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The influence of traditional midwifery and other factors on maternal health in Indigenous communities in the Americas: protocol for a scoping review ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-037922

Article Type: Protocol

Date Submitted by the 21-Feb-2020 Author:

Complete List of Authors: Sarmiento, Ivan; McGill University, Family Medicine; Universidad Del Rosario, Escuela de Medicina y Ciencias de la Salud Paredes Solís, Sergio; Universidad Autonoma de Guerrero, Centro de Investigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero Morris, Martin; McGill University, Schulich Library of Physical Sciences, Life Sciences and Engineering Cockcroft, Anne; McGill University, Department of Family Medicine Andersson, Neil; McGill University, Department of Family Medicine; Universidad Autonoma de Guerrero - Campus Acapulco, Centro de Investigación de Enfermedades Tropicales

Maternal medicine < OBSTETRICS, PRIMARY CARE, PUBLIC HEALTH, http://bmjopen.bmj.com/ Keywords: REPRODUCTIVE MEDICINE, STATISTICS & RESEARCH METHODS, SOCIAL MEDICINE

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1 2 3 The influence of traditional midwifery and other factors on maternal health in Indigenous 4 5 communities in the Americas: protocol for a scoping review 6 7 8 9 Ivan Sarmiento, MPH1,2; 10 3 11 Sergio Paredes-Solís, MD, MSc, DSc ; 12 4 13 Martin Morris, MSc ; 14 Anne Cockcroft, MBBS, MD, FRCP, FFOM1; 15 16 Neil Andersson, MD,For MSc, MPhil, peer PhD1,3 review only 17 18 19 20 1 Department of Family Medicine. McGill University. Montreal, Canada. 21 2 22 Grupo de Estudios en Sistemas Tradicionales de Salud. Universidad del Rosario. Bogotá, 23 24 Colombia. 25 3 Centro de Investigación de Enfermedades Tropicales. Universidad Autónoma de Guerrero. 26 27 Acapulco, Mexico. 28 29 4 Schulich Library of Physical Sciences, Life Sciences and Engineering. McGill University. 30 31 Montreal, Canada 32 33 http://bmjopen.bmj.com/ 34 Corresponding author: Ivan Sarmiento 35 36 McGill University, Department of Family Medicine, 5858 Chemin de la Côte des Neiges, Montreal, 37 38 Quebec H3S 1Z1, [email protected], +1 (438) 927-8710, https://orcid.org/0000-0003-2871- 39 40 1464 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 ABSTRACT 6 Introduction. 7 8 Mutual mistrust between Western practitioners and indigenous traditional midwives hampers 9 10 collaboration in health care in many indigenous settings. As a consequence, indigenous 11 12 mothers often receive culturally unsafe services that do not fully respond to their needs. To 13 14 improve this situation through intercultural dialogue, in 2017 we mapped perspectives held by 15 Mexican traditional midwives on maternal health. The current scoping review maps Western 16 For peer review only 17 perspectives reflected in published and unpublished literature. A subsequent step will compare 18 19 maps of western and traditional perspectives, to identify opportunities to bridge the 20 21 intercultural distance. The objective of this scoping review is to collate and assess literature 22 23 that identifies associations related to traditional midwives and maternal health in indigenous 24 25 communities in the Americas. 26 27 Methods and analysis. 28 This protocol describes adaptation of established scoping review methodology to explore 29 30 published and unpublished evidence. A librarian will support a comprehensive search strategy 31 32 of quantitative and qualitative studies with iterative and documented adjustments. Two 33 http://bmjopen.bmj.com/ 34 researchers will independently screen the identified manuscripts and blindly select those that 35 36 comply with the inclusion criteria. Discrepancies will be resolved through discussion and, if 37 38 necessary, a third party. The quality assessment of included manuscripts will rely on the Mixed 39 Method Appraisal Tool. Two independent researchers will extract data on factors promoting or 40 41 reducing maternal health in indigenous communities, including the role or influence of on September 25, 2021 by guest. Protected copyright. 42 43 traditional midwives. Fuzzy cognitive mapping will summarize the findings. 44 45 Ethics and dissemination 46 47 This review is part of a proposal approved by Institutional Review Boards of the McGill 48 49 University Faculty of Medicine and the Centro de Investigación de Enfermedades Tropicales in 50 Guerrero, Mexio (2017). Participating indigenous communities in Guerrero State approved the 51 52 study in 2015. The results of the scoping review will contribute to the field of cultural safety and 53 54 intercultural dialogue for the promotion of maternal health in indigenous communities. 55 56 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 PROSPERO registry number: In progress, PROSPERO acknowledgement of receipt 138575, 4 5 submitted on 4 February 2020 6 7 8 9 Word count: 2,843 10 11 12 13 Keywords: indigenous health, weight of evidence, intercultural dialogue, maternal health, safe 14 birth, traditional health systems 15 16 For peer review only 17 18 Strengths and limitations of this study 19 20  Viewed from different standpoints, maternal health has multiple interpretations and 21 22 multiple interacting factors that simple linear models cannot easily identify. 23 24  This scoping review uses fuzzy cognitive mapping to summarize results, generating soft 25 models of causal relationships that require empirical testing. 26 27  The review is part of a bigger initiative promoting intercultural dialogue between 28 29 indigenous and western perspectives, with a view to improving maternal health. 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 INTRODUCTION 6 Maternal morbidity and mortality are inequitable burdens for many indigenous women in the 7 8 Americas.[1–3] Living as they do at the very periphery of the Western health system, 9 10 indigenous mothers often receive low-quality care from attenuated health services that lack 11 12 human and financial resources. Colonial history in the Americas has weakened indigenous 13 14 cultures, including their traditions to promote safe motherhood.[4] Mutual mistrust between 15 Western practitioners and traditional midwives creates additional distance and hampers 16 For peer review only 17 collaboration.[5] While their traditional and Western health providers largely ignore each other, 18 19 indigenous mothers receive less appropriate Western services and they cannot rely solely on 20 21 their weakened traditional resources. 22 23 Since 2004, no less than 18 literature reviews focused on effectiveness of retraining traditional 24 25 midwives and redefining their traditional roles as auxiliary promoters of Western health 26 27 services (Error! Reference source not found.). A recurring problem is the reduction of 28 29 traditional midwife with traditional birth attendant (TBA), a term that refers to unskilled 30 31 personnel providing limited support during the childbirth event.[6] Several interventions 32 33 explored training birth attendants in Western birthing skills. http://bmjopen.bmj.com/ 34 35 In indigenous communities with traditional health systems, with particularities across different 36 37 cultural groups, traditional midwives accompany women from childhood and through 38 39 motherhood; their role is much wider (including family and other social relations) and deeper 40

