TERMINOLOGY BOX

• Model of care – a concept that outlines the different types of services provided and delivered.
• Medical model – a reductionist model of health viewing health and disease within the parameters of biomedical markers.
• Social model – a holistic model of health that embraces all aspects of health, human experiences, and social structures.
• Private care – privately funded healthcare, which includes private health insurance or out-of-pocket payments.
• Public care – publicly funded healthcare from the government, which can include funds raised through taxation and/or employer contributions.
• Continuity of care – continuous care and coordination from an identified health professional or team of health professionals.
• Shared care – the responsibility of maternity care and coordination is formally shared between local healthcare professionals and a public hospital.
• Combined care – similar to shared care; however, antenatal care is provided solely by the local practitioner and intrapartum care by the public hospital.
• Health policy – a broad statement of goals and objectives that aim to achieve standards of health within a society. They can include priority areas, action plans, roles of actors, timelines, and implementation recommendations.

INTRODUCTION

This chapter provides an overview of how women across the globe are cared for by maternity and obstetric services, and the different ways in which care is organized and delivered. We review the evidence around specialist models of maternity care and discuss the factors that support integrated, person-centered, and respectful care for women and their families. Exploring this ever-growing catalog of evidence allows us to reflect on what works at improving women and children’s outcomes and experiences according to their individual needs.

By recognizing that women have different needs and that those needs are heavily influenced by their social context, setting, and health, it becomes clear that there is no "one size fits all" model of care. This complexity can be further understood through the "syndemic" lens – that examines how disease, social, environmental, and economic factors interact with one another to reinforce health inequalities.

With this interaction in mind, it is important to understand that there are components of maternity care that are known to reduce health inequalities in clinical outcomes and experiences. Those designing services should consider the evidence-based components alongside more flexible aspects of a service that meet the needs of the local context and population.

GLOBAL MODELS OF CARE – CURRENT CONTEXT

Antenatal care

The care received by pregnant women, including how it is organized, who it is delivered by, and its quality and content varies widely across the globe. In low- and middle-income countries (LMIC), antenatal care is measured through the number of visits or interactions a woman has with a healthcare professional. Whilst 86% of women will access at least one antenatal appointment with a healthcare professional, only 62% access at least four antenatal appointments. In low-income countries where maternal mortality is the highest, particularly sub-Saharan Africa and parts of Asia, this percentage drops to around 50%.¹ Maternal mortality is defined as deaths due to complications from pregnancy or childbirth. Since 1990 the global maternal mortality rate has declined by 44%, from 385 maternal deaths per 100,000 births, to 216 (Figure 1).² Although this is encouraging, it falls well below the Millennium Development Goal 5 target.³ It is important to remember that almost all maternal deaths can be prevented, this is evident in the stark differences in maternal mortality rates between richer and poorer populations.

In 2016, the World Health Organization⁴ responded to the unacceptably high rates of maternal and infant mortality in LMIC in the antenatal care guidelines for pregnant women and adolescent girls. The guideline recommended an increased number of contacts between women and healthcare professionals from four to eight. An international group of experts led this change by presenting evidence (PMNCH, 2011) showing that the four-visit model was inadequate at reducing the maternal and infant mortality rate in line with the 75% Millennium Development Goal.³ This is thought to partly be due to substantial inequity of access and experience, for example an analysis of data from LMIC found that the wealthiest women were on average four times more likely to report good quality care than the poorest.⁵ If we consider that only around half of women currently receive the four-visit model, and that those living with the highest levels of poverty are the least likely to receive any antenatal care, the association between accessing services and the high maternal and infant mortality rates is clear.

When women do not have appropriate access to a healthcare professional, for example a midwife, doctor, or nurse, they do not receive services that are vital to their well-being, and in some cases, survival. Whether in high or LMIC, appropriate access to adequate maternity services during pregnancy significantly improves both maternal and infant mortality rates.⁴ This is due to the, often simple, interventions known to prevent or manage the most common causes of maternal and infant death – hemorrhage, sepsis, hypertension/eclampsia, unsafe abortion, premature birth, and intrauterine growth restriction.^6,7 Accessing health services during pregnancy can also identify and treat other causes of mortality such as HIV, malaria, malnutrition, and anemia.⁸ In many LMIC, community healthcare workers (CHWs) have been trained and placed in rural communities to improve access to basic preventative healthcare services including antenatal care. Women who have access to a CHW have reported improvements in their health behaviors and engagement with antenatal services.⁹ Following their introduction in the 1970s, there is an estimated 5 million CHWs around the world, and they have made significant improvements in childhood undernutrition, maternal and child health, access to family-planning services, and the control of communicable diseases.¹⁰

