Design and Registration
The review protocol has been registered within the Open Science Framework database [25] and is being reported in accordance with the guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) and the PRISMA extension for protocols (PRISMA-P) [26] (see PRISMA-P checklist in Supplemental File 1). The Arksey and O’Malley five-stage framework for conducting scoping reviews [27]. This framework stipulates the following steps: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing and reporting the results.
Stage 1: Identifying the research question
This scoping review is guided by two research questions:
RQ1: How has perceived maternal care quality been defined in low-, middle-, and high-income countries?
RQ2: How has perceived maternal care quality been conceptualized and measured in low-, middle, and high-income countries?
Stage 2: Identifying relevant studies (eligibility criteria)
Eligible studies will be selected according to the Population-Concept-Context (PCC) framework recommended by the Joanna Briggs Institute as shown in Table 1[24]. This review will be guided by the World Health Organization’s (WHO) definition of women of childbearing age (15-49). Also, while the timeframe of antenatal care and intrapartum care tends to be consistent across countries, the recommended period of postpartum (or postnatal) care may vary across countries. Therefore, this review will include studies focused on postpartum care to women up to one year after delivery—which falls within the WHO’s surveillance period for maternal mortality. Low-, middle-, high-income countries will be determined by the World Bank list of economies, which has classified the countries according to their economic status[28,29]. This review will have no time period restrictions. The authors recognize that the English language is not the universal language of science. However due to the study team’s lack of financial and language resources (e.g., funding, professional translators), only articles published in the English language or with an English-language translation available will be included. Prior research suggests that reviews that are compliant with standard reporting guidelines and use English-language restrictions do not contribute to systematic bias or demonstrate low credibility[30,31].
This review will include articles from the inception of each respective database to 2020. This review will include experimental studies, quasi-experimental studies, analytical observational studies (including prospective and retrospective cohort, case-control and cross-sectional studies), qualitative and quantitative studies focused on the measurement of MCQ, systematic and scoping reviews, and meta-analysis papers. To avoid publication bias, unpublished studies and grey literature will be included in this review. This review will exclude editorials, letters, and case reports because these sources will not provide empirical evidence needed to answer the present review’s research questions.
Table 1. PCC Framework
Criteria
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Description
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Population
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- Women (and girls) of childbearing age (15-49)
- Pregnant women and girls (up to 40 weeks gestation regardless of pregnancy outcome)
- Postpartum women and girls (up to one year post-delivery)
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Concept
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- All study designs focused on measuring the concept of ‘perceived maternal care quality’—women’s perceptions regarding the safety, effectiveness, timeliness, equity, and patient-centeredness of their antenatal, intrapartum, or postpartum care received in a medical facility
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Context
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- Articles published in all countries regardless of income classification
- Evidence published up until recently
- Articles published in English language or with an English-language translation available
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Inclusion Criteria:
To be included, articles must meet the following criteria:
- Article includes women and girls of childbearing age (15-49)
- Evidence published up to recent
- Studies conducted in low-, middle-, or high-income country
- All articles will be included irrespective of their study designs
- Grey literature resources include government and non-governmental organization reports and academic dissertations
Exclusion Criteria
Articles reporting the following will be excluded:
- Articles that do not include women and girls of childbearing age (15-49)
- Articles that do not measure women (and girls) perceptions of maternal care quality
- Articles that only measure clinical/objective indicators of maternal care quality
- Articles focused on measuring maternal care quality outside of a health facility (e.g., home births).
Stage 3: Study selection (Search strategy)
The research team will collaboratively identify the key terms for the search strategies; and the research librarians will develop initial strategies utilizing input from all authors and test for maximum sensitivity, keeping in mind specificity. Specificity will be calculated by dividing the total number of records identified by the number of relevant records identified. The research librarians will build the search strategy focusing on four major concepts: pregnancy and its outcomes and complications, maternal health care, quality of care, patient satisfaction, and assessment tools. For each concept, the research librarians will truncate keywords as necessary and include relevant subject headings to achieve a comprehensive set of citations. For the purposes of this protocol, the research team used the aforementioned steps to develop a draft central search strategy and had the draft central search strategy reviewed by an expert medical librarian at a different institution to provide feedback to help refine the strategy. The draft central search strategy is provided in Table 2.