(including counselling and emotional support from menarche to menopause) than can be on September 25, 2021 by guest. Protected copyright. 41 42 summarised as “birth attendance”[7,8] Traditional midwives usually have their own hierarchy 43 44 defined by capacity to deal with complex health problems.[9] There is little research on 45 46 interventions that support traditional midwives and recognises their knowledge, and even less 47 48 research on adjusting the western health system to work with traditional midwives.[7] 49 50 Maternal health is a capacious concept that incorporates complex socio-cultural mechanisms 51 52 affecting the well-being of women, their offspring and communities.[10] Existing literature 53 54 reviews (Error! Reference source not found.) focus on biomedical outcomes like maternal 55 56 morbidity and mortality, neonatal survival or uptake of Western health services. A scoping 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 review allows us to address broader questions, including what the outcomes are.[11] The 4 5 approach allows incorporation of intersectional factors in a general landscape that can improve 6 7 understanding of the full role of traditional midwifery. This is central to services that are 8 9 respectful of indigenous cultures where women still use this resource, improving interactions 10 11 between indigenous and Western health services.[12] More culturally safe health services 12 13 increase patient perceptions of physical, spiritual, social and emotional safety.[13] Another 14 benefit of a mutually respectful environment is the concerting of traditional and Western 15 16 services together toFor improve peermaternal health.[14] review only 17 18 19 20 Part of a larger initiative project to understand the role that traditional midwifery has in safe 21 22 birth in cultural safety, this scoping review aims to contribute to intercultural dialogue between 23 24 traditional and Western health systems.[15] The larger project will develop a composite theory 25 of change from three knowledge bases: (i) the scoping review described in this protocol, (ii) the 26 27 research team’s understanding of the intercultural dialogue dynamics as these relate to safe 28 29 birth, and (iii) traditional midwives’ understanding of safe birth. Representing each knowledge 30 31 set as a fuzzy cognitive map, we will adapt the Weight of Evidence[16,17] approach to combine 32 33 the three sources into one model to inform decision making and a stakeholder-led analysis of a http://bmjopen.bmj.com/ 34 cluster randomized controlled trial.[15] In this protocol we focus on the procedures to conduct 35 36 the scoping review, and mention the additional use of the review results. A full description of 37 38 the procedure to combine the three knowledge sources is the subject of an additional report. 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 METHODS 43 44 This protocol follows the PRISMA-P guidelines and the Joanna Briggs Institute Reviewer's 45 Manual to assure transparency, accuracy, and completeness.[18,19] It follows Arksey and 46 47 O’Malley’s methodological framework consisting of six stages.[20] All members of the research 48 49 team developed, reviewed and agreed the protocol. 50 51 52 53 54 55 56 57 58 59 5 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 Stage 1: Identify the research question 6 A convergent mixed studies review,[21,22] registered in PROSPERO[23] will address the 7 8 question: What factors, including the role and influence of traditional midwives, promote or 9 10 reduce maternal health in indigenous settings and, based on available qualitative and 11 12 quantitative evidence, what is the relative weight of their influence? 13 14 15 Secondary questions of the included studies are: 16 For peer review only 17  What are the indicators of maternal health? 18 19  How are the concepts of cultural safety and intercultural dialogue considered? 20 21  What is the influence of traditional midwifery on maternal health? 22 23  What is the effect on maternal health of interventions supporting traditional midwives? 24 25 26 27 Stage 2: Identifying relevant studies 28 29 A health librarian (MM) developed the comprehensive search strategy to explore the following 30 databases: Web of ScienceTM, Scopus, Lilacs, PubMed, Google Scholar and POPLINE®. The 31 32 review will include studies in human populations reported in English, Spanish, French, or 33 http://bmjopen.bmj.com/ 34 Portuguese, with no exclusion based on publication dates. All databases will be searched from 35 36 inception to date. 37 38 39 40 The strategy applies a targeted, iterative searching technique that documents new keywords on September 25, 2021 by guest. Protected copyright. 41 emerged from screened articles.[24] This strategy consists of two steps: (1) an initial search in 42 43 MEDLINE/PubMed to analyse the text words in the titles and abstracts retrieved and the index 44 45 terms used to describe the article; (2) using the updated terms, conduct a second search and 46 47 translate the search to run across the other databases and grey literature. The final report of 48 49 the review will document in detail these two steps. Online supplementary file 1 presents a draft 50 51 literature search strategy for step 1. 52 53 54 Using the Google (Google LLC) search engine we will identify unpublished studies and grey 55 56 literature, such as institutional and advocacy reports. Using consistent search terms, the 57 58 59 6 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 screening process will be limited to the first 100 results returned for reasons of feasibility. We 4 5 will use the title and short text underneath for initial screening.[25] To facilitate the 6 7 transparency of web searching, for each website, we will report the URL, dates searched, search 8 9 terms and the citation details of any included literature. 10 11 12 13 We will search the reference list of included references for additional studies, but we do not 14 propose to contact authors for further information. 15 16 For peer review only 17 18 Stage 3: Study selection 19 20 After completing the search and excluding duplicated records using Endnote (X9.3.1, Clarivate 21 22 Analytics), we will digitise the list of references in Rayyan QCRI[26] to support the selection 23 24 process, and two independent researchers will select the studies to include. The independent 25 researchers will reconcile the differences and if they do not reach consensus a third party will 26 27 define the inclusion or exclusion. The first selection round will use title and abstract as criteria, 28 29 and a second round will use full content to support the decision. 30 31 32 33 In scoping reviews, the selection process can be iterative. When the research team engages in http://bmjopen.bmj.com/ 34 study selection and more deeply explore the literature, they may get new information to 35 36 enhance the identification phase.[24] We will document any adjustment to the search strategy 37 38 occurring after the selection process has already started. Included studies will satisfy the 39 40 following four criteria: 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 a) The study addresses maternal health issues in indigenous populations. 45 The concept of maternal health is a broad term without a common definition and standard 46 47 identification criteria. Part of the challenge is the extended debate on defining health, which is 48 49 even deeper across different cultural backgrounds.[8] For example, traditional midwives in 50 51 Guerrero, Mexico, included in their definition of a healthy mother, those with a healthy baby 52 53 and a healthy husband. The World Health Organization focuses the definition on the mother 54 55 and uses a time period to circumscribe the concept as “the health of women during pregnancy, 56 57 58 59 7 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 childbirth and the postpartum period.”[27] In the negative interpretation of the concept of 4 5 maternal health, maternal mortality has usually been used as a critical measure. But it only 6 7 represents a small fraction of the problem when compared with the occurrence of maternal 8 9 morbidity, understood as “any health condition attributed to and/ or aggravated by pregnancy 10 11 and childbirth that has a negative impact on the woman’s wellbeing.”[28] 12 13 14 According to Graham, maternal health is commonly conceptualized as a discrete state of 15 16 negative outcomes Forin terms ofpeer morbidity andreview mortality, characterized only by physical rather than 17 18 social or mental manifestations, and by a narrow time-perspective.[29] Especially in the context 19 20 of indigenous communities, spiritual and environmental domains can have strong relevance. 21 22 Graham suggested the need for flexible interpretations to recognize that “maternal health 23 24 encompasses positive or negative outcomes – physical, social or mental, in a woman from any 25 cause related to childbearing or its management.” 26 27 28 29 Our review will therefore include studies that report on maternal health irrespective of the 30 31 definition of this concept. The review will include studies on positive or negative outcomes 32 33 from any cause related to childbearing or its management. http://bmjopen.bmj.com/ 34 35 36 b) The study reports on the role or influence of traditional midwives. 37 38 Birth traditions in most if not all indigenous cultures involve someone attending women 39 40 throughout pregnancy and delivery, many of them including support from menarche to 41 on September 25, 2021 by guest. Protected copyright. 42 menopause.[10] To clarify terminology, we distinguish between three categories of birth 43 44 attendants in indigenous contexts: (1) authentic traditional midwives, whose recognition by 45 their communities is reflected in the number of births they attend each year, the outcomes for 46 47 their patients, and the traditional knowledge they hold, (2) casual or coincidental birth helpers, 48 49 who might help in a family or neighbourhood emergency, (3) trained birth attendants (different 50 51 to traditional birth attendants, but conflated by the acronym TBA), who are individuals who 52 53 receive training in Western birth practices and who might have received an official certification. 54 55 56 57 58 59 8 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 We will only include studies of authentic traditional midwives. We will consider the study as 4 5 including authentic traditional midwives if the report explicitly uses this term or traditional 6 7 birth attendants, or if it describes their link to the traditional culture of the community and 8 9 refers to a locally-recognized role helping women during pregnancy, delivery or postpartum. 10 11 12 13 c) It is an empirical study. 14 The review will include qualitative and quantitative studies, observational or experimental, that 15 16 address maternal healthFor outcomes. peer We will review not include ethnographic only descriptions of traditional 17 18 midwifery that do not report on its effects on maternal health outcomes. 19 20 21 22 d) The study setting is in the Americas. 23 24 Given the variability in traditions and cultural practices, we will restrict the review to studies in 25 indigenous communities in the Americas. 26 27 28 29 Exclusion criteria 30 31 The review will exclude theoretical models without empirical support. The final report will 32 33 contain a list of the studies excluded and the reasons for doing so. We will document the http://bmjopen.bmj.com/ 34 process in a diagram according to the PRISMA guidelines.[30] 35 36 37 38 Quality appraisal 39 40 Although some scoping reviews do not conduct quality appraisal,[24] we consider it is 41 on September 25, 2021 by guest. Protected copyright. 42 necessary in this study to determine the strength of the current evidence. Quality assessment 43 44 of the included studies will follow the Mixed Methods Appraisal Tool (MMAT),[31] the results 45 from the quality assessment will contribute to interpret the weights in the fuzzy cognitive maps 46 47 described in Stage 5. 48 49 50 51 Stage 4: Charting the data 52 53 Based on the reading of full texts, two independent authors will extract concepts related to safe 54 55 birth using an electronic form with the following items: 56 57 58 59 9 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 a) Study (title, year of the study, publication type (published/unpublished), year of publication, 4 5 country, type of study (qualitative/ quantitative/mixed), study design, population) 6 7 b) Study citation details 8 9 c) MMAT tool 10 11 d) Maternal health outcomes reported in the study 12 13 e) Factors related to maternal health studied and reported (complete f to h for all relationships) 14 f) If quantitative: what is the measure? And what is the value of the relationship with maternal 15 16 health? (Include confidenceFor intervals)peer review only 17 18 g) If qualitative: what is the argument or insight about the importance of this relationship with 19 20 safe birth (copy and paste)? 21 22 h) Does the study report other relations among factors? If yes, identify all the relationships and 23 24 complete f. or g. for all of them. 25 26 27 To ensure consistency and to test the data abstraction format, a data abstraction pilot will 28 29 include five randomly selected articles. The pilot will identify necessary changes prior to 30 31 abstracting the remaining articles. The data extractors will compare results and a third party 32 33 will resolve irreconcilable discrepancies. http://bmjopen.bmj.com/ 34 35 36 Stage 5: Collating, summarizing, and reporting the results 37 38 The reporting will follow the PRISMA-ScR guidelines.[30] Reporting will produce tables and 39 40 charts of the geographic and population distribution of studies; the factors included in the 41 on September 25, 2021 by guest. Protected copyright. 42 review; the approach to traditional midwifery of each study; the research methods adopted; 43 44 and the measures of maternal health used. The report will present an illustrative fuzzy cognitive 45 map, summarizing the literature and the interpretation of its weights in terms of the influence 46 47 that each factor might have on maternal health according to the model. 48 49 50 51 Fuzzy cognitive mapping 52 53 The pivotal tool for summarising the results of this review is fuzzy cognitive mapping (FCM). 54 55 This is a graphic representation of soft models composed of elements or concepts and relations 56 57 58 59 10 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 between elements. Each element is a node (factors identified in point e of the data extraction 4 5 form), and each relationship is represented as an edge (arrow) linking nodes together. These 6 7 graphics represent assumptions on causal relations and can be based on data or unwritten 8 9 knowledge.[32] The edges represent causal relations, so the direction of the arrows 10 11 matters.[33] The relations or edges can be assigned different values to quantify their strength 12 13 in a relative way (hence the term fuzzy). As the causal knowledge is often uncertain, or at least 14 different from the viewpoints of different stakeholders (for each of whom it might feel certain), 15 16 fuzzy models allow Forus to understand peer “hazy review degrees of causality only between hazy causal concepts” 17 18 using fuzzy causal algebra.[34] Figure 1 illustrates a fuzzy cognitive map from traditional 19 20 midwives in Guerrero State, describing their views about protective factors for maternal health. 21 22 23 24 An edge list is a tabular format to represent the relationships in a fuzzy cognitive map. An edge 25 list consists of a table with two initial columns, the first to indicate the origin factor (from) and 26 27 the second to indicate the consequence factor (to). Additional columns will indicate the 28 29 supporting evidence of the relationship (items f or g of the data extraction form) and the 30 31 corresponding reference. Each relationship corresponds to a row. 32 33 http://bmjopen.bmj.com/ 34 Based on extracted data, we will plot a fuzzy cognitive map using yEd graphical tools, scaling 35 36 the effect measures into a range (-1,1) assigning negative and positive signs for inhibitory and 37 38 excitatory relationships, respectively. Adapting the Weight of Evidence approach proposed by 39 40 Dion et al,[35] it is possible to calculate common effect estimates to summarize quantitative 41 on September 25, 2021 by guest. Protected copyright. 42 data on the influence between factors. Wherever odds ratios are available, the formula 43 44 proposed by Šajna[11] will transform the values into a measure of the weight (w) in the 45 symmetric range (-1,1): 46 47 48 49 50 51 When multiple effect estimates describe the same relationship between factors, we will 52 53 calculate a summary measure using standard approaches to meta-analysis. If the studies 54 provide statistics other than odds ratios, such as chi-square or mean differences, we will 55 56 57 58 59 11 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 convert them to the standardized mean difference (d), and then convert d to an odds ratio 4 5 using a widely accepted formula.[36] 6 7 8 9 10 11 12 13 Where p is the mathematical constant (approximately 3.14159). 14 15 16 For qualitative relationships,For peerbased on their review reading of the context only and report, two independent 17 18 researchers will propose a value in the range (-1,1) to indicate their interpretation of the weight 19 20 and direction of the influence of each factor. They will propose these weights for qualitative 21 22 relationships, considering all the qualitative and quantitative relationships in the map. They will 23 24 reconcile differences by consensus, resolving discrepancies with the intervention of a third 25 reviewer. 26 27 28 29 In the final map, with all relationships identified in the scoping review, the transitive closure 30 31 algorithm will calculate the weights of the relationships considering the entire system.[37] This 32 33 procedure is available in CIETmap, an open-source windows-like interface with the R http://bmjopen.bmj.com/ 34 35 programming language.[38] 36 37 38 Stage 6: Consultation exercise 39 40 Arksey and O’Malley recognize the benefit of discussing the final results with experts.[20] The 41 on September 25, 2021 by guest. Protected copyright. 42 Weight of Evidence[16] approach goes further, recognizing that the literature review presents a 43 44 valuable side of the story to be contrasted and expanded with the views and experiences of 45 those affected by the issue. We will use this to generate a composite model incorporating two 46 47 additional sources, the knowledge of traditional midwives in Guerrero, and the views of the 48 49 research team involved in a cluster randomized controlled trial supporting traditional 50 51 midwifery.[15] This will be completed and reported separately. 52 53 54 55 56 57 58 59 12 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 CONCLUSIONS 6 7 This protocol describes a scoping review to map factors, including the roles of traditional 8 9 midwives that can contribute to or hinder maternal health among indigenous communities. The 10 11 review will contribute to the understanding of maternal health in complex interaction of 12 13 variables where indigenous cultures meet Western medicine. It reflects a shift in approach to 14 traditional midwifery, recognizing its influence on health outcomes cannot be understood in 15 16 isolation. Fuzzy cognitiveFor mapping peer offers areview systematic and visual only way to deal with heterogeneity 17 18 and uncertainty of epidemiological data, as well as a common language to juxtapose Western 19 20 knowledge with other sources of knowledge such as indigenous wisdom and experience. 21 22 23 24 Fuzzy cognitive maps are conceptual models depicting causal assumptions and prior beliefs. The 25 maps expand the realm of possible improvement strategies by identifying factors from multiple 26 27 knowledge bases and, in each knowledge base reflect direct or indirect interactions. The 28 29 influences between factors, however, do not translate as probabilities as they might from some 30 31 meta-analysis. The map generated by the scoping review will inform a participatory process to 32 33 update currently available knowledge with additional evidence from the experience of http://bmjopen.bmj.com/ 34 traditional midwives and experimental data. 35 36 37 38 Patient and public involvement 39 40 This research involves no direct patient or public involvement, but the design of the study is the 41 on September 25, 2021 by guest. Protected copyright. 42 result of participatory research involving traditional midwives from Guerrero State, Mexico. 43 44 45 Contributors 46 47 IS is the guarantor. IS, NA, and AC drafted the manuscript. All authors contributed to the 48 49 development of the selection criteria, the risk of bias assessment strategy and data extraction 50 51 criteria. MM developed the search strategy and the compliance with quality standards for 52 53 scoping reviews. NA provided statistical expertise as a coauthor of the Weight of Evidence. AC 54 55 56 57 58 59 13 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 adjusted the manuscript for dissemination. SP is the sponsor of the work with traditional 4 5 midwives in Guerrero. All authors read, provided feedback and approved the final manuscript. 6 7 8 9 Acknowledgements 10 11 Participatory Research at McGill, particularly Anna Dion, contributed valuable insights on the 12 13 use of fuzzy cognitive mapping. Genevieve Gore offered initial ideas to adjust the search 14 strategy. German Zuluaga and Anne Marie Chomat read and commented on the initial version 15 16 of this protocol. For peer review only 17 18 19 Funding 20 21 22 This scoping review is funded by CIETcanada and the Centre for Intercultural Medical Studies in 23 24 Colombia. IS is a scholar of the Fonds de la Recherche en Sante du Quebec and CeiBA 25 Foundation. The Centro de Investigación de Enfermedades Tropicales at the Universidad 26 27 Autónoma de Guerrero is the sponsor of the study. 28 29 30 31 Competing interests 32 33 None declared http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 14 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 Tables 6 7 Table 1. List of systematic reviews related to the field of traditional midwifery in relation to 8 9 maternal health 10 11 # Review Approach 12 Reference Sibley L & Sipe TA. (2004).[39] 13 Compare trained and untrained Time searched 14 1 traditional birth attendants ? to 1997? (inferred, not stated) 15 (TBA). 16 Inclusion For peer review only 17 Studies involving training of TBAs (not stated) 18 Reference 19 Kruske S, Barclay L. (2004).[7] Time 20 Documents that address TBA 2 1970 to 2003 21 training. Inclusion 22 “A review of the health and sociological literature and international policy 23 documents that address TBA training” 24 Reference 25 Sibley L, Sipe TA, Koblinsky M. (2004).[40] 26 Time Effectiveness of TBA training to 27 January 1970 to June 1999 improve access to skilled birth 28 3 Inclusion attendance for obstetric 29 Published and unpublished studies: treatment was TBA training; emergencies 30 treatment group data were derived from TBAs or mothers and neonates 31 whose care was provided by TBAs or who were living in areas where 32 more than 50% of births were attended by TBAs. 33 Reference http://bmjopen.bmj.com/ 34 Sibley LM, Sipe TA, Koblinsky M. (2004).[41] 35 Time Effectiveness of TBA training to 36 1970 to 2002 4 increase use of professional Inclusion 37 antenatal care 38 Published and unpublished studies on the relationship between traditional 39 birth attendant (TBA) training and increased use of professional antenatal 40 care (ANC). 41 Reference on September 25, 2021 by guest. Protected copyright. 42 Sibley L, Sipe T, Brown C, et al. (2007).[42] Time 43 Effects of TBA training on ? to 2006 44 5 health behaviours and pregnancy Inclusion 45 outcomes. 46 Published and unpublished randomized controlled trials, controlled before/after and interrupted time series studies comparing trained and 47 untrained TBAs or women cared for/living in areas served by TBAs. 48 Reference 49 Effect of community-based Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, et al. 50 cadres –community-based skilled (2009).[43–48] birth attendants, TBAs, and 51 Time 6 community health workers– in 52 ? to 2002 (updated in 2009) improving perinatal and 53 Inclusion intrapartum-related outcomes. 54 Interventions and strategies that avert intrapartum-related adverse 55 outcomes. 56 57 58 59 15 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Reference 4 Kidney E, Winter HR, Khan KS, et al. (2009).[49] Effectiveness of community- 5 Time level interventions to reduce 6 From inception to 2006 7 maternal mortality. Some 7 Inclusion interventions included traditional 8 Maternity or childbearing age women, comparative study designs with midwives. 9 concurrent controls, community-level interventions and maternal death as 10 an outcome 11 Reference Byrne A, Morgan A.[50] 12 Increase of skilled birth Time 13 8 attendance after integration of From inception to October 2010 14 TBAs with the health system 15 Inclusion 16 Interventions of integrationFor betweenpeer TBA and review formal health system only 17 Reference 18 Wilson A, Gallos ID, Plana N, et al. (2011).[51] Effectiveness of training and 19 Time support of traditional birth 20 9 From inception to April 2011 attendants on the outcomes of Inclusion perinatal, neonatal, and maternal 21 Search terms were “birth attend*”, “traditional midwife”, “lay birth death. 22 attendant”, “dais”, and “comadronas”. In developing countries 23 Reference Explore factors affecting the 24 Glenton C, Colvin CJ, Carlsen B, et al. (2013).[52] implementation of lay Health 25 Time Workers (LHW) programmes for 26 10 From inception to 2011 maternal and child health. 27 Inclusion (In eight studies, LHWs were 28 Studies that used qualitative methods for data collection and analysis and traditional birth attendants who 29 that focused on the experiences and attitudes of stakeholders had received additional training). 30 Reference 31 Vieira C, Portela A, Miller T, et al. (2012).[53] Effects of interventions to 32 Time