Why then, are so many women still not accessing antenatal care in LMIC? A review of the academic literature¹¹ found that for many women in LMIC, perceptions of antenatal services were not in line with the aims of the service. Women felt that pregnancy is a normal, healthy event, so accessing services was unnecessary. This belief was often compounded by the context of poverty, the location of available services, and other family members control over women’s choice. If we refer to Perry et al.,¹⁰ we can see that there is an inequitable provision of CHWs across LMIC that impacts on access to antenatal care. This represents syndemics in action – multiple factors interacting to worsen the health outcomes experienced by particular populations. In order to tackle health inequalities in a systematic way, all of these factors, and how they interact, need to be considered when planning models of care for pregnant women in LMIC.

In high-income countries (HIC) antenatal care coverage is consistently high and correlates with relatively low maternal and infant mortality rates when compared to the LMIC.¹² Despite this overall success there are marked inequalities in access to services, health outcomes, and women’s experiences. The number of face-to-face antenatal contacts varies between five and 14 worldwide, with the Netherlands having the highest number of visits for women at low risk of complications.^4,13,14

In HIC a marked socioeconomic gradient persists and is associated with poor birth outcomes. Pregnancies to women living in areas with the highest levels of poverty in the UK are over 50% more likely to end in stillbirth or neonatal death. These women experience increased rates of premature birth, low birth weight, cesarean section, and maternal death.^15,16,17,18 Again, these inequalities are often explained by variations in how maternity care is organized and delivered, including access to free, high-quality antenatal care. Examples of this variation include in the USA, a disproportionately expensive system where maternal and infant mortality, preterm birth and low birth weight rates are significantly low compared with other HIC. In the USA the majority of women receive antenatal care from a private physician or obstetrician, who will usually supervise the labor and birth. Payment for maternity care is often through private insurance and supplemented by savings. This payment system leads to overmedicalization and unnecessary intervention, and inequities in access and birth outcomes, particularly for poorer and black and minority ethnic women.¹⁹

There is a strong evidence base that good quality midwifery care leads to improved outcomes for women and children and the demedicalization of birth.^20,21 The Lancet series on Midwifery concluded that “national investment in midwives and in their work environment, education, regulation, and management . . . is crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health”.²²

Access to midwifery services in the USA is markedly lower than in other HIC. Sweden has one of the lowest maternal mortality rates. Antenatal care coverage is high despite the country being sparsely populated with women traveling long distances from remote islands and mountainous areas and having one of the highest birth rates.²³ Midwives provide the vast majority of maternity care to women, with shared care between midwives and obstetricians for those women with high-risk pregnancies.

Another HIC with a very low maternal mortality rate is Australia, where women receive care through one of four models: private maternity care, combined maternity care, public hospital care, and shared maternity care (see Terminology section for definitions). There is a strong emphasis and increasing demand for continuity of care in Australia, whereby a woman is able to develop a trusting relationship with a known healthcare professional, often a midwife, throughout her pregnancy journey. This is discussed in more depth in the section on "Evidence of models of maternity care". In the past decade, there has been a radical reform of maternity care in many HIC with increased policy focus on improving midwife-led continuity and specialist models of care.^24,25

INTRAPARTUM AND POSTNATAL CARE

In most LMIC women are encouraged to give birth in medical settings including hospitals and local clinics where they may have received antenatal care. Their care is provided by a "skilled birth attendant" (SBA) such as a midwife, doctor, or a nurse who is trained in normal pregnancy and childbirth.²⁶ Although most women are now giving birth in these facilities, the improvement in health outcomes predicted by health policy researchers have not been met.²⁷ This is thought to be due to the wide variation in the quality of care, the birthing environment and the level of training, skills, and attitudes of SBAs.²⁸ A review of women’s experiences of facility-based intrapartum care in LMIC found that disrespectful care and abuse is a powerful deterrent to accessing these facilities and is thought to be a greater barrier than geographical and financial obstacles.²⁹ Compared with antenatal and intrapartum care in these settings, access to postnatal care tends to be relatively low with a marked variation in socioeconomic status and between women living in urban and rural settings.³⁰ Two examples of this are the Democratic Republic of the Congo, where approximately 93% of pregnant women receive at least one antenatal contact by a SBA, but only 35% receive postnatal care;³¹ and Ethiopia, where fewer than 20% of women use postnatal care services.³² Increasing coverage of postnatal services to identify, refer and manage potentially life-threatening postpartum complications has been prioritized in an effort to improve the high maternal and infant mortality rates.³³