The research librarians will modify the strategies so that they are appropriate for each database. The review team plans to search for peer-reviewed publications in the following databases from inception to 2020: Ovid MEDLINE, Embase, AMED, WHO Global Index Medicus, Grey: BioMed Central Journals, Google Scholar, and ProQuest Dissertations and Theses. The World Health Organization International Clinical Trials Registry Platform (ICTRP) will not be used because it is currently closed indefinitely to non-WHO staff due to high use during COVID-19 pandemic.
The research librarians will collect and upload metadata from all identified records to EndNote and remove duplicates. This review will use a two-stage screening process as a large number of studies are expected. The first screening phase will consist of reviewing the titles and abstracts of each record and removing articles that are irrelevant. The second screening phase will consist of reviewing the full text of included articles. After reading each paper, further irrelevant articles will be removed from the study sample. The remaining articles will have relevance to the study question and will be put forward for data extraction. Each stage of this process will be completed by two reviewers (KB and GB) independently with disagreement resolved initially by consensus and if needed by a third reviewer. A summary of the study selection process will be presented as a PRISMA flowchart. A table of excluded studies and reasons for exclusion will be provided.
Table 2. Draft Central Search Strategy
Ovid/MEDLINE Search
1. Postpartum Period/ or Pregnancy/ or Labor, Obstetric/ or Pregnancy, High-Risk/ or Labor, Obstetric/ or Fetus/ or Breast Feeding/ or exp Parturition/ or exp Pregnancy Outcome/ or exp Pregnancy, Multiple/ or Pregnancy, Unplanned/ or exp Pregnancy Complications/ or Cerclage, Cervical/
2. (obstetric* or prenatal or postnatal or perinatal or maternal or pregnan* or childbirth or birth or reproductive or antenatal or breastfe* or eclampsia or preeclampsia or pre-eclampsia or gestation* or antepartum or postpartum or labor or labour or preterm or stillbirth or neonatal or intrapartum or fetal or fetus or induction or induce).ti,kw.
3. 1 or 2
4. 3 not Abortion, Induced/
5. exp Health Personnel/ or exp Health Occupations/ or exp "Health Care Quality, Access, and Evaluation"/ or exp Health Education/ or "Referral and Consultation"/ or exp Office Visits/ or House Calls/
6. (physician or nurse or healthcare or health care or birth attendant or peer counselor or nutrition or home health or doula or community health worker or CHW or lay health worker or LHW or hospital or clinic or screen or screening or counseling or monitor or monitoring or center or centre or unit or facilit* or exam or provider or practitioner or educat* or induction or induce or midwi* or referral or surgery or surgical or procedure).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
7. 5 or 6
8. 7 not (Veterinarians/ or exp Veterinary Medicine/)
9. exp Perinatal Care/ or exp Maternal Health Services/ or Prenatal Care/ or exp Obstetric Surgical Procedures/
10. (4 and 8) or 9
11. exp Health Care Surveys/ or Patient Health Questionnaire/ or Patient Satisfaction/
12. ((patient or mother or wom?n*) and (quality or satisf* or assessment or feedback or questionnaire or interview or rating or opinion or experience)).ti,kw.
13. 11 or 12
14. 10 and 13
15. limit 14 to (english language and humans)
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Stage 4: Charting the data (Data Extraction)
To ensure the most relevant and comprehensive information is extracted in a systematic way, we will create a data extraction table in Microsoft Word. As shown in Table 3, the extraction of charting elements will be based on guidance from the JBI Review’s Manual[32] and additional columns relevant to this review’s research questions using a format illustrated in other protocols[33,34]. We will record additional result details including:(1) database searched, (2) search date, (3) search string with limiters, (4) results retrieved, and (5) number of duplications removed. The data extraction tool will be piloted by two reviewers on two papers initially and where indicated, modifications will be made. However, there may be further refinements added to include any relevant data that was not initially included during the extraction process. Data from all included studies will then be charted by the first reviewer (KB) and extraction checked by the second reviewer (GB).
Table 3. Preliminary table of charting elements and relevant questions for data
Chart Elements
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Associated Questions
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Publication details
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Author(s)
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Who wrote the article?
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Year of publication
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What year was the article published?
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Country of origin
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Where was the study/document conducted and/or published?
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Country economic classification
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Is the country of origin classified as low-, middle-, or high-income?
