Our aim was to undertake a narrative synthesis (NS) of a wide range of empirical literature, including grey literature, to provide stakeholders with perspectives on maternity care access and interventions (NHS and non-NHS) directed at immigrant women in the UK. The topic is of great significance to the NHS because of the strategic commitment to address inequalities and the changing patterns of migration to the UK. Because established immigrant communities feature disproportionately in maternal and perinatal mortality, and because 26.5% of all UK births in 2013 were to foreign-born women,2 the topic is highly relevant.
We planned to identify the most effective and appropriate methods of services delivery by identifying the acceptability of relevant processes at the individual, community and organisational levels. These factors are recognised to be critical determinants of the effectiveness of services and of patient and client outcomes. We also planned to identify specific critical points in care delivery, which will enable the provision of tailored solutions for policy and practice changes. In addition, we aimed to explore the factors affecting the implementation of particular interventions that are designed to enhance access, equity, and clinical and psychosocial outcomes for immigrant women. To reach this aim, we used a Project Advisory Group (PAG) that included not only patient and public involvement, but also clinicians [an obstetrician, a general practitioner (GP) and midwives], commissioners and a policy-maker. This group was initiated during the establishment of our research questions and our early plans for dissemination, and its involvement continued for the entire duration of the project. We wanted to meet the following objectives:
- to identify, appraise and synthesise empirical studies on the topic that used qualitative, quantitative or mixed methods of research
- to identify, appraise and synthesise grey literature and non-empirical reports
- to identify additional knowledge users and mechanisms of knowledge transfer
- to share our findings through strategic end-of-grant knowledge transfer (ultimately, we wanted to establish the current knowledge base and generate important recommendations for future policy, practice and programming, thus mapping out pathways to health equity).
Methodology
Protocol and PROSPERO registration
Our study is registered with PROSPERO as CRD42015023605 (URL: www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015023605; accessed 5 June 2019) and the protocol has been published.84
Narrative synthesis methods
A NS review comprises four main elements (Box 1 and Figure 2).
Element 1: developing a theory of why and for whom.
Element 2: developing a preliminary synthesis of the findings of the included studies, following implementation of the search strategy.
Element 3: exploring relationships in the data.
Element 4: assessing the robustness of the synthesis.
FIGURE 2 The four elements of a NS review. Reproduced from Higginbottom et al.24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure. (Figure not reproduced here; see the original article.)
Although a wide range of approaches exist on the spectrum of systematic reviews, ranging from aggregative to interpretive approaches,85 the purpose of selecting a NS approach (see Figure 2) was to produce highly relevant policy and practice evidence. Some systematic reviews are highly theoretical in nature; however, in considering our initial scoping review, it was established that much of our evidence was likely to be descriptive in nature and suitable for a thematic analysis which is associated with NS. A focus on narrative findings and the production of a thematic analysis is not merely the collation of key perspectives; importantly, the theming achieves a level of abstraction that produces new and potentially innovative insights. We conducted the review taking account of the original conceptualisation of the NS approach86 and of the new and emerging insights and guidance.
Element 1: developing a theory
This review had no predefined hypotheses. Our review focus on immigrant women’s access to and interventions in maternity care was developed and refined by mapping the available knowledge, and also ensuring the relevance of the knowledge synthesis (to policy-makers, other potential knowledge users and immigrant communities). The literature spanned a range of specific maternity care services, including antenatal, labour and postnatal care; maternal risk factors; health promotion; access to and availability and competency of maternity services; the role of culture and tradition; maternity outcomes in relation to perceived maternal risk factors; and responses to care interventions. We engaged in additional consultation with our PAG to further refine the review questions to increase their relevancy. We utilised Gulliford et al.’s23 theory of access to inform our thematic outcomes (Box 2 gives an example of the scoping search strategy and Appendix 1 gives an exemplar of a final search strategy).