increase the use of skilled health http://bmjopen.bmj.com/ 33 11 From inception? to June 2010 (additional materials received until 2012) personnel by women for 34 Inclusion childbirth care. 35 TBAs had been attending births prior to the intervention; and a transition 36 to skilled health personnel was in progress or planned. 37 Reference 38 Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, 39 Gülmezoglu AM. (2014).[54] Facilitators and barriers to Time increase the use of skilled health 40 12 41 From inception to April 2013 personnel by women for on September 25, 2021 by guest. Protected copyright. 42 Inclusion childbirth care. 43 Study objectives related to barriers and/or facilitators to facility-based 44 delivery and reporting qualitative data. 45 Reference Bohren MA, Hunter EC, Munthe-Kaas HM, et al. (2017) [55] 46 Effects, on women and their Time 47 babies, of continuous, one-to-one 13 From inception to April 2013 48 intrapartum support compared Inclusion 49 with usual care, in any setting. Randomised controlled trials comparing continuous support during labour 50 with usual care. 51 Reference Effectiveness of care delivered 52 Lassi ZS, Das JK, Salam RA, et al. (2014).[56] through community level inputs 53 14 Time for improving maternal and 54 From inception to April 2013 newborn health outcomes. 55 Inclusion (Interventions involving TBAs 56 57 58 59 16 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Systematic reviews were focused on training) 4 Reference 5 Lassi ZS, Middleton PF, Bhutta ZA, et al. (2016).[57] Impact of different strategies to 6 Time improve maternal and neonatal 7 From inception to January 2015 15 health care seeking. 8 Inclusion (Interventions involving TBAs 9 All experimental studies from LMICs that assessed the health care were focused on training) 10 seeking behavior or pattern for maternal and newborn health care and 11 illnesses were included. 12 Effects of health interventions 13 Reference during pregnancy, childbirth and 14 World Health Organization. WHO recommendations on health promotion the postnatal period. 15 interventions for maternal and newborn health 2015. Geneva; Effects of health behaviours of 2015.[58,59] women during these periods to 16 16 For peer review only 17 Time care for herself and her baby. 18 ? to 2015? (not indicated) (Interventions involving TBAs 19 Inclusion included training, promotion of 20 Not explained skilled attendance and promotion of partnership and linkage) 21 Reference 22 Miller T, Smith H. (2017).[60] 23 Effectiveness of interventions to Time 24 find new roles for TBAs on 17 2000 to 2012 (updated 2015? not indicated) maternal and newborn health 25 Inclusion outcomes. 26 Secondary analysis of studies identified in previous reviews[50,53,58] 27 and a mapping of maternal health literature.[61] 28 Reference Assess cost-effectiveness of 29 Mangham-Jefferies L, Pitt C, Cousens S, et al. (2014).[62] strategies to improve the demand 30 Time and supply of maternal and 31 18 January 1990 to October 2016 newborn health care in low- 32 Inclusion

income and lower-middle- http://bmjopen.bmj.com/ 33 Peer-reviewed and grey literature reporting cost-effectiveness measures income countries 34 based on primary data. 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 17 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 Figures 6 Figure 1. Fuzzy cognitive map of protective factors for maternal health from Me'Phaa and 7 8 Nancue ñomda traditional midwives in Guerrero 9 10 Legend: Solid arrows represent excitatory relationships and dashed arrows represent inhibitory 11 12 relationships. The thickness of the arrows varies according to the weight of the relationships. 13 14 The numbers on the arrows represent the weight of the influence of one factor on another, 15 with 1 being the highest influence. 16 For peer review only 17 18 19 20 Supplementary Files 21 22 Supplementary File 1. Preliminary Search Strategy for Ovid Medline 23 24 File format: PDF 25 26 File Name: Search_20200104.pdf 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 18 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

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1 2 3 (WHO/MCA). MASCOT/Wotro Map of Maternal Health Research (database). 4 5 2013.http://eppi.ioe.ac.uk/webdatabases4/Intro.aspx?ID=11 (accessed 12 Dec 2019). 6 7 62 Mangham-Jefferies L, Pitt C, Cousens S, et al. Cost-effectiveness of strategies to improve 8 9 the utilization and provision of maternal and newborn health care in low-income and 10 11 lower-middle-income countries: a systematic review. BMC Pregnancy Childbirth 12 13 2014;14:243. doi:10.1186/1471-2393-14-243 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 25 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Solid arrows represent excitatory relationships and dashed arrows represent inhibitory relationships. The 33 thickness of the arrows varies according to the weight of the relationships. The numbers on the arrows http://bmjopen.bmj.com/ represent the weight of the influence of one factor on another, with 1 being the highest influence. 34 35 264x206mm (72 x 72 DPI) 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Preliminary 4 Search Strategy for Ovid Medline 5 6 January 4, 2020 7 8 1. exp Maternal Health/ 9 2. exp Maternal Welfare/ 10 3. exp Maternal Health Services/ 11 4. exp Pregnancy/ 12 5. exp Pregnancy Complications/ 13 14 6. exp Midwifery/ 15 7. (maternal or maternity or mother? or pregnan* or gravid* or midwif* or (birth adj1 16 attendant?) or doula?).tw,kf.For peer review only 17 8. 1 or 2 or 3 or 4 or 5 or 6 or 7 18 9. exp Health Services, Indigenous/ 19 10. (aborigine? or aboriginal?).tw,kf. 20 21 11. indigenous.tw. 22 12. natives.tw. 23 13. (tribe* or tribal*).tw. 24 14. autochton*.tw. 25 15. or/9-14 26 16. "*** COMMENT: North America ***".sm. 27 17. exp Indians, North American/ 28 29 18. exp Indians, Central American/ 30 19. exp Inuits/ 31 20. native american?.tw. 32 21. american indian?.tw. 33 22. first nation?.tw. http://bmjopen.bmj.com/ 34 23. alaska* native*.tw. 35 24. (athabascan or ahtna or aleut* or alutor or chelkancy or chukchi or chulymcy or 36 37 chuvancy or koryak or nanaicy or manci or kumadincy or negidalcy or nenets or orochi 38 or nganasan or nivkhy or oroki or sa?mi or selkup or shorcy or soioty or tazy or telengity 39 or teleuty or tofolar or tubolar or tuvin-todjin or udege or ukagiry or ulchi or veps or "deg 40 hit?an" or dena?ina or holikachuk or kolchan or koyukon or tanacross or eyak or haida 41 or tlingit or tsimshian* or inupiat or yup?ik or cup?ik or sugpiaq or alutiiq or alutiqu or on September 25, 2021 by guest. Protected copyright. 42 chugach or koniag or unanga? or yup?ik or cree or mohawk or salish or nuxalk or 43 44 kimsquit or tallheo or stuie or kwatna or shishalh or sechelt or squamish or 45 Skwxwu7mesh or qualicum or comox or sliammon or comos or klahoose or halkomelem 46 or cowichan or somena or s?amuna? or quw?utsun or quamichan or clemclemalut* or 47 l?uml?umulut* or comiaken or qwum?yiqun? or khenipsen or hinupsum or kilpahla* or 48 tl?ulpalu* or koksilah or hwulqwselu or penelakut or lamalcha or musqueam or 49 snuneymuxw or tsleil-waututh or ts?ailes or chehali* or sto?lo or aitchelitz or matsqui or 50 popkum or skway or skawahlook or skowkale or squiala or sumas or tzeachten or 51 52 yakweakwioose or chawathil or cheam or kawaw-kawaw-apilt or scowlitz or scaulit* or 53 shxw?ow?hamel or soowahlie or katzie or kwantlen or kwikwetlem or tsawwassen or 54 songhee* or t?souke or sooke or semiahmoo or malahat or tsartlip or tsawout or 55 esquimalt or tsimshian* or gitxsan or nisga?a or haida or nuu-chah-nulth or nootka or 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 mowachaht* or ahousaht or ehattesaht or hesquiaht or cheklesahht or kyuquot or 4 nuchatlaht or huu-ay-aht or ohiaht or hupacasath or opetchesaht or toqaht or tseshaht 5 6 or uchucklesaht or ucluelet or ditidaht or pacheedaht or kwakwaka?wakw or laich-kwil- 7 tach or euclataws or yuculta or weewaikai or wewaykum or koskimo or namgis or haisla 8 or kiamaat or henaksiala or heiltsuk or wuikinuxv or owekeeno or tlingit or (("aa tlein" or 9 deisleen) adj2 kwaan) or athapaskan or dakelh or wet?suwet?en or dene-thah or dene- 10 thah or slavey or tsilhqot?in or chilcotin or sekani or dunne-za or tahltan or "kaska dena" 11 or nlaka?pamux or okanagan or secwepemc or shuswap or sinixt or st?at?imc or lillooet 12 or lil?wat or stl?atl?imx or skatin or semahquam or xa?xtsa or nequatque or ktunaxa or 13 14 kootenay or ashinaabe or plains_ojibwa or blackfoot or kainai or peigan or siksika or 15 dene or chipewyan or nakoda or assiniboine or ((plains or oji or "james bay") adj1 cree) 16 or "eeyou istchee"For or tasttine peer or "tsuu t?ina"review or ktunaxa oronly sahtu or "tli cho" or 17 yellowknives or dunne?za or gwich?in or kutchin or loucheaux or han or kaska or tagish 18 or tutchone or anishinaabe or algonquin or nipissing or ojibwa or mississaugas or 19 saulteaux or potawatomi or cree or innu or montagnais or naskapi or beothuk or 20 21 maliseet or mi?kmaq or passamaquoddy or iroquois or haudenosaunee or cayuga or 22 guyohkohnyo or kanien?kehaka or oneida or onayotekaono or on?ndaga* or tuscarora 23 or wyandot or huron or onondowahgah or ganonsyoni or seneca).tw. 24 25. or/17-24 25 26. "*** COMMENT: South America ***".sm. 26 27. exp Indians, South American/ 27 28. (amanye or atikum or awa-guaja or baniwa or botocudo or bara or caingang or 28 29 enawene or guarani or kadiweu or kaingang or kamayura or kamaiura or karaja or 30 kayapo or kubeo or kaxinawa or kokama or korubo or kulina madiha or mbya or makuxi 31 or matses or mayoruna or munduruku or nambikwara or ofaye or "pai tavytera" or 32 panara or pankararu or pataxo or piraha or paiter or potiguara or satere mawe or surui 33 do para or tapirape or terena or ticuna or tremembe or tupi or parakana or waipi or http://bmjopen.bmj.com/ 34 urubu-kaapor or waorani or wapixana or wauju or witoto or xakriaba or xavante or 35 xukuru or yanomami).tw. 36 37 29. 27 or 28 38 30. 15 or 25 or 29 39 31. 8 and 30 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Reporting checklist for protocol of a systematic review. 4 5 6 Based on the PRISMA-P guidelines. 7 8 9 Instructions to authors 10 11 Complete this checklist by entering the page numbers from your manuscript where readers will find each of the 12 items listed below. 13 14 15 Your article may not currently address all the items on the checklist. Please modify your text to include the 16 missing information. If youFor are certain peer that an item review does not apply, pleaseonly write "n/a" and provide a short 17 18 explanation. 19 20 Upload your completed checklist as an extra file when you submit to a journal. 21 22 In your methods section, say that you used the PRISMA-Preporting guidelines, and cite them as: 23 24 25 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. Preferred 26 Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 27 2015;4(1):1. 28 29 30 Page 31 Reporting Item Number 32 33 http://bmjopen.bmj.com/ 34 Title 35 36 Identification #1a Identify the report as a protocol of a systematic review 1 37 38 Update #1b If the protocol is for an update of a previous systematic review, na 39 40 identify as such 41 on September 25, 2021 by guest. Protected copyright. 42 Registration 43 44 #2 If registered, provide the name of the registry (such as PROSPERO) 3 45 46 and registration number 47 48 Authors 49 50 51 Contact #3a Provide name, institutional affiliation, e-mail address of all protocol 1 52 authors; provide physical mailing address of corresponding author 53 54 Contribution #3b Describe contributions of protocol authors and identify the guarantor 13 55 56 of the review 57 58 Amendments 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 31 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 #4 If the protocol represents an amendment of a previously completed or na 2 3 published protocol, identify as such and list changes; otherwise, state 4 plan for documenting important protocol amendments 5 6 Support 7 8 9 Sources #5a Indicate sources of financial or other support for the review 14 10 11 Sponsor #5b Provide name for the review funder and / or sponsor 14 12 13 Role of sponsor or #5c Describe roles of funder(s), sponsor(s), and / or institution(s), if any, 14 14 15 funder in developing the protocol 16 For peer review only 17 Introduction 18 19 20 Rationale #6 Describe the rationale for the review in the context of what is already 4 21 known 22 23 Objectives #7 Provide an explicit statement of the question(s) the review will 6 24 25 address with reference to participants, interventions, comparators, and 26 outcomes (PICO) 27 28 29 Methods 30 31 Eligibility criteria #8 Specify the study characteristics (such as PICO, study design, setting, 7 32 33 time frame) and report characteristics (such as years considered, http://bmjopen.bmj.com/ 34 language, publication status) to be used as criteria for eligibility for 35 36 the review 37 38 Information sources #9 Describe all intended information sources (such as electronic 6 39 databases, contact with study authors, trial registers or other grey 40 41 literature sources) with planned dates of coverage on September 25, 2021 by guest. Protected copyright. 42 43 Search strategy #10 Present draft of search strategy to be used for at least one electronic 6 44 45 database, including planned limits, such that it could be repeated 46 47 Study records - data #11a Describe the mechanism(s) that will be used to manage records and 9 48 49 management data throughout the review 50 51 Study records - #11b State the process that will be used for selecting studies (such as two 7 52 selection process independent reviewers) through each phase of the review (that is, 53 54 screening, eligibility and inclusion in meta-analysis) 55 56 Study records - data #11c Describe planned method of extracting data from reports (such as 9 57 58 collection process piloting forms, done independently, in duplicate), any processes for 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 31 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from obtaining and confirming data from investigators 1 2 3 Data items #12 List and define all variables for which data will be sought (such as 7 4 PICO items, funding sources), any pre-planned data assumptions and 5 6 simplifications 7 8 Outcomes and #13 List and define all outcomes for which data will be sought, including 7 9 prioritization prioritization of main and additional outcomes, with rationale 10 11 12 Risk of bias in #14 Describe anticipated methods for assessing risk of bias of individual 8 13 individual studies studies, including whether this will be done at the outcome or study 14 15 level, or both; state how this information will be used in data synthesis 16 For peer review only 17 Data synthesis #15a Describe criteria under which study data will be quantitatively 10 18 19 synthesised 20 21 Data synthesis #15b If data are appropriate for quantitative synthesis, describe planned 10 22 summary measures, methods of handling data and methods of 23 24 combining data from studies, including any planned exploration of 25 consistency (such as I2, Kendall’s τ) 26 27 28 Data synthesis #15c Describe any proposed additional analyses (such as sensitivity or na 29 subgroup analyses, meta-regression) 30 31 32 Data synthesis #15d If quantitative synthesis is not appropriate, describe the type of 10 33 summary planned http://bmjopen.bmj.com/ 34 35 Meta-bias(es) #16 Specify any planned assessment of meta-bias(es) (such as publication 10 36 37 bias across studies, selective reporting within studies) 38 39 Confidence in #17 Describe how the strength of the body of evidence will be assessed 12 40 41 cumulative (such as GRADE) on September 25, 2021 by guest. Protected copyright. 42 evidence 43 44 45 The PRISMA-P checklist is distributed under the terms of the Creative Commons Attribution License CC-BY 46 4.0. This checklist was completed on 21. February 2020 using https://www.goodreports.org/, a tool made by the 47 EQUATOR Network in collaboration with Penelope.ai 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