The vast majority of women in HIC give birth in obstetric settings with a small percentage choosing to give birth at home, and an existing trend towards use of midwife-led birth centers for those with low-risk pregnancies. Although strong evidence has demonstrated the safety and benefits of midwife-led birth centers,^34,35 access varies from country to country. In the USA only around 0.5% of women give birth in a midwife-led birth center, compared to over 10% in The Netherlands, New Zealand, and the UK.³⁵ The model of maternity care received by women appears to influence their decision on where to give birth, with those receiving continuity of care models more likely to report choice in place of birth, give birth at home or in a midwife-led birth center.³⁶ Conversely, women who receive standard/traditional maternity care are more likely to give birth in an obstetric led unit, and less likely to know the midwife caring for them in labor. Other factors that determine where women give birth in HIC is thought to be affected by sociocultural factors, the role and status of midwives in different countries, regulations and insurance, funding, policy drivers, and the extent of integration between midwife-led and obstetric-led units.^37,38 Two of the authors of the recently updated Cochrane review that compared different models of maternity care for childbearing women³⁶ stated:

"The perception is that in order to get the highest quality of care, they [women] must be cared for by a senior clinician and that is simply not the case. Midwives provide a sense of normality and by having a midwife they know during pregnancy it allows the mother to feel comfortable and at ease during labor which in turn is much better for the baby.” Professor Hora Soltani, Sheffield Hallam University.³⁹

"Policymakers in areas of the world where health systems do not provide midwife-led care should consider the importance of midwives in improving maternity care and how financing of midwife-led services can be reviewed to support this,“ Jane Sandall, King's College London.³⁹

The postnatal period is a time of increased risk for maternal and infant mortality, yet it is known to be an under-researched area of maternity care with most of the research focusing on pregnancy and birth.⁴⁰ Postnatal care varies widely across the globe in terms of who provides the care, how it is organized, where it is delivered and the content and quality of care. In HIC most women have access to some degree of postnatal care, often through home visits delivered by midwives and health visitors,¹² but countries often lack consistent guidelines for routine postnatal care. In fact, postnatal services have been described by healthcare researchers as "inconsistent across jurisdictions, fragmented across disciplines and sectors, and currently do not adequately meet the needs of the population".⁴¹ In Australia, women accessing public services are contacted by a midwife or a child and family health nurse within 10 days of birth via phone or a home visit. Those accessing private care are seen at around 6 weeks after birth by their obstetrician, often with no prior scheduled contact by a healthcare professional.⁴² In the UK, guidelines developed by the National Institute of Clinical Excellence⁴³ recommends a minimum of three home postnatal contacts by a healthcare professional. Despite these efforts, reviews of women’s experiences of postnatal care in Australia, the UK, and the USA have consistently found poor satisfaction, fragmented care, concerns about physical and mental health not being listened to, and inconsistent advice on infant feeding.^44,45,46

Countries such as Norway, Sweden, The Netherlands, and Taiwan, provide more intensive postpartum support including home care (including support with the infant and older children, physical and mental health, and housework) and maternity centers offering hotel-like accommodation for families. These services are under-evaluated and often do not promote integration with antenatal and intrapartum maternity services, impacting on continuity of care. There have been few improvements made to the provision of care in recent years, despite strong evidence and policy focus for extending continuity of care to the intrapartum and postnatal period. This is thought to be due to financial barriers and cut backs to postnatal services.⁴⁰ Further research on the implementation and sustainability of safe, cost-effective services is required.

MODELS OF MATERNITY CARE – THE EVIDENCE

This section of the chapter addresses the inequities and variations reported in the previous section by providing an overview on what models of care are known to work at improving women and children’s health outcomes and experiences of maternity care. This is sub-divided into two different parts to focus on the vast, complex differences between LMIC and HIC.

