Table 2 Key process review findings

Methods

 Including WHO and UN statements and reports allowed us to identify key background information to frame and focus our qualitative findings.

 Iteratively considering the WHO-INTEGRATE criteria, sub-criteria and framing questions as we became more familiar with WHO-INTEGRATE and the body of evidence resulted in extracting findings most relevant to our decision-making context.

 Restricting selection of economic evidence to trial-based studies, to avoid challenges with assessing model validity and generalizability.

 Adapting our a priori protocol to include additional primary studies beyond the included QES that addressed evidence gaps. This allowed us to include a study on healthcare provider attitudes to induction of labour [42], the only study conducted in a low-income setting [40], and studies with additional findings relating to pain and women experiencing prolonged pregnancy [41, 43, 44].

Searches

 Investigate usefulness of separate search strategies and/or additional search sources for areas with limited evidence coverage e.g. feasibility and/or equity.

 Search for primary qualitative studies with important perspectives, settings, populations or subgroups published after the last search dates of the included QES. This was done informally, but the process would have benefited from a more systematic approach.

Mapping the evidence (gaps)

 Use systematic mapping methods to identify evidence gaps for each of the WHO-INTEGRATE criteria in settings and populations of specific interest (e.g. country income setting, populations who are systematically discriminated against and denied equitable access to social, political and economic resources). This would both emphasize these issues for discussion, and guide evidence searches for future recommendation updates.

Additional frameworks

 Explicitly consider intersectional theory and approaches when designing methods to search for, identify and interpret qualitative findings. This may allow greater coherence and credibility of evidence presentation. Including frameworks relating to the period and/or process of care may also allow findings to be differentiated that are specific to the intervention being examined or more broadly applicable to the period and/or process of care.

The literature on feasibility and equity is sparse (and possibly not current) if relying on QES and screening reference lists of WHO recommendations and Cochrane reviews. Separate searches for additional information are likely to be required.

Further development of methods for search, identification and interpretation of evidence would result in more robust analysis of the intersection of all factors impacting equity. Inclusion of a social sciences equity researcher on the team would strengthen theoretical understanding, application of methods and interpretation of evidence.

Production of evidence gap maps may help highlight which settings and populations are not included in the evidence base, providing a research agenda for primary qualitative research and a baseline for targeted searching in recommendation updates.

Process

 Iterative collaboration between team members to ensure WHO-INTEGRATE was applied consistently, and to identify relevant findings that represented breadth and diversity of voices and experiences.

Extract population/setting characteristics of QES included studies and any additional primary studies before extracting and interpreting findings to better inform discussions around inequity.

Discuss the extent to which prior knowledge of the effectiveness evidence is likely to influence the team’s interpretation of the qualitative and other evidence findings and explicitly take this into account during the process to reduce bias.

Understanding the included and excluded settings and populations in the qualitative evidence base provides vital information to consider questions of inequity.

Outputs

 Providing the GDG with a high-level evidence review summary in the EtD documents and a supplemental file with more detailed findings.

Provide three outputs to guide decision-making and future recommendation updates: (1) high-level summary of evidence review for each criterion in EtD document; (2) detailed findings from evidence review for each criterion in a supplemental file, including methods and characteristics of studies; and (3) evidence gap map for each criterion, including country income setting and other pre-determined characteristics of interest.

Investigate how best to overcome the challenges posed by the lack of qualitative evidence from low- and middle-income country settings for many key EtD domains.

Using WHO-INTEGRATE and providing both high-level and detailed findings to the GDG centred women’s voices and allowed us to explore health rights and inequity in detail. This facilitated meaningful consideration of women’s experiences, values and preferences, impacts on rights and inequity, as well as feasibility issues, particularly in low- and middle-income settings.