Factors influencing maternal health in Indigenous communities with presence of traditional midwifery in the Americas: protocol for a scoping review ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-037922.R1

Article Type: Protocol

Date Submitted by the 20-May-2020 Author:

Primary Subject http://bmjopen.bmj.com/ Obstetrics and gynaecology Heading:

Secondary Subject Heading: Health services research, Global health

Maternal medicine < OBSTETRICS, PRIMARY CARE, PUBLIC HEALTH, Keywords: REPRODUCTIVE MEDICINE, STATISTICS & RESEARCH METHODS, SOCIAL MEDICINE

on September 25, 2021 by guest. Protected copyright.

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1 2 3 Factors influencing maternal health in Indigenous communities with presence of traditional 4 5 midwifery in the Americas: protocol for a scoping review 6 7 8 9 Ivan Sarmiento, MPH1,2; 10 3 11 Sergio Paredes-Solís, MD, MSc, DSc ; 12 4 13 Martin Morris, MSc ; 14 Anne Cockcroft, MBBS, MD, FRCP, FFOM1; 15 16 Neil Andersson, MD,For MSc, MPhil, peer PhD1,3 review only 17 18 19 20 1 Department of Family Medicine. McGill University. Montreal, Canada. 21 2 22 Grupo de Estudios en Sistemas Tradicionales de Salud. Universidad del Rosario. Bogotá, 23 24 Colombia. 25 3 Centro de Investigación de Enfermedades Tropicales. Universidad Autónoma de Guerrero. 26 27 Acapulco, Mexico. 28 29 4 Schulich Library of Physical Sciences, Life Sciences and Engineering. McGill University. 30 31 Montreal, Canada 32 33 http://bmjopen.bmj.com/ 34 Corresponding author: Ivan Sarmiento 35 36 McGill University, Department of Family Medicine, 5858 Chemin de la Côte des Neiges, Montreal, 37 38 Quebec H3S 1Z1, [email protected], +1 (438) 927-8710, https://orcid.org/0000-0003-2871- 39 40 1464 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 ABSTRACT 6 Introduction. 7 8 Indigenous mothers often receive culturally unsafe services that do not fully respond to their 9 10 needs. The objective of this scoping review is to collate and assess evidence that identifies 11 12 factors, including the role and influence of traditional midwives, that affect maternal health in 13 14 indigenous communities in the Americas. The results will map Western perspectives reflected 15 in published and unpublished literature to indicate the complex network of factors that 16 For peer review only 17 influence maternal outcomes. These maps will allow for comparison with local stakeholder 18 19 knowledge and discussion to identify what needs to change to promote culturally safe care. 20 21 Methods and analysis. 22 23 A librarian will search studies with iterative and documented adjustments in CINAHL, Scopus, 24 25 LILACS, MEDLINE®, Embase®, and Google Scholar, without any time restrictions, and use Google 26 27 search engine for gray literature. Included studies will be empirical (quantitative, qualitative or 28 mixed); address maternal health issues among indigenous communities in the Americas; and 29 30 report on the role or influence of traditional midwives. Two researchers will independently 31 32 screen and blindly select the included studies. The quality assessment of included manuscripts 33 http://bmjopen.bmj.com/ 34 will rely on the Mixed Method Appraisal Tool. Two independent researchers will extract data 35 36 on factors promoting or reducing maternal health in indigenous communities, including the role 37 38 or influence of traditional midwives. Fuzzy cognitive mapping will summarize the findings as a 39 list of relationships between identified factors and outcomes with weights indicating strength 40 41 of the relationship and the evidence supporting this. on September 25, 2021 by guest. Protected copyright. 42 43 Ethics and dissemination. 44 45 This review is part of a proposal approved by ethics committees at McGill University and the 46 47 Centro de Investigación de Enfermedades Tropicales in Guerrero. Participating indigenous 48 49 communities in Guerrero State approved the study in 2015. The results of the scoping review 50 will contribute to the field of cultural safety and intercultural dialogue for the promotion of 51 52 maternal health in indigenous communities. 53 54 Keywords: indigenous health, weight of evidence, intercultural dialogue, maternal health, safe 55 56 birth, traditional health systems 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Strengths and limitations of this study 4 5  Viewed from different standpoints, maternal health has multiple interpretations and 6 7 multiple interacting factors that simple linear models cannot easily identify. 8 9  Disentangling whether a study included traditional midwives or not will be challenging in 10 11 times when retraining and professionalization are becoming more prominent in Latin 12 13 America 14  15 This scoping review uses fuzzy cognitive mapping to summarize results, generating soft 16 models of causalFor relationships peer that require review empirical testing. only 17 18  Heterogeneity of exposures and outcomes might require developing soft models 19 20 generalized to a larger scale to allow for comparability. 21 22  The review is part of a bigger initiative promoting intercultural dialogue between 23 24 indigenous and western perspectives, with a view to improving maternal health. 25 26 27 Word count: 3,864 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 INTRODUCTION 6 Maternal morbidity and mortality are inequitable burdens for many indigenous women in the 7 8 Americas.[1–3] Living as they do at the very periphery of the Western health system, 9 10 indigenous mothers often receive low-quality care from attenuated health services that lack 11 12 human and financial resources. Colonial history in the Americas has weakened indigenous 13 14 cultures, including their traditions to promote safe motherhood.[4] Mutual mistrust between 15 Western practitioners and traditional midwives creates additional distance and hampers 16 For peer review only 17 collaboration.[5] While their traditional and Western health providers largely ignore each other, 18 19 indigenous mothers receive less appropriate Western services and they cannot rely solely on 20 21 their weakened traditional resources. 22 23 Since 2004, no less than 18 literature reviews focused on effectiveness of retraining traditional 24 25 midwives and redefining their traditional roles as auxiliary promoters of Western health 26 27 services (Table 1). A recurring problem is the reduction of traditional midwife with traditional 28 29 birth attendant (TBA), a term that refers to unskilled personnel providing limited support during 30 31 the childbirth event.[6] Several interventions explored training birth attendants in Western 32 33 birthing skills. http://bmjopen.bmj.com/ 34 35 36 37 Table 1. List of systematic reviews related to the field of traditional midwifery in relation to 38 39 maternal health 40 41 # Review Approach on September 25, 2021 by guest. Protected copyright. 42 Reference Sibley L & Sipe TA. (2004).[7] 43 Compare trained and untrained Time searched 44 1 traditional birth attendants ? to 1997? (inferred, not stated) 45 (TBA). Inclusion 46 Studies involving training of TBAs (not stated) 47 Reference 48 Kruske S, Barclay L. (2004).[8] 49 Time Documents that address TBA 50 2 1970 to 2003 training. 51 Inclusion 52 “A review of the health and sociological literature and international policy 53 documents that address TBA training” 54 Reference Effectiveness of TBA training to 3 55 Sibley L, Sipe TA, Koblinsky M. (2004).[9] improve access to skilled birth 56 57 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Time attendance for obstetric 4 January 1970 to June 1999 emergencies 5 Inclusion 6 Published and unpublished studies: treatment was TBA training; 7 treatment group data were derived from TBAs or mothers and neonates 8 whose care was provided by TBAs or who were living in areas where 9 more than 50% of births were attended by TBAs. 10 Reference 11 Sibley LM, Sipe TA, Koblinsky M. (2004).[10] Time 12 Effectiveness of TBA training to 1970 to 2002 13 4 increase use of professional Inclusion 14 antenatal care 15 Published and unpublished studies on the relationship between traditional 16 birth attendant (TBA)For training peer and increased reviewuse of professional antenatal only 17 care (ANC). 18 Reference 19 Sibley L, Sipe T, Brown C, et al. (2007).[11] Time 20 Effects of TBA training on ? to 2006 21 5 health behaviours and pregnancy Inclusion 22 outcomes. Published and unpublished randomized controlled trials, controlled 23 before/after and interrupted time series studies comparing trained and 24 untrained TBAs or women cared for/living in areas served by TBAs. 25 Reference Effect of community-based 26 Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, et al. cadres –community-based skilled 27 (2009).[12–17] birth attendants, TBAs, and 28 Time 6 community health workers– in 29 ? to 2002 (updated in 2009) improving perinatal and 30 Inclusion intrapartum-related outcomes. 31 Interventions and strategies that avert intrapartum-related adverse 32 outcomes. 33 Reference http://bmjopen.bmj.com/ 34 Kidney E, Winter HR, Khan KS, et al. (2009).[18] Effectiveness of community- 35 Time level interventions to reduce 36 From inception to 2006 7 maternal mortality. Some Inclusion 37 interventions included traditional Maternity or childbearing age women, comparative study designs with 38 midwives. 39 concurrent controls, community-level interventions and maternal death as 40 an outcome 41 Reference on September 25, 2021 by guest. Protected copyright. Byrne A, Morgan A (2011).[19] 42 Increase of skilled birth Time 43 8 attendance after integration of From inception to October 2010 44 TBAs with the health system 45 Inclusion 46 Interventions of integration between TBA and formal health system 47 Reference Wilson A, Gallos ID, Plana N, et al. (2011).[20] Effectiveness of training and 48 Time support of traditional birth 49 9 From inception to April 2011 attendants on the outcomes of 50 Inclusion perinatal, neonatal, and maternal 51 Search terms were “birth attend*”, “traditional midwife”, “lay birth death. 52 attendant”, “dais”, and “comadronas”. In developing countries 53 Reference Explore factors affecting the 54 10 Glenton C, Colvin CJ, Carlsen B, et al. (2013).[21] implementation of lay Health 55 Time Workers (LHW) programmes for 56 57 58 59 5 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 From inception to 2011 maternal and child health. 4 Inclusion (In eight studies, LHWs were 5 Studies that used qualitative methods for data collection and analysis and traditional birth attendants who 6 that focused on the experiences and attitudes of stakeholders had received additional training). 7 Reference 8 Vieira C, Portela A, Miller T, et al. (2012).[22] Effects of interventions to 9 Time increase the use of skilled health 10 11 From inception to June 2010 (additional materials received until 2012) personnel by women for Inclusion 11 childbirth care. 12 TBAs had been attending births prior to the intervention; and a transition 13 to skilled health personnel was in progress or planned. 14 Reference 15 Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, 16 Gülmezoglu AM. (2014).[23] Facilitators and barriers to Time For peer review onlyincrease the use of skilled health 17 12 18 From inception to April 2013 personnel by women for 19 Inclusion childbirth care. 20 Study objectives related to barriers and/or facilitators to facility-based delivery and reporting qualitative data. 21 Reference Effectiveness of care delivered 22 Lassi ZS, Das JK, Salam RA, et al. (2014).[24] through community level inputs 23 Time for improving maternal and 24 13 From inception to April 2013 newborn health outcomes. 25 Inclusion (Interventions involving TBAs 26 Systematic reviews were focused on training) 27 Reference Assess cost-effectiveness of 28 Mangham-Jefferies L, Pitt C, Cousens S, et al. (2014).[25] strategies to improve the demand 29 Time and supply of maternal and 30 14 January 1990 to October 2016 newborn health care in low- 31 Inclusion income and lower-middle- 32 Peer-reviewed and grey literature reporting cost-effectiveness measures

