An 'Integrated' Realist Review: Informing Service Innovation in Maternity Care

Background & Rationale As part of a larger programme of research (the ‘REACH Pregnancy Programme’), a realist review was undertaken with the explicit aim of integrating findings into the planning and development of a Pilot... [ view full abstract ]

Background & Rationale
As part of a larger programme of research (the ‘REACH Pregnancy Programme’), a realist review was undertaken with the explicit aim of integrating findings into the planning and development of a Pilot study of Group Antenatal Care within a London NHS Trust. This model of care has been implemented at small-scale in various contexts globally, with some promising results, as shown in individual trials and a Cochrane systematic review. Notwithstanding, we considered that the theories underpinning the approach and mechanisms of action were in need of further analysis and clarification, particularly if the model is to be developed and utilised more widely, and in diverse community and population settings. Benefit was also envisaged from an improved understanding of the complex contextual factors of relevance, recognising large variations across healthcare systems. Consequently, a realist review was considered a superior approach compared with a traditional systematic review, enabling articulation of theories and mechanisms of effect, ‘lessons learned’ and subsequent application of findings to our programme context.

Aim
This study aims to describe process issues, challenges encountered and ‘translation’, within a realist review appointed with the specific purpose of applying findings to maternity services innovation in the East London context.

Methods
Additional to engaging in the actual review process, a group of (largely) novice realist reviewers reflected on the experience. EPPI-Reviewer v4 was used to manage the review progression including screening, data extraction and synthesis. As prescribed by the method, logic models/programme theories were developed by all researchers as integral to the iterative process. The Context, Mechanism, Outcomes (CMO) schema guided data extraction and synthesis of study findings, and our initial programme theories were revised accordingly.

Key Findings
While a clearly articulated plan for use of the findings was present at the outset, specific challenges were encountered in conducting the review process embedded within a wider research programme context. Nevertheless, this context facilitated the integrated utilisation of review findings throughout broader programme activities, ensuring immediate usefulness and application, as well as dissemination and impact within local clinical settings.

Discussion (Tentative)
Our experience shows that realist synthesis can be concurrently employed and findings integrated with other data, and then successfully ‘translated’ within a relatively short timeframe. In our case the review work was particularly useful for engaging local maternity services stakeholders through communication of ‘lessons learned’ from other settings. This engagement was crucial to the overall development, implementation and future evaluation of the services innovation (‘Pregnancy Circles’). We would value discussion with others on whether our experiences resonate and/or are contrary.