Barriers to and facilitators of engagement with support services by pregnant women at risk of child removal: a mixed methods systematic review

Abstract

Objective: The objective of this review was to synthesize existing qualitative, quantitative, and mixed methods evidence to identify and examine the barriers to and facilitators of pregnant people at risk of child removal engaging with preventive support services.

Introduction: Despite a stated shift towards early intervention, prevention, and support, the rate in which children are entering statutory child protection systems remains high. Of particular concern is the number of infants being removed at or close to birth. Engaging pregnant people with support during the prenatal period is an important component in reducing rates of child harm and removal; however, many pregnant people either do not receive this support or struggle to engage with it. The barriers and facilitators of pregnant people engaging with support must be identified and addressed for prevention and support efforts to be successful in reducing child harm and removal.

Eligibility criteria: This mixed methods systematic review included qualitative, quantitative, and mixed methods studies of pregnant people at risk of child removal. Studies were included if they reported on barriers to or facilitators of engagement with support services that address risk factors for child removal.

Methods: The systematic review was conducted in accordance with JBI methodology for mixed methods systematic reviews. A range of databases were searched, including MEDLINE (Ovid), ProQuest Central and Social Sciences Premium (ProQuest), PsycINFO (Ovid), and Scopus. Critical appraisal and data extraction for studies meeting the inclusion criteria were performed by 2 reviewers using standardized JBI tools. Data synthesis followed the convergent integrated approach to mixed methods systematic reviews.

Results: A total of 10,061 studies were screened for inclusion, of which 23 were included for review. The included studies represented 5013 participants. Most participants were pregnant women, while some were clinicians and prenatal health care staff. The included studies were observational, quasi-experimental, randomized controlled trials, and qualitative studies. Mixed methods studies contributed quantitative and qualitative components to the review. Methodological quality of the studies was varied. Barriers were reported at the individual and service level, and most related to perceived consequences of engaging with services or the lack of availability and accessibility of services. In addition to more commonly reported issues in help-seeking research, such as stigma and judgment, were those specific to pregnant women at risk of child removal, such as fear of child removal and fear of criminal prosecution. Services were often inaccessible due to unavailability and cost, and inaccessibility was exacerbated by social disadvantage. Trust, safety, encouragement, an absence of stigma and discrimination, and support tailored towards the specific needs of disadvantaged pregnant women were facilitators to engagement at the service level, and an internal sense of need and social support were facilitators to engagement at the individual level.

Conclusions: Significant barriers to engagement with support services exist for pregnant people who are at risk of child removal. Efforts to increase the engagement of pregnant people with support services should be done alongside reconsideration of the policies and practices that dissuade them from engaging with support. More needs to be done to increase the accessibility of support services and to reduce social disadvantage among pregnant people who are at risk of child removal.

Review registration: PROSPERO CRD42021254794.

Keywords: barriers; child protection; engagement; facilitators; prevention.