income countries http://bmjopen.bmj.com/ 33 based on primary data. 34 Effects of health interventions 35 during pregnancy, childbirth and Reference 36 the postnatal period. World Health Organization. WHO recommendations on health promotion 37 Effects of health behaviours of interventions for maternal and newborn health 2015. (2015).[26,27] women during these periods to 38 15 Time care for herself and her baby. 39 ? to 2015? (not indicated) (Interventions involving TBAs 40 Inclusion included training, promotion of on September 25, 2021 by guest. Protected copyright. 41 Not explained 42 skilled attendance and promotion 43 of partnership and linkage) 44 Reference Lassi ZS, Middleton PF, Bhutta ZA, et al. (2016).[28] 45 Impact of different strategies to Time 46 improve maternal and neonatal From inception to January 2015 47 16 health care seeking. Inclusion 48 (Interventions involving TBAs All experimental studies from LMICs that assessed the health care 49 were focused on training) seeking behavior or pattern for maternal and newborn health care and 50 illnesses were included. 51 Reference Effectiveness of interventions to 52 Miller T, Smith H. (2017).[29] find new roles for TBAs on 53 17 Time maternal and newborn health 54 2000 to 2012 (updated 2015? not indicated) outcomes. 55 Inclusion 56 57 58 59 6 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Secondary analysis of studies identified in previous reviews [19,21] and a 4 mapping of maternal health literature.[30] 5 Reference 6 Blanchard AK, Prost A, Houweling TAJ. (2019).[31] 7 Time CHW include trained lay 8 Studies conducted after 1990 and published between 1 January 1996 and workers, health volunteers, 9 18 30 August 2017 community health agents, 10 Inclusion traditional births attendants and 11 Studies examining the effects of Community Health Workers (CHW) community midwives. 12 interventions in low-income and middle-income countries on maternal 13 and newborn health outcomes across socioeconomic groups 14 15 16 For peer review only 17 In indigenous communities with traditional health systems, with particularities across different 18 19 cultural groups, traditional midwives accompany women from childhood and through 20 21 motherhood; their role is much wider (including family and other social relations) and deeper 22 (including counselling and emotional support from menarche to menopause) than can be 23 24 summarised as “birth attendance.”[8,32] Traditional midwives usually have their own hierarchy 25 26 defined by capacity to deal with complex health problems.[33] There is little research on 27 28 interventions that support traditional midwives and recognises their knowledge, and even less 29 30 research on adjusting the western health system to work with traditional midwives.[8] 31 32 Maternal health is a capacious concept that incorporates complex socio-cultural mechanisms 33 http://bmjopen.bmj.com/ 34 affecting the well-being of women, their offspring and communities.[34] Existing literature 35 36 reviews (Table 1) focus on biomedical outcomes like maternal morbidity and mortality, 37 38 neonatal survival or uptake of Western health services. A scoping review allows us to address 39 broader questions, including what the outcomes are.[35] The approach allows incorporation of 40 41 intersectional factors in a general landscape that can improve understanding of the full role of on September 25, 2021 by guest. Protected copyright. 42 43 traditional midwifery. This is central to services that are respectful of indigenous cultures where 44 45 women still use this resource, improving interactions between indigenous and Western health 46 47 services.[36] More culturally safe health services increase patient perceptions of physical, 48 spiritual, social and emotional safety.[37] Another benefit of a mutually respectful environment 49 50 is the concerting of traditional and Western services together to improve maternal health.[38] 51 52 53 54 Part of a larger initiative project to understand the role that traditional midwifery has in safe 55 56 birth in cultural safety, this scoping review aims to contribute to intercultural dialogue between 57 58 59 7 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 traditional and Western health systems.[39] The larger project will develop a composite theory 4 5 of change from three knowledge bases: (i) the scoping review described in this protocol, (ii) the 6 7 research team’s understanding of the intercultural dialogue dynamics as these relate to safe 8 9 birth, and (iii) traditional midwives’ understanding of safe birth. Representing each knowledge 10 11 set as a fuzzy cognitive map, we will adapt the Weight of Evidence[40,41] approach to combine 12 13 the three sources into one model to inform decision making and a stakeholder-led analysis of a 14 cluster randomized controlled trial.[39] In this protocol we focus on the procedures to conduct 15 16 the scoping review,For and mention peer the additional review use of the review only results. A full description of 17 18 the procedure to combine the three knowledge sources is the subject of an additional report. 19 20 21 22 METHODS 23 24 This protocol follows the PRISMA-P guidelines and the Joanna Briggs Institute Reviewer's 25 Manual to assure transparency, accuracy, and completeness.[42,43] It follows Arksey and 26 27 O’Malley’s methodological framework consisting of six stages.[44] All members of the research 28 29 team developed, reviewed and agreed the protocol. 30 31 32 33 Stage 1: Identify the research question http://bmjopen.bmj.com/ 34 A convergent mixed studies review,[45,46] will address the question: What factors, including 35 36 the role and influence of traditional midwives, promote or reduce maternal health in 37 38 indigenous settings and, based on available qualitative and quantitative evidence, what is the 39 40 relative weight of their influence? 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 Secondary questions of the included studies are: 45  46 What are the indicators of maternal health? 47  How are the concepts of cultural safety and intercultural dialogue considered? 48 49  What is the influence of traditional midwifery on maternal health? 50 51  What is the effect on maternal health of interventions supporting traditional midwives? 52 53 54 55 Stage 2: Identifying relevant studies 56 57 58 59 8 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 A health librarian (MM) developed the comprehensive search strategy to explore the following 4 5 databases: Web of ScienceTM, CINAHL Nursing Journal Databases, Scopus, Latin American & 6 7 Caribbean Health Sciences Literature (LILACS), MEDLINE®, Embase® and Google Scholar. The 8 9 review will include studies in human populations reported in English, Spanish, French, or 10 11 Portuguese published at any time up to the date of the search. 12 13 14 The strategy applies a targeted, iterative searching technique that documents new keywords 15 16 emerged from screenedFor articles.[47] peer This strategyreview consists of only two steps: (1) an initial search in 17 18 MEDLINE/PubMed to analyse the text words in the titles and abstracts retrieved and the index 19 20 terms used to describe the article; (2) using the updated terms, conduct a second search and 21 22 translate the search to run across the other databases and grey literature. The final report of 23 24 the review will document in detail these two steps. Online supplementary file 1 presents a draft 25 literature search strategy for step 1. 26 27 28 29 Using the Google (Google LLC) search engine we will identify unpublished studies and grey 30 31 literature, such as institutional and advocacy reports. In the advanced search section, we will 32 33 use consistent search terms identified during the screening stage of published literature. To http://bmjopen.bmj.com/ 34 increase precision, each search will use the Google versions for the country of interest and limit 35 36 the results for that country. We will use the computer of the leading author to guarantee that 37 38 the personal filters of Google are in favour of academic information about traditional midwives. 39 40 The screening process will be limited to the first 100 results returned for reasons of feasibility. 41 on September 25, 2021 by guest. Protected copyright. 42 We will use the title and short text underneath for initial screening.[48] To facilitate the 43 44 transparency of web searching, for each website, we will report the URL, dates searched, search 45 terms and the citation details of any included literature. To document specific searches of 46 47 government information and reports that are not published commercially, we will complete 48 49 hand-searches of the websites following the procedure of the Canadian Agency for Drugs and 50 51 Technologies for Health checklist.[49] 52 53 54 55 56 57 58 59 9 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 We will search the reference list of included references for additional studies, but we do not 4 5 propose to contact authors for further information. 6 7 8 9 Stage 3: Study selection 10 11 After completing the search and excluding duplicated records using Endnote (X9.3.1, Clarivate 12 13 Analytics), we will digitise the list of references in Rayyan QCRI[50] to support the selection 14 process, and two independent researchers will select the studies to include. The independent 15 16 researchers will reconcileFor the peer differences andreview if they do not reachonly consensus a third party will 17 18 decide the inclusion or exclusion. The first selection round will use title and abstract as criteria, 19 20 and a second round will use full content to support the decision. 21 22 23 24 In scoping reviews, the selection process can be iterative. When the research team engages in 25 study selection and more deeply explore the literature, they may get new information to 26 27 enhance the identification phase.[47] We will document any adjustment to the search strategy 28 29 occurring after the selection process has already started. Included studies will satisfy the 30 31 following four criteria: 32 33 http://bmjopen.bmj.com/ 34 a) The study addresses maternal health issues in indigenous populations. 35 36 The concept of maternal health is a broad term without a common definition and standard 37 38 identification criteria. Part of the challenge is the extended debate on defining health, which is 39 40 even deeper across different cultural backgrounds.[32] For example, traditional midwives in 41 on September 25, 2021 by guest. Protected copyright. 42 Guerrero, Mexico, included in their definition of a healthy mother, those with a healthy baby 43 44 and a healthy husband. The World Health Organization focuses the definition on the mother 45 and uses a time period to circumscribe the concept as “the health of women during pregnancy, 46 47 childbirth and the postpartum period.”[51] In the negative interpretation of the concept of 48 49 maternal health, maternal mortality, has usually been used as a critical measure. But it only 50 51 represents a small fraction of the problem when compared with the occurrence of maternal 52 53 morbidity, understood as “any health condition attributed to and/ or aggravated by pregnancy 54 55 and childbirth that has a negative impact on the woman’s wellbeing.”[52] 56 57 58 59 10 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 According to Graham, maternal health is commonly conceptualized as a discrete state of 6 7 negative outcomes in terms of morbidity and mortality, characterized by physical rather than 8 9 social or mental manifestations, and by a narrow time-perspective.[53] Especially in the context 10 11 of indigenous communities, spiritual and environmental domains can have strong relevance. 12 13 Graham suggested the need for flexible interpretations to recognize that “maternal health 14 encompasses positive or negative outcomes – physical, social or mental, in a woman from any 15 16 cause related to childbearingFor peeror its management.” review only 17 18 19 20 Our review will therefore include studies that report on maternal health irrespective of the 21 22 definition of this concept. The review will include studies on positive or negative outcomes 23 24 from any cause related to childbearing or its management. 25 26 27 b) The study reports on the role or influence of traditional midwives. 28 29 Birth traditions in most if not all indigenous cultures involve someone attending women 30 31 throughout pregnancy and delivery, many of them including support from menarche to 32 33 menopause.[34] To clarify terminology, we distinguish between three categories of birth http://bmjopen.bmj.com/ 34 attendants in indigenous contexts: (1) casual or coincidental birth helpers, who might help in a 35 36 family or neighbourhood emergency, (2) trained birth attendants (different to traditional birth 37 38 attendants, but conflated by the acronym TBA), are individuals who receive training in Western 39 40 birth practices and who might have received an official certification, and (3) authentic 41 on September 25, 2021 by guest. Protected copyright. 42 traditional midwives, whose recognition by their communities is reflected in the number of 43 44 births they attend each year, the outcomes for their patients, and the traditional knowledge 45 they hold. Traditional midwives “provide basic health care and advice before, during and after 46 47 pregnancy and childbirth (…) based primarily on experience and knowledge acquired informally 48 49 through the traditions and practices of the communities where they originated.”[54] With 50 51 significant cultural particularities in their knowledge, training, and practice between and within 52 53 indigenous groups, traditional midwives have their own hierarchy defined by their capacity to 54 55 deal with complex health problems.[33] 56 57 58 59 11 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 We will only include studies of authentic traditional midwives. However, this concept receives 6 7 multiple interpretations in the literature, which are reflected in the use of apparently 8 9 equivalent terms such as community midwives, lay midwives, or traditional birth 10 11 attendants.[55] These terms are often conflated under the broader concept of community 12 13 health worker[31,56], which, although it recognizes the community roots of traditional 14 midwives, neglects the culture specific roots of their practice. In a similar way, the appellation 15 16 of lay midwives is usedFor to suggest peer lack of professionalreview qualification only or expert knowledge. 17 18 Extensive use of the term traditional birth attendant[57,58] in the literature suggests limiting 19 20 the role of traditional midwives to the actual delivery, ignoring their experience, cultural 21 22 relevance and social role, and that they usually accompany women throughout pregnancy and 23 24 even from the menarche.[6,59] 25 26 27 Contemporary distortions or misunderstandings of traditional health practitioner roles have 28 29 reinforced mistrust in official health personnel. This has not been helped by charlatans and 30 31 health entrepreneurs who mimic the traditional healer role on a fee-for-service basis, but who 32 33 lack the training and spiritual foundations to play this role.[56] An additional layer of complexity http://bmjopen.bmj.com/ 34 is that mainstream Western medicine often bundles indigenous health systems, anchored in 35 36 specific cultures and history, with alternative or complementary therapies,[60] which are 37 38 abstracted from cultural identities and might not have proven effectiveness or safety.[61] We 39 40 will accept reports of traditional midwifery assuming authenticity, but the hierarchy and 41 on September 25, 2021 by guest. Protected copyright. 42 genuineness of participants will be discussed in the final report. 43 44 45 The review will distinguish traditional midwives from professional midwives. The main 46 47 difference between these categories is the origin of their knowledge and practice. The 48 49 appellative of traditional recognizes the link with traditional knowledge and worldviews of 50 51 indigenous cultures, whereas professional situates midwives in an institutional context of 52 53 Western biomedicine and international standards.[62] Professionalization of midwifery started 54 55 in Europe, after the replacement of traditional midwives,[63,64] and has expanded since the 56 57 58 59 12 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 XIX century mainly through colonial education.[65] Professional midwives receive formal 4 5 education to perform their role, either through direct entry or after basic nursing, with diverse 6 7 cadres and appellations.[66] Their practice has a wide scope that includes primary care of 8 9 woman and newborns, less biomedical interventions, and more humanized interaction with 10 11 patients.[62,67] An essential difference between traditional and professional midwives is that 12 13 the latter enjoy official accreditation and licencing according to global guidelines. A practical 14 consequence is higher esteem for professional midwives in biomedical contexts.[68] Promotors 15 16 of this category of healthFor worker, peer often equate review it with the concept only of skilled attendant, 17 18 assuming that compliance with international regulations and standards assures a higher level of 19 20 competency and quality of care.[69] 21 22 23 24 Yet there is no unanimously accepted international definition of what constitutes “skilled”. 25 Among professional (licenced) midwives, for example, there is a discussion on whether 26 27 practitioners should conform to a restrictive Western definition or celebrate the diversity of 28 29 cultural perspectives.[70,71] It is becoming increasingly common that licenced midwives adopt 30 31 and apply indigenous techniques learned from traditional midwives.[72] And at the same time, 32 33 more indigenous people and even traditional midwives are receiving formal training, http://bmjopen.bmj.com/ 34 accreditation and permission to practice.[73] This landscape becomes even more complex if we 35 36 consider emerging roles such as doulas, who provide continuous, one-on-one emotional and 37 38 informational support during the perinatal period but do not provide medical services.[74,75] 39 40 Non-indigenous doulas sometimes apply practices learned from indigenous traditions and 41 on September 25, 2021 by guest. Protected copyright. 42 indigenous doulas usually accompanying other indigenous mother in navigating Western 43 44 services in countries where traditional midwifery is forbidden.[76] 45 46 47 To address the multiple interpretations expressed in terminology referring to traditional 48 49 midwives, we will consider the study as including authentic traditional midwives if the report 50 51 explicitly uses this term or traditional birth attendants, or if it describes the link of their practice 52 53 to the traditional culture of the community and refers to a traditional locally-recognized role 54 55 helping women during pregnancy, delivery or postpartum, even if the traditional midwives have 56 57 58 59 13 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 received some informal training. The review will exclude studies reporting on professional 4 5 midwives even if they come from an indigenous community. Online supplementary file 2 6 7 presents a list of terms that could be referring to traditional midwives. To allow for a 8 9 comprehensive search, we will not restrict the search strategy using these terms, but the list 10 11 will guide the screening process. 12 13 14 c) It is an empirical study. 15 16 The review will includeFor qualitative peer and quantitative review studies, observationalonly or experimental, that 17 18 address maternal health outcomes. We will not include ethnographic descriptions of traditional 19 20 midwifery that do not report on its effects on maternal health outcomes. 21 22 23 24 d) The study setting is in the Americas. 25 Given the variability in traditions and cultural practices, we will restrict the review to studies in 26 27 indigenous communities in the Americas. 28 29 30 31 Exclusion criteria 32 33 The review will exclude theoretical models without empirical support. The final report will http://bmjopen.bmj.com/ 34 contain a list of the studies excluded and the reasons for doing so. We will document the 35 36 process in a diagram according to the PRISMA guidelines.[77] 37 38 39 40 Quality appraisal 41 on September 25, 2021 by guest. Protected copyright. 42 Although some scoping reviews do not conduct quality appraisal,[47] we consider it is 43 44 necessary in this study to determine the strength of the current evidence. Quality assessment 45 of the included studies will follow the Mixed Methods Appraisal Tool (MMAT),[78] the results 46 47 from the quality assessment will contribute to interpret the weights in the fuzzy cognitive maps 48 49 described in Stage 5. 50 51 52 53 Stage 4: Charting the data 54 55 56 57 58 59 14 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Based on the reading of full texts, two independent authors will extract concepts related to safe 4 5 birth using an electronic form with the following items: 6 7 a) Study (title, year of the study, publication type (published/unpublished), year of publication, 8 9 country, type of study (qualitative/ quantitative/mixed), study design, population) 10 11 b) Study citation details 12 13 c) MMAT tool 14 d) Maternal health outcomes reported in the study 15 16 e) What are the characteristicsFor peer of traditional review midwives involved only in the study? 17 18 f) Factors related to maternal health studied and reported (complete f to h for all relationships) 19 20 g) If quantitative: what is the measure? And what is the value of the relationship with maternal 21 22 health? (Include confidence intervals) 23 24 h) If qualitative: what is the argument or insight about the importance of this relationship with 25 safe birth (copy and paste)? 26 27 i) Does the study report other relations among factors? If yes, identify all the relationships and 28 29 complete f. or g. for all of them. 30 31 32 33 To ensure consistency and to test the data abstraction format, a data abstraction pilot will http://bmjopen.bmj.com/ 34 include five randomly selected articles. The pilot will identify necessary changes prior to 35 36 abstracting the remaining articles. The data extractors will compare results and a third party 37 38 will resolve irreconcilable discrepancies. 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 Stage 5: Collating, summarizing, and reporting the results 43 44 The reporting will follow the PRISMA-ScR guidelines.[77] Reporting will produce tables and 45 charts of the geographic and population distribution of studies; the factors included in the 46 47 review; the approach to traditional midwifery of each study; the research methods adopted; 48 49 and the measures of maternal health used. The report will present an illustrative fuzzy cognitive 50 51 map, as a logic framework for convergent synthesis[46] of the literature and the interpretation 52 53 of its weights in terms of the influence that each factor might have on maternal health 54 55 according to the model. 56 57 58 59 15 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 Fuzzy cognitive mapping 6 7 The pivotal tool for summarising the results of this review is fuzzy cognitive mapping (FCM). 8 9 This is a graphic representation of soft models composed of elements or concepts and relations 10 11 between elements. Each element is a node (factors identified in point e of the data extraction 12 13 form), and each relationship is represented as an edge (arrow) linking nodes together. These 14 graphics represent assumptions on causal relations and can be based on data or unwritten 15 16 knowledge.[79] TheFor edges represent peer causal review relations, so the onlydirection of the arrows 17 18 matters.[80] The relations or edges can be assigned different values to quantify their strength 19 20 in a relative way (hence the term fuzzy). As the causal knowledge is often uncertain, or at least 21 22 different from the viewpoints of different stakeholders (for each of whom it might feel certain), 23 24 fuzzy models allow us to understand “hazy degrees of causality between hazy causal concepts” 25 using fuzzy causal algebra.[81] Figure 1 illustrates a fuzzy cognitive map from traditional 26 27 midwives in Guerrero State, describing their views about protective factors for maternal health. 28 29 30 31 An edge list is a tabular format to represent the relationships in a fuzzy cognitive map. An edge 32 33 list consists of a table with two initial columns, the first to indicate the origin factor (from) and http://bmjopen.bmj.com/ 34 the second to indicate the consequence factor (to). Additional columns will indicate the 35 36 supporting evidence of the relationship (items f or g of the data extraction form) and the 37 38 corresponding reference. Each relationship corresponds to a row. 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 Based on extracted data, we will plot a fuzzy cognitive map using yEd graphical tools, scaling 43 44 the effect measures into a range (-1,1) assigning negative and positive signs for inhibitory and 45 excitatory relationships, respectively. Adapting the Weight of Evidence approach proposed by 46 47 Dion et al,[82] it is possible to calculate common effect estimates to summarize quantitative 48 49 data on the influence between factors. Wherever odds ratios are available, the formula 50 51 proposed by Šajna will transform the values into a measure of the weight (w) in the symmetric 52 53 range (-1,1): 54 55 56 57 58 59 16 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 6 7 When multiple effect estimates describe the same relationship between factors, we will 8 9 calculate a summary measure using standard approaches to meta-analysis. If the studies 10 11 provide statistics other than odds ratios, such as chi-square or mean differences, we will 12 convert them to the standardized mean difference (d), and then convert d to an odds ratio 13 14 using a widely accepted formula.[83] 15 16 For peer review only 17 18 19 20 21 22 Where π is the mathematical constant (approximately 3.14159). 23 24 25 For qualitative relationships, based on their reading of the context and report, two independent 26 27 researchers will propose a value in the range (-1,1) to indicate their interpretation of the weight 28 29 and direction of the influence of each factor. They will propose these weights for qualitative 30 31 relationships, considering all the qualitative and quantitative relationships in the map. They will 32

