Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care.

BACKGROUND: Implementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care. METHODS: A systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models' characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria. RESULTS: From 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0-32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported. CONCLUSIONS: The QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.

Comparing level of expenditure on HIV health promotion and incidence of HIV in Greater Glasglow and Lothian Health

Legislation through the AIDS Control Act (1987) required regional health boards in Scotland to account for their expenditure on HIV/AIDS services by æring-fencingÆ funding allocated for HIV health promotion. This aimed to ensure monies allocated for expenditure on HIV health promotion by health boards would be used for this purpose and not to finance other health board services. We analysed health board expenditure on HIV health promotion in relation to the incidence of HIV transmission for two Scottish health boards, Greater Glasgow and Lothian (the region in which the Scottish capital Edinburgh is situated). Lothian region which had a higher incidence of HIV transmission than Greater Glasgow similarly had a greater expenditure on HIV health promotion. However, for either health board there was no consistent increase in expenditure after HIV incidence increased. Likewise it was more often the exception than the norm for the incidence of HIV to decline after increased expenditure on HIV health promotion. While it is tentatively concluded that increased HIV health promotion expenditure did not apparently make a significant difference to the incidence of HIV in either health board, this ignores the effect of practical measures funded by the expenditure...