Maternity care services and culture: a systematic global mapping of interventions.

BACKGROUND: A vast body of global research shows that cultural factors affect the use of skilled maternity care services in diverse contexts. While interventions have sought to address this issue, the literature on these efforts has not been synthesised. This paper presents a systematic mapping of interventions that have been implemented to address cultural factors that affect women's use of skilled maternity care. It identifies and develops a map of the literature; describes the range of interventions, types of literature and study designs; and identifies knowledge gaps. METHODS AND FINDINGS: Searches conducted systematically in ten electronic databases and two websites for literature published between 01/01/1990 and 28/02/2013 were combined with expert-recommended references. Potentially eligible literature included journal articles and grey literature published in English, French or Spanish. Items were screened against inclusion and exclusion criteria, yielding 96 items in the final map. Data extracted from the full text documents are presented in tables and a narrative synthesis. The results show that a diverse range of interventions has been implemented in 35 countries to address cultural factors that affect the use of skilled maternity care. Items are classified as follows: (1) service delivery models; (2) service provider interventions; (3) health education interventions; (4) participatory approaches; and (5) mental health interventions. CONCLUSIONS: The map provides a rich source of information on interventions attempted in diverse settings that might have relevance elsewhere. A range of literature was identified, from narrative descriptions of interventions to studies using randomised controlled trials to evaluate impact. Only 23 items describe studies that aim to measure intervention impact through the use of experimental or observational-analytic designs. Based on the findings, we identify avenues for further research in order to better document and measure the impact of interventions to address cultural factors that affect use of skilled maternity care.

Ethical issues: the multi-centre low-risk ethics/governance review process and AMOSS.

BACKGROUND: The Australasian Maternity Outcomes Surveillance System (AMOSS) conducts surveillance and research of rare and serious conditions in pregnancy. This multi-centre population health study is considered low risk with minimal ethical impact. OBJECTIVE: To describe the ethics/governance review pathway undertaken by AMOSS. METHOD: Prospective, descriptive study during 2009-2011 of the governance/ethical review processes required to gain approval for Australian and New Zealand (ANZ) maternity units with more than 50 births per year (n = 303) to participate in AMOSS. RESULTS: Review processes ranged from a single application for 24 NZ sites, a single application for eligible hospitals in two Australian states, full Health Research Ethics Committee (HREC) applications for individual hospitals, through simple letters of support. As of September 2011, 46 full/expedited ethics applications, 131 site governance applications and 136 letters of support requests were made over 33 months, involving an estimated 3261 hours by AMOSS staff/investigators, and an associated resource burden by participating sites, to obtain approval to receive nonidentifiable data from 291 hospitals. CONCLUSION: The AMOSS research system provides an important resource to enhance knowledge of conditions that cause rare and serious maternal morbidity. Yet the highly variable ethical approval processes required to implement this study have been excessively repetitive and burdensome. This process jeopardises timely, efficient research project implementation, without corresponding benefits to research participants. The resource burden to establish research governance for AMOSS confirms the urgent need for the Harmonisation of Multi-centre Ethical Review (HoMER) to further streamline ethics/governance review processes for multi-centre research.

Hospital ethics approval for a population-based case-control study of very preterm birth.

AIM: To describe the process involved in obtaining ethics approval for a study aiming to recruit women from all maternity hospitals in Victoria, Australia. DESIGN: Observational data of the application process involving 85 hospitals throughout Victoria in 2001. RESULTS: Twenty-three of the 85 hospitals had a Human Research Ethics Committee (HREC) constituted in accordance with the National Health and Medical Council requirements; 27 agreed to accept decisions from other hospitals having HRECs and 27 relied on ethics advisory committees, hospital managers, clinical staff, quality assurance committees or lawyers for ethics decisions. Four of the latter did not approve the study. Eight hospitals no longer provided maternity services in the recruitment period. The process took 16 months, 26,000 sheets of paper, 258 copies of the application and the cost was about $30,000. Approval was eventually obtained for recruitment at 73 hospitals. DISCUSSION: Difficulties exist in obtaining timely ethics approval for multicentre studies due to a complex uncoordinated system. All hospitals should have explicit protocols for dealing with research ethics applications so that they can be processed in a straightforward and timely manner. To facilitate this, those without properly constituted HRECs should be affiliated with one hospital that has an HREC.

[Care ethics committees]. / Comités de ética asistencial.

The author, who in 1976 started the first Healthcare Ethics Committees in Spain, analyses the advantages of being able to count, from the outset, on a moral community of strongly motivated health professionals at a public, university, maternal-infant hospital of reference, privately managed by the Order of San Juan de Dios. From his perspective, he considers that the evolution of these committees shows patterns of similar conflicts in overcoming the ethical-philosophical conflicts of scientific and ethical-religious reductionisms. He considers that only interdisciplinary and transdisciplinary dialogue makes it possible, in our plural society, to find--through deliberation--the best route for solving ethical conflicts respecting the dignity of the patients and the health professionals. He opted for an autonomous ethics in a context of faith. He considers it to be an error to replace interdisciplinary dialogue within the hospital with consulting groups or persons specialising in professional ethics, the self-denominated "bioethical consultants", whether they be doctors or lawyers. He is very critical of the widespread error of confusing criteria of positive evaluation of the "Joint Commission" with criteria of careful deliberation, and he schematises models for analysing problems and placing them in context.