reconcile differences by consensus (both agreeing on a new value after discussion), resolving http://bmjopen.bmj.com/ 33 34 discrepancies with the intervention of a third reviewer. To facilitate weighting using and 35 36 ordered scale between 1 and 5,[84] researchers will answer two if-then questions for each 37 38 relationship.[85] First, if (the origin factor) increases, then (the resulting factor) would increase 39 40 or decrease? Weights will be positive for the former and negative for the later. Second, if (the 41 on September 25, 2021 by guest. Protected copyright. 42 origin factor) increases, then (the resulting factor) would rarely change or very often change? In 43 a scale of one for rarely to five for very often. Researchers will review all the weights that they 44 45 assigned in a second round to guarantee that the weights are comparable across all the 46 47 relationships in the map. We will contrast the results of the classification with a technique for 48 49 operator-independent weighting based on Harris’s method for discourse analysis[86] that 50 51 assigns the weight of the relationship based on the number of times a relationship was 52 53 identified. We do not use it as the primary method because it is still under development. 54 55 56 57 58 59 17 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 In the final map, with all relationships identified in the scoping review, the transitive closure 4 5 algorithm will calculate the weights of the relationships considering the entire system.[37] This 6 7 procedure is available in CIETmap, an open-source windows-like interface with the R 8 9 programming language.[87] 10 11 12 13 Stage 6: Consultation exercise 14 Arksey and O’Malley recognize the benefit of discussing the final results of a scoping review 15 16 with experts.[44] TheFor Weight peer of Evidence [41]review approach goes onlyfurther, recognizing that the 17 18 literature review presents a valuable side of the story to be contrasted and expanded with the 19 20 views and experiences of those affected by the issue. We will use this to generate a composite 21 22 model incorporating two additional sources, the knowledge of traditional midwives in 23 24 Guerrero, and the views of the research team involved in a cluster randomized controlled trial 25 supporting traditional midwifery.[39] This will be completed and reported separately. 26 27 28 29 Patient and public involvement 30 31 This research involves no direct patient or public involvement, but the design of the study is the 32 33 result of participatory research involving traditional midwives from Guerrero State, Mexico. http://bmjopen.bmj.com/ 34 35 36 CONCLUSIONS 37 38 This protocol describes a scoping review to map factors, including the roles of traditional 39 40 midwives that can contribute to or detract from maternal health in indigenous communities. 41 on September 25, 2021 by guest. Protected copyright. 42 The review will contribute to the understanding of maternal health in a complex interaction of 43 44 variables where indigenous cultures meet Western medicine. It reflects a shift in approach to 45 traditional midwifery, recognizing its influence on health outcomes cannot be understood in 46 47 isolation. Fuzzy cognitive mapping offers a systematic and visual way to deal with heterogeneity 48 49 and uncertainty of epidemiological data, as well as a common language to juxtapose Western 50 51 knowledge with other sources of knowledge such as indigenous wisdom and experience. 52 53 54 55 56 57 58 59 18 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Fuzzy cognitive maps are conceptual models depicting causal assumptions and prior beliefs. The 4 5 maps expand the realm of possible improvement strategies by identifying factors from multiple 6 7 knowledge bases and, in each knowledge base reflect direct or indirect interactions. The 8 9 influences between factors, however, do not translate as probabilities as they might from some 10 11 meta-analyses. The map generated by the scoping review will inform a participatory process to 12 13 update currently available knowledge with additional evidence from the experience of 14 traditional midwives and experimental data. 15 16 For peer review only 17 18 Contributors 19 20 IS is the guarantor. IS, NA, and AC drafted the manuscript. All authors contributed to the 21 22 development of the selection criteria, the risk of bias assessment strategy and data extraction 23 24 criteria. MM developed the search strategy and the compliance with quality standards for 25 scoping reviews. NA provided statistical expertise as a coauthor of the Weight of Evidence. AC 26 27 adjusted the manuscript for dissemination. SP is the sponsor of the work with traditional 28 29 midwives in Guerrero. All authors read, provided feedback and approved the final manuscript. 30 31 32 33 Acknowledgements http://bmjopen.bmj.com/ 34 Participatory Research at McGill, particularly Anna Dion, contributed valuable insights on the 35 36 use of fuzzy cognitive mapping. Genevieve Gore offered initial ideas to adjust the search 37 38 strategy. German Zuluaga and Anne Marie Chomat read and commented on the initial version 39 40 of this protocol. 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 Funding 46 47 48 This scoping review is funded by CIETcanada and the Centre for Intercultural Medical Studies in 49 50 Colombia. IS is a scholar of the Fonds de la Recherche en Sante du Quebec and CeiBA 51 52 Foundation. The Centro de Investigación de Enfermedades Tropicales at the Universidad 53 Autónoma de Guerrero is the sponsor of the study. 54 55 56 57 58 59 19 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 Competing interests 4 5 None declared 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 20 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 Figures 6 Figure 1. Fuzzy cognitive map of protective factors for maternal health from Me'Phaa and 7 8 Nancue ñomda traditional midwives in Guerrero 9 10 Legend: Solid arrows represent excitatory relationships and dashed arrows represent inhibitory 11 12 relationships. The thickness of the arrows varies according to the weight of the relationships. 13 14 The numbers on the arrows represent the weight of the influence of one factor on another, 15 with 1 being the highest influence. 16 For peer review only 17 18 19 20 Supplementary Files 21 22 Supplementary File 1. Preliminary Search Strategy for Ovid Medline 23 24 File format: PDF 25 26 File Name: BMJopen_SF1.docx 27 28 29 30 Supplementary File 2. Terms potentially referring to traditional midwives and their implications 31 for the search strategy 32 33 File format: Word http://bmjopen.bmj.com/ 34 35 File Name: BMJopen_SF2.docx 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 21 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 4 5 References 6 7 1 Department of Economic and Social Affairs. Division for Social Policy and Development 8 9 Secretariat. Secretariat of the Permanent Forum on Indigenous Issues. State of the 10 11 World’s indigenous peoples. New York: : United Nations 2009. doi:10.1016/S0140- 12 13 6736(10)60721-0 14 2 Armenta-Paulino N, Sandín-Vázquez M, Bolúmar F. Indigenous language and inequitable 15 16 maternal healthFor care, Guatemala,peer Mexico,review Peru and the only Plurinational state of Bolivia. Bull 17 18 World Health Organ 2019;97:59–67. doi:10.2471/BLT.18.216184 19 20 3 Lalonde AB, Butt C, Bucio A. Maternal Health in Canadian Aboriginal Communities: 21 22 Challenges and Opportunities. J Obstet Gynaecol Canada 2009;31. doi:10.1016/S1701- 23 24 2163(16)34325-0 25 4 King M, Smith A, Gracey M. Indigenous health part 2: The underlying causes of the health 26 27 gap. Lancet 2009;374:76–85. doi:10.1016/S0140-6736(09)60827-8 28 29 5 Ohaja M, Murphy-Lawless J. Unilateral collaboration: The practices and understandings 30 31 of traditional birth attendants in southeastern Nigeria. Women and Birth 2017;30:e165– 32 33 71. doi:10.1016/J.WOMBI.2016.11.004 http://bmjopen.bmj.com/ 34 6 Pigg SL. Acronyms and effacement: Traditional medical practitioners (TMP) in 35 36 international health development. Soc Sci Med 1995;41:47–68. 37 38 7 Sibley L, Sipe TA. What can a meta-analysis tell us about traditional birth attendant 39 40 training and pregnancy outcomes? Midwifery 2004;20:51–60. doi:10.1016/S0266- 41 on September 25, 2021 by guest. Protected copyright. 42 6138(03)00053-6 43 44 8 Kruske S, Barclay L. Effect of shifting policies on traditional birth attendant training. J 45 Midwifery Womens Health 2004;49:306–11. doi:10.1016/j.jmwh.2004.01.005 46 47 9 Sibley L, Sipe TA, Koblinsky M. Does traditional birth attendant training improve referral 48 49 of women with obstetric complications: A review of the evidence. Soc Sci Med 50 51 2004;59:1757–68. doi:10.1016/j.socscimed.2004.02.009 52 53 10 Sibley LM, Sipe TA, Koblinsky M. Does traditional birth attendant training increase use of 54 55 antenatal care? A review of the evidence. J Midwifery Women’s Heal 2004;49:298–305. 56 57 58 59 22 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

