objective is to identify: The effectiveness of novel or innovative interventions designed to improve access to and utilization of prenatal care on the timing of the initial prenatal care visit and the total number of prenatal care visits in pregnant women. Background Prenatal care (PNC) is an important form of healthcare for pregnant women and their infants. PNC is generally defined as any healthcare services provided to pregnant women between conception and childbirth.1 There is evidence that PNC existed as far back as the 1800's. During this time, medical attention during pregnancy was focused on detection of eclampsia, a rare but life threatening condition where pregnant women develop dangerously high blood pressure.2 PNC has since evolved into one of the most common forms of preventive health services, involving medical screening, physical examinations, education and counselling. An additional purpose of PNC for low income and/or vulnerable women is the provision of social supports.3 In Western countries, such as Canada, typical PNC usually involves a longer initial visit followed by a series of shorter visits becoming more frequent as the pregnancy progresses.3 The Society of Obstetricians and Gynecologists of Canada (SOGC) recommends a PNC visit every four to six weeks until 30 weeks, a visit every two to three weeks until 36 weeks followed by a visit every one to two weeks until delivery.4 The American College of Obstetricians and Gynecologists recommends one visit per month for the first 28 weeks, one visit every two weeks until 36 weeks, followed by weekly visits until delivery.5 In less developed nations women receive far fewer PNC visits. The World Health Organization recommends that pregnant women in developing countries attend at least four prenatal visits.6 The adequacy of PNC is often associated with its efficacy and can be measured in a number of ways. For example, some studies use the trimester of initiation of care, while others use the number of visits. The two most common indices for determining the adequacy of PNC are the Adequacy of Prenatal Care Utilization Index (APNCU)7 and the revised GINDEX (R-GINDEX).8 Although these indices are both used frequently in studies examining pregnancy outcomes and their relationship to PNC adequacy, caution is needed as the two do not categorize adequacy equally.8–10 The two indices both measure the timing of initiation of PNC as well as offering categories of adequacy related to total number of PNC visits, adjusted for gestational age at birth. Adequate PNC has the potential to detect and respond to conditions which may jeopardize the health and wellbeing of both mother and baby. The receipt of PNC has been linked to a number of positive outcomes, including reduced rates of pre-term birth and low birth weight.11–13 However, there is evidence to suggest that PNC adequacy alone may not be sufficient to reduce the risk of pre-term birth in all populations.14 The content or quality of the care given is also an important factor.15–17 Until recently, there have not been any published instruments specifically designed to determine PNC quality. However, Heaman et al. recently developed the Quality of Prenatal Care Questionnaire (QPCQ), a 46-item self-report questionnaire containing six subscales.18 Despite well documented evidence to support the benefits of PNC, some women, particularly those in more disadvantaged circumstances, receive inadequate PNC or even no care at all.19 Many women who receive inadequate PNC are ethnic minorities, immigrants, women living in poverty, women who smoke and those who abuse alcohol or illicit substances.9,20–25 This subset of women are also those most at risk of experiencing adverse outcomes.13,26 A 2007 study conducted in the Canadian province of Manitoba found that women of higher parity (>four children) and teenage mothers were at higher risk of receiving inadequate PNC. The same study also found that socio-ecologic variables increased the risk of inadequate PNC. The highest rates of inadequate PNC were among women living in neighborhoods with the lowest average family income and the highest percentages of the population reporting Aboriginal or recent immigrant status, single parent families, less than nine years of education and unemployment.25 Therefore it is clear that conventionally delivered PNC may not be effective in reaching those women who may be in the greatest need of preventive care. Most PNC services in Western countries are generally delivered by physicians and/or midwives and consist of office visits, although midwives may conduct care in the woman's home.27 There is a considerable body of literature which explores the barriers women encounter when attempting to access conventional PNC.20,22,28–32 These barriers include difficulty with transportation and childcare, lack of trust in healthcare providers and financial difficulties. A recent study conducted in the Canadian province of Manitoba found that psychosocial, structural and attitudinal barriers all contribute to difficulties in accessing PNC. The study also examined facilitators and motivators for accessing PNC. Motivators included incentives