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Publication type
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What type of publication is this? (empirical study, grey literature)
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Study/Article details
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Aims/Purpose
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What were the aims of the study/article?
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Methodological design
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What methodological design was used?
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Type of care
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Did this study/article focus on antenatal, intrapartum, or postpartum care?
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Structure and process of care
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Does the study/article describe the structure and process of care as it relates to the country context?
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Study population and sample size
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Who was the target population and how many were included in the study/article?
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Methods
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What specific methods were used?
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Construct(s) Measured
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What constructs were measured? What were the study measures?
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Intervention
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Was an intervention used in this study? (yes or no)
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Comparator and duration of the intervention (if applicable)
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If yes, what was the comparator and duration of the intervention?
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Outcomes (if applicable)
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If yes, what was the intervention outcome?
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Conceptualization and measurement details
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What is perceived maternal care quality?
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How is perceived maternal care quality defined or conceptualized?
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Theoretical/Conceptual Framework
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What theory or framework was used to conceptualize maternal care quality in this study/article?
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Donabedian concept category
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Which of the following Donabedian concept categories are relevant to the constructs measured in this study/article? (process, structure, outcomes)
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How is perceived maternal care measured?
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What type of instrument was used for measurement? (e.g., questionnaire, scaling, interview guide)
If applicable, what level of measurement was used (nominal, ordinal, interval, ratio) to measure perceived maternal care quality?
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Number of instrument items
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How many items were included in the instrument?
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Instrument dimensions
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What dimensions are measured or conceptualized?
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Number of dimensions
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How many dimensions are included?
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Instrument psychometric properties
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Was the instrument validated?
What was the reliability statistic?
What was the content validity?
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Limitations and challenges
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Were there any reported limitations or quality issues (not a critical appraisal)
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Recommendations for further study
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Were there any recommendations for further study?
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Stage 5: Collating, summarizing, and reporting results
This stage will consist of four major steps that include the use of numerical, graphical, tabular, and narrative summaries. In the first analytic step, the review will provide a descriptive numerical and tabular summary that includes the total number of included articles, including a breakdown of articles by year of publication, country economic classification (low, middle, and high income), type of care (antenatal, intrapartum and postpartum), type of study design, and type of instrument used (qualitative or quantitative).
The Arksey and O’Malley methodology recommends adopting a framework to collate and summarize the extracted data in a systematic manner [27]. Therefore, the review results will utilize country economic classification (low, middle, high income) and Donabedian’s model of care quality (structure, process, outcome) to organize the results in a structured, systematic manner, and thereby enhance the articulation of the results [27,32]. The second analytic step will aim to answer the first research question (RQ1: How has perceived maternal care quality been defined in low-middle-, and high-income countries?). This review will present a table (see Table 4 in Supplemental File 2), organized by country economic classification, to report the following information for each included article: author/year, country name, sample description, type of care (antenatal, intrapartum, postpartum), definition of perceived maternal care quality, theoretical framework used to conceptualize maternal care quality from the patient’s perspective. Based on this table, a written narrative will describe similarities and differences in the way in which perceived maternal care quality has been defined within each country economic classification and across the three different classifications. This written narrative will also describe identified gaps in the literature.
The third analytic step will aim to answer the second research question (RQ2: How has perceived maternal care quality been conceptualized and measured in low-, middle-, and high-income countries?). First, this review will include a chart (see Figure 1 in Supplemental File 2) to visually map the number of articles by country economic classification (low, middle, high income) and by Donabedian concept category (process, structure, outcome). If a single article, focuses on constructs that fall within two or more Donabedian concept categories, each one will be counted separately. The purpose of this chart is to illustrate trends and patterns in the overarching maternal care quality concepts measured overall and by country economic classification.
Second, this review will present a table (see Table 5 in Supplemental File 2), organized by Donabedian’s concept categories. This table will report the following information for each article: author/year, country income classification, construct(s) measured, type of care (antenatal, intrapartum, and postpartum), and type of instrument used. This table is intended to provide a more detailed breakdown of the information presented in Figure 1. The intent of this table is not to assess the quality of the article or instruments used. Based on this table, a narrative summary will be organized according to the three Donabedian concept categories. For each Donabedian concept category, the written narrative will (a) summarize patterns in the types of constructs measured in the overall literature and by country income classification and (b) patterns in the types of constructs measured by type of care and by country income classification. The narrative summary will also describe any identified gaps.