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1 2 3 77 Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): 4 5 Checklist and Explanation. Ann Intern Med 2018;169:467. doi:10.7326/M18-0850 6 7 78 Hong QN, Gonzalez-Reyes A, Pluye P. Improving the usefulness of a tool for appraising 8 9 the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods 10 11 Appraisal Tool (MMAT). J Eval Clin Pract 2018;24:459–67. doi:10.1111/jep.12884 12 13 79 Gray S, Zanre E, Gray SRJ. Fuzzy cognitive maps as representations of mental models and 14 group beliefs. In: Papageorgiou EI, ed. Fuzzy cognitive maps for applied sciences and 15 16 engineering. ForBerlin: : Springerpeer 2014. review 29–48. doi:10.1007/978-3-642-39739-4_2 only 17 18 80 Glymour M, Greenland S. Causal Diagrams. In: Rothman K, Greenland S, Lash T, eds. 19 20 Modern Epidemiology. Philadelphia: : Wolters Kluwer Health/Lippincott Williams & 21 22 Wilkins 2008. 183–211. 23 24 81 Kosko B. Fuzzy cognitive maps. Int J Man Mach Stud 1986;24:65–75. doi:10.1016/S0020- 25 7373(86)80040-2 26 27 82 Dion A, Robert E, Sarmiento I, et al. A guideline for the Weight of Evidence. Montreal: 28 29 2019. 30 31 83 Borenstein M, Hedges L V. Effect size for meta-analysis. In: Cooper HM, Hedges L V, 32 33 Valentine J, eds. Handbook of research synthesis and meta-analysis. New York: : Russell http://bmjopen.bmj.com/ 34 Sage Foundation 2019. 208–43.https://muse.jhu.edu/book/65827/ (accessed 5 Jan 35 36 2020). 37 38 84 Papageorgiou EI, Kontogianni A. Using Fuzzy Cognitive Mapping in Environmental 39 40 Decision Making and Management: A Methodological Primer and an Application. In: 41 on September 25, 2021 by guest. Protected copyright. 42 International Perspectives on Global Environmental Change. InTech 2012. 43 44 doi:10.5772/29375 45 85 Stylios CD, Groumpos PP, Georgopoulos VC. Fuzzy Cognitive Map Approach to Process 46 47 Control Systems Chrysostomos. J Adv Comput Intell Intell Informatics 1999;3:409–17. 48 49 doi:10.20965/jaciii.1999.p0409 50 51 86 Harris ZS. Discourse Analysis. Language (Baltim) 1952;28:1. doi:10.2307/409987 52 53 87 Andersson N, Mitchell S. Epidemiological geomatics in evaluation of mine risk education 54 55 in Afghanistan: introducing population weighted raster maps. Int J Health Geogr 56 57 58 59 30 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 38 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

1 2 3 2006;5:1. doi:10.1186/1476-072X-5-1. 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 25, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 31 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 38 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from

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3 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from 4 5 6 Online supplementary file 1. 7 nd 8 Search strategy (2 version) 9 May 4, 2020

10 Developed for Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other 11 Non-Indexed Citations 12 13 Librarian: Martin Morris 14 McGill University 15 16 1. exp Maternal Health/ 17 2. exp Maternal Welfare/ 18 3. exp MaternalFor Health peer Services/ review only 19 4. exp Pregnancy/ 5. exp Pregnancy Complications/ 20 21 6. exp Midwifery/ 7. (maternal or maternity or mother? or midwif* or (birth adj1 attendant?) 22 or doula?).tw,kf. 23 8. pregnan*.ti. 24 9. or/1-8 25 10. exp American Native Continental Ancestry Group/ 26 11. exp Health Services, Indigenous/ 27 12. (aborigine? or aboriginal?).tw,kf. 28 13. indigenous.tw. 29 14. natives.tw. 30 15. (tribe* or tribal*).tw. 31 16. autochton*.tw.

32 17. or/11-16 18. "*** COMMENT: North America ***".sm. 33 19. native american?.tw. 34 20. american indian?.tw. 35 21. first nation?.tw. 36 22. alaska* native*.tw. 37 23. (athabascan or ahtna or aleut* or alutor or chelkancy or chukchi or http://bmjopen.bmj.com/ 38 chulymcy or chuvancy or koryak or nanaicy or manci or kumadincy or 39 negidalcy or nenets or orochi or nganasan or nivkhy or oroki or sa?mi or 40 selkup or shorcy or soioty or tazy or telengity or teleuty or tofolar or 41 tubolar or tuvin-todjin or udege or ukagiry or ulchi or veps or "deg 42 hit?an" or dena?ina or holikachuk or kolchan or koyukon or tanacross or 43 eyak or haida or tlingit or tsimshian* or inupiat or yup?ik or cup?ik or sugpiaq or alutiiq or alutiqu or chugach or koniag or unanga? or yup?ik or 44 cree or mohawk or salish or nuxalk or kimsquit or tallheo or stuie or 45 kwatna or shishalh or sechelt or squamish or Skwxwu7mesh or qualicum or on September 25, 2021 by guest. Protected copyright. 46 comox or sliammon or comos or klahoose or halkomelem or cowichan or somena 47 or s?amuna? or quw?utsun or quamichan or clemclemalut* or l?uml?umulut* or 48 comiaken or qwum?yiqun? or khenipsen or hinupsum or kilpahla* or tl?ulpalu* 49 or koksilah or hwulqwselu or penelakut or lamalcha or musqueam or 50 snuneymuxw or tsleil-waututh or ts?ailes or chehali* or sto?lo or 51 aitchelitz or matsqui or popkum or skway or skawahlook or skowkale or 52 squiala or sumas or tzeachten or yakweakwioose or chawathil or cheam or 53 kawaw-kawaw-apilt or scowlitz or scaulit* or shxw?ow?hamel or soowahlie or 54 katzie or kwantlen or kwikwetlem or tsawwassen or songhee* or t?souke or 55 sooke or semiahmoo or malahat or tsartlip or tsawout or esquimalt or tsimshian* or gitxsan or nisga?a or haida or nuu-chah-nulth or nootka or 56 mowachaht* or ahousaht or ehattesaht or hesquiaht or cheklesahht or kyuquot 57 or nuchatlaht or huu-ay-aht or ohiaht or hupacasath or opetchesaht or 58 59 60