such as food vouchers and assistance with transportation expenses. Facilitators included factors such as the desire to have a healthy baby and the desire to protect their own health.33 Group PNC has been proposed as an alternative to conventional care delivery. In group PNC women attend PNC classes in groups of varying size and typically involves fewer sessions then conventional, individual care.34 The most frequently reviewed form of group PNC is CenteringPregnancy© which was developed in the United States in the early 1990s.35 There have been a number of studies comparing individual and group PNC and four systematic reviews were found which examine the outcomes of these studies.27,36–38 These reviews found mixed results as to the ability of group PNC to impact outcomes such as preterm birth and low birth weight, and most studies reviewed lacked rigor. The currently proposed review will exclude those studies already evaluated in the systematic reviews of group PNC, and focus instead on other forms of innovative PNC programs. This review will summarize evidence on the effectiveness of PNC interventions on the timing of PNC initiation and number of PNC visits. A review of the literature did not find any other reviews or review protocols with a similar focus, including any reviews published in Spanish. An examination of the Cochrane Library of Systematic Reviews, the JBI Database of Systematic Reviews and Implementation Reports and the PROSPERO database indicated that no systematic reviews had been completed (or proposed) on this topic as of September 2014. Inclusion criteria Types of participants This review will consider studies that include pregnant women. Types of intervention(s)/phenomena of interest The review will consider studies that evaluate novel and innovative interventions designed to increase accessibility and utilization of prenatal care and comparing these programs against the regular existing programs. Studies evaluating group prenatal care and/or CenteringPregnancy© will be excluded from this review, because four systematic reviews27,36–38 have already examined the outcomes of these studies. The interventions of interest involve novel or innovative programs or specific interventions (e.g. incentives, enablers) intended to improve accessibility and utilization of prenatal care. Types of outcomes This review will consider studies that include the following outcome measures: timing of initiation of prenatal care, number of prenatal care visits or use of a utilization index to measure adequacy of care. Definition A utilization index is defined as a measurement tool designed to categorize PNC utilization as being adequate or inadequate based on timing of initiation of care and number of visits with adjustments made for gestational age at delivery.39 Types of studies This quantitative review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies. Search strategy The search strategy aims to find both published and unpublished studies. A three step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all included reports and articles will be searched for additional relevant studies not captured in the bibliographic databases. Studies published in English and Spanish will be considered for inclusion in this review, as our review panel includes a native Spanish speaker. Spanish articles will be reviewed initially by Yenly Londono, who is the Spanish speaking team member. Google translator will be used to translate into English any articles which are to be reviewed by the second reviewer. Studies published in the past 20 years (e.g. 1994 to 2014) will be considered for inclusion in this review. This time frame was selected as the majority of studies which examine programs intended to increase the utilization of PNC have been conducted during the last two decades. The databases to be searched include: Pubmed, CINAHL, Scopus, Cochrane library, Web of Science, ERIC (Educational Resources Information Center) and LILACS (Latin American and Caribbean Health Science Literature) The search for unpublished studies will include: government reports, hospital protocols, grey literature, dissertations indexed with ProQuest Dissertations & Theses Initial English language keywords to be used will be: prenatal care, prenatal visits, antenatal care, antenatal visits, pregnancy care, interven*, access*,utiliz*, program*, project*,initial, initat* Initial Spanish language keywords to be used will be: control prenatal, cuidado antenatal, intervención, acceso, utilización, programa, projecto, inicial, iniciar, iniciado, iniciación Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Data extraction Quantitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes, expressed as odds ratio (for categorical data) or weighted mean differences (for continuous data), and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest None Acknowledgements The primary and secondary reviewers received an award from the Manitoba Center for Nursing and Health Research (MCNHR) to support this systematic review. Suzanne Lennon and Yenly Londono are each supported by a studentship from the Manitoba Institute of Child Health/Research Manitoba.