Realist Synthesis of Maternity Care Access

A data extraction tool was devised and completed for each paper to identify explanatory contexts (C), mechanisms (M), and outcomes (0), and to develop program theories arising from these configurations. Program theories were constructed using “if….., then…” sentences. For example, “migrants who arrived in the country late in their pregnancy or had re‐located or been re‐dispersed from elsewhere in the UK (C), were unable to register with a GP in sufficient time to access maternity services before birth (O)” was converted into the following program theory: “If women who arrive in the country late in their pregnancy or have been re‐located or re‐dispersed from elsewhere in the UK are able to book maternity care directly with a midwife, then barriers to early access will be overcome and those who have difficulty registering with a GP will not be excluded.”
This process ensured transparency in converting findings into tangible, testable hypotheses or “program theory.” A total of 354 program theories were constructed from the findings of the 22 included studies. This collected the voices of 936 women with various social risk factors. Program theories were organized using data analysis software53 to uncover themes and develop middle‐range theories as recommended by Forster e al55 to increase transparency in decision making. This process enabled similar theories to be condensed, the extraction of theories specific to certain social risk factors, and the identification of conflicting theories. These conflicting theories give insight into what works in different contexts and for different populations.56 Once all papers had been classified according to the social risk factors included and the model of maternity care received and similar program theories condensed, 85 program theories remained. These final theories were grouped into the most commonly occurring themes and further refined into eight CMO configurations.
Middle‐range theories help conceptualize complex reality so that empirical testing of the more specific program theories becomes possible and generalizable.57, 58, 59 This conceptualization aided the development of the final CMO headings and has enabled a theoretically informed approach to the design of the subsequent realist evaluation, with the theories incorporated into the interview guides.