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3 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from 4 5 6 toqaht or tseshaht or uchucklesaht or ucluelet or ditidaht or pacheedaht or 7 kwakwaka?wakw or laich-kwil-tach or euclataws or yuculta or weewaikai or 8 wewaykum or koskimo or namgis or haisla or kiamaat or henaksiala or 9 heiltsuk or wuikinuxv or owekeeno or tlingit or (("aa tlein" or deisleen) adj2 kwaan) or athapaskan or dakelh or wet?suwet?en or dene-thah or dene- 10 thah or slavey or tsilhqot?in or chilcotin or sekani or dunne-za or tahltan 11 or "kaska dena" or nlaka?pamux or okanagan or secwepemc or shuswap or 12 sinixt or st?at?imc or lillooet or lil?wat or stl?atl?imx or skatin or 13 semahquam or xa?xtsa or nequatque or ktunaxa or kootenay or ashinaabe or 14 plains_ojibwa or blackfoot or kainai or peigan or siksika or dene or 15 chipewyan or nakoda or assiniboine or ((plains or oji or "james bay") adj1 16 cree) or "eeyou istchee" or tasttine or "tsuu t?ina" or ktunaxa or sahtu or 17 "tli cho" or yellowknives or dunne?za or gwich?in or kutchin or loucheaux 18 or han or kaskaFor or tagish peer or tutchone review or anishinaabe only or algonquin or 19 nipissing or ojibwa or mississaugas or saulteaux or potawatomi or cree or 20 innu or montagnais or naskapi or beothuk or maliseet or mi?kmaq or 21 passamaquoddy or iroquois or haudenosaunee or cayuga or guyohkohnyo or kanien?kehaka or oneida or onayotekaono or on?ndaga* or tuscarora or 22 wyandot or huron or onondowahgah or ganonsyoni or seneca).tw. 23 24. or/19-23 24 25. "*** COMMENT: Central and Meso- America ***".sm. 25 26. ("chichimeca jonaz" or "huastec teenek" or achi or amuzgo or tzjon or 26 tzotyio or nanncue or aztecan or bokota or boruca or bribri or cabecar or 27 chorti or chatino or chibchan or chinantec or choc?o or ngiwai or ixcatec 28 or chontal or chorotega or mangue or mankeme or chuj or cora or naayarite 29 or corachol or cuicatec or guaymi or waimi or huave or huichol or wixarita* 30 or itza or ixil or jakalteki or popti or kiche or kaqchikel or kuna or dule 31 or tule or lacandon or "hach winik" or lenca or maleku or mamean or 32 manguean or matlatzinca or maya? or mazahua or tetjo or mazatec or miskit? or misumalpan or ayuukjaay or mixtec* or mopan or nahua* or teribe or "tjer 33 di" or ngabe-bugle or oto-manguean or oto-pamean or otomi or popoloca? or 34 poqom* or qanjob* or qeqchi or qichea* or sumalpan or mayangna or 35 talamancal or tarascan or tequistlatecan or "chontal de oaxaca" or tlapanec 36 or tojolabal or tolupan or jicaque or totonac* or tutunacu or trique or 37 tzutujil or tzeltal or tzotzil or uto-aztecan or votic or xin?a or yucatec* http://bmjopen.bmj.com/ 38 or zambo or cafuso or zapotec* or zoque).tw,kf. 39 27. "*** COMMENT: South America ***".sm. 40 28. (abip?n or achagua or achuar or aguano or aguaruna or akawaio or akurio 41 or amahuaca or amany? or amorua or andaqu? or andoque or araona or arawak 42 or arhuacos or ijka or ash?ninka or atacama or atacame?o or atikum or 43 atorada or auak? or av? guaran? or aw?-guaj? or aymara or ayoreo or baniwa or bara or barasana or motilon or baure or betoye or bora or bor?ro or 44 botocudo or cabiyar? or callawalla or ca?ari or candoshi or canelos-quichua 45 or canichana or caranqui or carapana or carib or carijona or cashibo or on September 25, 2021 by guest. Protected copyright. 46 cat?o or cavine?a or cayambi or cayubaba or ch?cobo or chamacoco or chanka 47 or charr?a or chimbuelo or chimila or chincha or chipaya or chiquitano or 48 chiricoa or chirip? or cholones or chorote or chulupi or ?ocama or 49 cocamilla or coconuco or cof?n or kof?n or comeching?n or coreguaje or 50 cubeo or cuiba or curripaco or desano or diaguita or ebytoso or ember? or 51 "enawene nawe" or "ese ejja" or guahibo or guambiano or misak or guana or 52 guane or guaran? or guarayu or guat? or guayabero or guayupe or harakmbut 53 or huambisa or huanca or huarpe or hupda or ignaciano or inga or ingarik? 54 or itene or itonama or jaoi or jibito or jivaro or jor? or kadiw?u or 55 kaingang or kali?na or kalina or kamayur? or kams? or kankuamo or karaj? or kawaskhar or kaxinaw? or kayapo or kogui or k?ggaba or kokama or kolla or 56 korubo or kubeo or kulina or kuna or leco or letuama or lokono or 57 machiguenga or machinere or macushi or maimar? or maina or makaguaje or 58 59 60

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3 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from 4 5 6 makuna or makuxi or mapidian or mapuche or "mapuches aymara" or mashco-piro 7 or masiguare or matap? or mats?s or mawayana or mayoruna or mbay? or mbya* 8 or mira?a or mocov? or mokan? or "motilone bar?" or movima or muinane or 9 muisca or munduruku or nambikwara or nepuyo or nivacl? or nonuya or nukak or oca?na or ofay? or omaguaca or orealla or otavale?os or pacabuy or 10 pacahuara or p?ez or nasa or "pai tavytera" or pai-tavyter or paiter or 11 pampa or panar? or panche or pankararu or panzaleo or patamona or patax? or 12 paunaka or pauserna or pemon or piapoco or piaroa or pichincha or pijao or 13 pilag? or piraha or piratapuyo or pitsamira or potiguara or puinave or 14 puruh? or q?ero or qu?chua or querand? or quijos-quichua or rankulche or 15 "rapa nui" or reyesano or salasacan or s?liba or sanapan? or sanavir?n or 16 saraguro or saraveca or "sater? maw?" or secoya or shapra or shinabo or 17 shipibo-conibo or shuar or sikiana or siona or siriano or sirion? or "suru? 18 do par?" or sutagaoFor or peer tacana or review taiwano or tanimuka only or tapiet? or tapirape 19 or tariano or tatuyo or tehuelche or terena or ti?una or tiriy? or toba or 20 tom?raho or tonocote or toromona or totor? or trememb? or trinitario or 21 tsiman? or tugua or tukano or tungurahua or tupi or "tup? guaran?" or tuyuca or u?wa or tunebo or umbr? or urarina or uru or vilela or waiwai or 22 wanano or waorani or wapishana or wapixana or waranka or warao or wauja or 23 wayana or wayu? or wich? or witoto or huitoto or uitoto or wiwa or sanh? or 24 wounaan or xakriab? or xavante or xukuru or ya?nomam? or yaghan or yagua or 25 yaminaw? or yanacona or yanesha? or yanomami or yarigui or yaruro or 26 ye?kuana or yine or yukpa or yuko or yukuna* or yuqui or yuracare or yuri 27 or yurut? or zamuco or zaparo or zenu).tw,kf. 28 29. exp Qualitative Research/ 29 30. (qualitative adj (research or stud$3)).ti,ab,kf. 30 31. (mixed adj (method* or studies)).ti,ab,kf. 31 32. "Surveys and Questionnaires"/

32 33. exp Interviews as Topic/ 34. interview*.ti,ab,kf. 33 35. focus groups/ 34 36. focus group*.ti,ab,kf. 35 37. self report/ 36 38. ((action or participatory) and research).ti,ab,kf. 37 39. exp Community-Based Participatory Research/ http://bmjopen.bmj.com/ 38 40. grounded theory/ 39 41. grounded theory.ti,ab,kf. 40 42. phenomenolog*.ti,ab,kf. 41 43. exp Narration/ 42 44. narrat*.ti,ab,kf. 43 45. conversation*.ti,ab,kf. 46. discourse*.ti,ab,kf. 44 47. (ethnograph* or ethnomethodolog* or ethno methodolog* or 45 autoethnograph*).ti,ab,kf. on September 25, 2021 by guest. Protected copyright. 46 48. hermeneutic*.ti,ab,kf. 47 49. constructivis*.ti,ab,kf. 48 50. ((case or field) adj (study or studies)).ti,ab,kf. 49 51. ((participant* or field) adj observ*).ti,ab,kf. 50 52. ((purpos* or theoretical or judg?ment or "maximum variation" or 51 convenience or "critical case" or "deviant case" or "key informant" or 52 snowball or cluster) adj sampl*).ti,ab,kf. 53 53. (experience* or perspective* or perception* or meaning* or view? or 54 viewpoint*).ti. 55 54. ((lived or life or personal* or patient? or survivor*) adj3 (experience* or perspective* or perception* or meaning* or view? or 56 viewpoint*)).ti,ab,kf. 57 55. ((thematic or content) adj analys*).ti,ab,kf. 58 59 60

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3 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from 4 5 6 56. "group discussion*".ti,ab,kf. 7 57. (cope or copes or coping or thrive or thrives or 8 thriving).ti,ab,kf. 9 58. finding?.ti,ab,kf. 59. or/29-58 10 60. 17 or 24 or 26 or 28 11 61. 9 and 59 and 60 12 62. (traditional* adj3 (birth adj1 (attendant? or midwi* or 13 doula?))).tw,kf. 14 63. 60 and 62 15 64. ((randomized controlled trial or controlled clinical trial).pt. or 16 randomized.ab. or randomised.ab. or placebo.ab. or drug therapy.fs. or 17 randomly.ab. or trial.ab. or groups.ab.) not (exp animals/ not 18 humans.sh.) For peer review only 19 65. Epidemiologic studies/ or exp case control studies/ or exp cohort 20 studies/ or (Case control or (cohort adj (study or studies)) or cohort 21 analy$ or (Follow up adj (study or studies)) or (observational adj (study or studies)) or longitudinal or retrospective or cross sectional).tw. 22 66. 9 and (59 or 64 or 65) and 60 23

24 25 26 27 28 29 30 31 32 33 34 35 36

37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44

45 on September 25, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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3 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from 4 5 6 Online supplementary file 2 7 8 Terms potentially referring to traditional midwives and their implications for the search strategy 9 10 Term Action 11 Trained birth attendants Does the reference link their practice to the 12 Training programs for traditional midwives traditional culture of the community and refers 13 are frequent, but not all the trained birth to a traditional locally recognized role helping 14 attendants are traditional midwives. We are women during pregnancy, delivery or 15 not interested in just trained community postpartum? 16 members but in the traditional part of their 17 practice. If yes, then include. Else, exclude. 18 Casual or coincidentalFor birth peer helpers. reviewExclude. only 19 20 They do not have the years of experience 21 and traditional training; therefore, they 22 should be excluded 23 Midwife (midwives). Does the reference link their practice to the 24 Partera/partero (SP). traditional culture of the community and refers 25 Sages-femmes (FR). to a traditional locally recognized role helping 26 Accoucheuse/accoucheur (FR) women during pregnancy, delivery or 27 Parteiras (PT) postpartum? 28 29 This term is often used to indicate If yes, then include. Else, exclude. 30 professional midwives and to delimitate 31 32 authoritative knowledge of Western cadres 33 with international accreditation. 34 Traditional birth attendants. Does the reference link their practice to the 35 Comadrona/matrona (SP) traditional culture of the community and refers 36 to a traditional locally recognized role helping

37 Although inherently disrespectful of the role women during pregnancy, delivery or http://bmjopen.bmj.com/ 38 and practice of traditional midwives, it has postpartum? 39 been used since 1920’s to describe them. 40 If yes, then include. Else, exclude. 41 Community midwives. Does the reference link their practice to the 42 43 Recognizes the community aspect, but it traditional culture of the community and refers 44 does not distinguish if the practice is framed to a traditional locally recognized role helping

45 in the traditional knowledge of the group. women during pregnancy, delivery or on September 25, 2021 by guest. Protected copyright. 46 postpartum? 47 48 If yes, then include. Else, exclude. 49 Lay midwives. Does the reference link their practice to the 50 The term refers to practitioners without traditional culture of the community and refers 51 accreditation or professional status. But it is to a traditional locally recognized role helping 52 not necessarily a synonym of traditional women during pregnancy, delivery or 53 practices. postpartum? 54 55 56 If yes, then include. Else, exclude. 57 58 59 60

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3 BMJ Open: first published as 10.1136/bmjopen-2020-037922 on 27 October 2020. Downloaded from 4 5 6 Doula. Exclude 7 This is a recent term that does not 8 correspond to the practice of traditional 9 midwives. Doulas accompany women to 10 prepare for delivery and to navigate health 11 services. Some people have proposed that 12 13 traditional midwives could transition 14 towards a doula-like role to exclude them 15 from the participation in health care 16 practice. 17 Skilled birth attendant. Does the reference link their practice to the 18 Often used to excludeFor traditional peer midwives review traditional culture only of the community and refers 19 based on cadres with international to a traditional locally recognized role helping 20 recognition. women during pregnancy, delivery or 21 postpartum? 22 23 If yes, then include. Else, exclude. 24 25 Midwifery Associate Professionals. Does the reference link their practice to the 26 This is one of the applicable names in the traditional culture of the community and refers 27 List of health-related occupations according to a traditional locally recognized role helping 28 to International Standard classification of women during pregnancy, delivery or 29 Occupations (ISCO-08). postpartum? 30 31 If yes, then include. Else, exclude. 32 Traditional or complementary medicine Does the reference link their practice to the 33 associate professional. traditional culture of the community and refers 34 This is another category from the ISCO-08 to a traditional locally recognized role helping 35 36 that include traditional practitioners. women during pregnancy, delivery or

37 postpartum? http://bmjopen.bmj.com/ 38 39 If yes, then include. Else, exclude. 40 Nurses with obstetrical/perinatal Exclude 41 experience. 42 Closer to professional midwife, sometimes 43 this term could include indigenous midwives, 44 often without traditional background. 45 on September 25, 2021 by guest. Protected copyright. Complementary or alternative providers. Exclude 46 47 The roles of these providers are abstract 48 from cultural identities. 49 50 51 SP: Spanish, FR: French, PT: Portuguese 52 53 54 55 56 57 58 59 60

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml