Equity in prenatal healthcare services globally: an umbrella review.

BACKGROUND: Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics. METHODS: For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews. RESULTS: The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors. CONCLUSIONS: This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

Tranexamic Acid Use in the Postpartum Period Since the WOMAN Trial: A Retrospective Chart Review.

OBJECTIVE: To analyze the use of tranexamic acid (TXA) in postpartum patients since the World Maternal Antifibrinolytic (WOMAN) trial. METHODS: A retrospective chart review was conducted from May 2017 to March 2020 at a tertiary care centre to identify all patients who received TXA for postpartum bleeding. The primary outcome was to identify the proportion of patients who received TXA as per World Health Organization guidelines created using results of the World Maternal Antifibrinolytic trial. RESULTS: A total of 231 patients were included in our analysis. Use increased over time with 18 patients in 2017, 51 in 2018, and 134 in 2019 receiving TXA. In all, 203 patients (87.9%) received TXA within recommended guidelines, and these patients were less likely to require surgery or interventional radiology (12.3% vs. 42.9%, P < 0.001) or blood transfusion (23.6% vs. 42.9%, P = 0.030), and they had a lower likelihood of overall adverse outcomes (1.62 (1.6) vs. 2.60 (2.0), P = 0.024). TXA was commonly used as the first-line agent for postpartum bleeding (48.9% of patients), more likely administered at cesarean section (77.0%) and when estimated blood loss did not meet criteria for "true" postpartum hemorrhage (41.6% of patients). Use of TXA as the first medication was associated with fewer overall adverse outcomes than misoprostol (P = 0.035). A shorter time to administration of the first medication was associated with shorter postpartum admission time (P = 0.042). CONCLUSIONS: The majority of patients received TXA within guidelines and experienced fewer adverse outcomes. Further study is needed to identify the best order of TXA administration with additional uterotonics and whether TXA should be used prophylactically in some groups for postpartum bleeding.