Factors influencing appropriate use of interventions for management of women experiencing preterm birth: A mixed-methods systematic review and narrative synthesis

Abstract

Background Preterm birth-related complications are the leading cause of death in newborns and children under 5. Health outcomes of preterm newborns can be improved with appropriate use of antenatal corticosteroids (ACSs) to promote fetal lung maturity, tocolytics to delay birth, magnesium sulphate for fetal neuroprotection, and antibiotics for preterm prelabour rupture of membranes. However, there are wide disparities in the rate and consistency in the use of these interventions across settings, which may underlie the differential health outcomes among preterm newborns. We aimed to assess factors (barriers and facilitators) affecting the appropriate use of ACS, tocolytics, magnesium sulphate, and antibiotics to improve preterm birth management. Methods and findings We conducted a mixed-methods systematic review including primary qualitative, quantitative, and mixed-methods studies. We searched MEDLINE, EMBASE, CINAHL, Global Health, and grey literature from inception to 16 May 2022. Eligible studies explored perspectives of women, partners, or community members who experienced preterm birth or were at risk of preterm birth and/or received any of the 4 interventions, health workers providing maternity and newborn care, and other stakeholders involved in maternal care (e.g., facility managers, policymakers). We used an iterative narrative synthesis approach to analysis, assessed methodological limitations using the Mixed Methods Appraisal Tool, and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. Behaviour change models (Theoretical Domains Framework; Capability, Opportunity, and Motivation (COM-B)) were used to map barriers and facilitators affecting appropriate use of these interventions. We included 46 studies from 32 countries, describing factors affecting use of ACS (32/46 studies), tocolytics (13/46 studies), magnesium sulphate (9/46 studies), and antibiotics (5/46 studies). We identified a range of barriers influencing appropriate use of the 4 interventions globally, which include the following: inaccurate gestational age assessment, inconsistent guidelines, varied knowledge, perceived risks and benefits, perceived uncertainties and constraints in administration, confusion around prescribing and administering authority, and inadequate stock, human resources, and labour and newborn care. Women reported hesitancy in accepting interventions, as they typically learned about them during emergencies. Most included studies were from high-income countries (37/46 studies), which may affect the transferability of these findings to low- or middle-income settings. Conclusions In this study, we identified critical factors affecting implementation of 4 interventions to improve preterm birth management globally. Policymakers and implementers can consider these barriers and facilitators when formulating policies and planning implementation or scale-up of these interventions. Study findings can inform clinical preterm birth guidelines and implementation to ensure that barriers are addressed, and enablers are reinforced to ensure these interventions are widely available and appropriately used globally.

Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review

“…For example, studies on factors affecting multiple micronutrient supplementation, iron folic acid and lipid-based nutrients reported women’s knowledge, acceptance, motivation, and attitudes towards the medication play an important role 43 44. Furthermore, a study on factors affecting use of intervention for preterm management also reported women felt hesitant to consume the medications to improve labour outcome due to fears about baby’s growth and development 45. This highlights the need to ensure that women are aware on the benefits of the supplement and given assurance on the safety of its use.…”

Effective and simple interventions to improve outcomes for preterm infants worldwide: The FIGO PremPrep‐5 initiative

“…Concerns were also raised regarding potential tocolytic effects, and staff can be reassured that these are not founded in evidence. 20,21 Specific evidence relating to training and education in LMIC settings is lacking. However, a successful national program based in the UK (PReCePT) that aimed to increase the uptake of magnesium sulfate before preterm delivery relied heavily on the training of small numbers of staff across multiple sites who, in turn, could train other staff in interdisciplinary training, as well as infographics and patient information.…”

“…A systematic review investigating reasons for non‐compliance by healthcare staff to magnesium sulfate guidelines globally identified particular concerns regarding the toxicity of magnesium sulfate 20 : magnesium toxicity at the regimen suggested is very unlikely, 21 and (perhaps unlike in pre‐eclampsia) women are most likely to have preserved renal function, further reducing the risk. Concerns were also raised regarding potential tocolytic effects, and staff can be reassured that these are not founded in evidence 20,21 …”

The efficacy of antenatal corticosteroids to improve preterm newborn outcomes in low‐resource countries: Are we there yet?

“…These recommendations reiterated that ACS should be used up to 34 weeks of gestation (Box 1). In making its recommendations, the GDG drew on the 2020 Cochrane review, 23 and also on evidence from a mixed‐methods systematic review on factors affecting the implementation of ACS 34 . The latter review highlighted that ensuring appropriate ACS use needs accurate gestational age assessment, consistent guidelines and training for providers, as well as sufficient supplies and trained, well‐supported staff.…”