Low- and middle-income countries

To date, initiatives to tackle the unacceptably high maternal and infant mortality rates have focused on centralized, public provision of antenatal and intrapartum care to screen risk factors and manage life-threatening conditions.⁴⁷ Although this has been successful for some women with declining rates of mortality and morbidity, there remains significant disparity and inequity of service use and health outcomes. Finlayson and Downe¹¹ suggest that this top-down approach to the provision of maternity care marginalizes women by not taking into account the local context, for example, women’s beliefs, attitudes, and cultural norms. As discussed earlier, when women do access these centralized services, they often experience disrespectful care and abuse. Health policy researchers suggest that in order to improve access to maternity services, policy makers and service providers must align services with the needs, practical constraints, and cultural practices of the local community. This includes ensuring that once women access services they are treated with dignity, respect, and compassion.¹¹ Programs evaluated in both Nepal and Cambodia aimed to integrate local cultural context into the planning and delivery of maternity care by involving local women and community leaders, showed significant improvements in access and a reduction in maternal and infant mortality.^48,49 Involving women and the local community in planning models of maternity care does not only ensure services are culturally appropriate and more aligned to their needs, but also empowers the voices of those seldom-heard. Finlayson and Downe¹¹ concluded that if models of maternity care are not aligned with local contexts, then they will remain underused by some local pregnant women, despite good quality care and easy access. Munabi-Babigumira et al.⁵⁰ recognized the importance of focusing on the SBAs influence when addressing the inequities in health outcomes and women’s experiences. They recommended increased training provision and supervision, appropriate SBA to women ratio, improved salaries and living conditions, and access to well-equipped healthcare facilities with water, electricity and transport. To address the needs of those women with a lower socioeconomic status, there is also a need to improve the trust and collaboration between healthcare workers and women, again, reversing the "top-down", utilitarian approach to designing models of maternity care. Montagu²⁷ emphasizes this by recommending a restructure of maternity services that focuses on facility infrastructure, scaling up midwifery and specialized models of care to promote patient-centered support. A study of a midwife-led continuity model of care in the West Bank, Palestine, improved access across the pregnancy continuum and quality indicators of maternity services.⁵¹ Further research is needed on the practicality, acceptance, and effectiveness of this model of care across low- and middle-income settings. The recommendations in the Lancet series on Midwifery alongside the use of the evidence-based framework for quality maternal and newborn care (QMNC) can inform the development of models of maternity care that are sustainable, achievable, and have the potential to significantly improve maternal and infant mortality and morbidity.⁵²

High-income countries

As previously stated, there is a strong evidence base documenting improved birth outcomes and experiences for women who have received continuity models of care. Care from a known healthcare professional enables the development of a trusting relationship with numerous benefits. The recently updated Cochrane review of models of midwifery care during pregnancy, birth and early parenting found that women who received continuity of care from a known midwife experienced fewer clinical interventions, reported higher satisfaction, and had significantly fewer preterm births, fetal loss, and neonatal death than those receiving standard maternity care.³⁶ There were no trials in LMIC, and additional trials may be required in such settings. The review does not report on whether outcomes differed for socially disadvantaged women, but recommended that future research should explore this population, as well as whether the observed benefits can be attributed to continuity, a midwifery philosophy, or to the quality and degree of relationship between the midwife and woman.

Maternal mortality is disproportionately high among African American women (at rates 3–4 times the rates for Hispanic and non-Hispanic whites),⁵³ black and minority ethnic women in the UK,¹⁷ Aboriginal and Torres Strait Islander women in Australia,⁵⁴ and refugee and migrant women in Europe.⁵⁵ These women often have a common experience of social and economic disadvantage, which results in poor birth outcomes including increased cesarean section rates, preterm birth, and low birth weight infants. Compared with non-indigenous women, pregnant American, Canadian, and Australian indigenous women are more likely to smoke during pregnancy and have gestational diabetes, pre-existing diabetes and poor mental health.^16,53,54,5 Specialist models of maternity care are increasingly aimed at those women who are more likely to experience poor outcomes. See Table 1 for a list of social risk factors associated with poor birth outcomes and experiences of maternity care that has been used to identify local population need when designing continuity of care models in the UK.¹³ An observational study⁵⁶ found that women with socially complex factors who received continuity of care experienced improved birth outcomes, less clinical intervention, shorter hospital stays, fewer neonatal unit admissions, and increased liaison with multidisciplinary services.

In order to provide integrated and personalized care that meets the individual needs of women and their families, maternity care should be flexible, respectful, and clinically competent. Flexibility refers to the number of appointments, the timing of those appointments, and the location. Providing maternity care in hospital, community, and home settings may increase women’s access and overall experience of care. The royal Dutch Organization of Midwives⁵⁷ recommend that maternity care should be organized around women’s needs and preferences, and they should be in control of how their care is organized. Respectful and clinically competent care refers to individualized, culturally and contextually appropriate humane care, delivered with respect for women’s fundamental rights and based on individual care plans responding to changing needs.⁵⁸ Women value appropriate clinical interventions, as well as information and support so they can maintain control and dignity.⁵⁹ Most women should be offered midwifery continuity of care, as it improves pregnancy and postnatal outcomes for mother and babies with no identified adverse effects. However, future research should test these models in women with existing serious pregnancy or health complications. See below for an overview of the evidence to support integrated, person-centered, respectful, and compassionate care:

• Women who receive models of midwife led continuity of care are seven times more likely to be attended at birth by a known midwife, 19% less likely to lose their baby before 24 weeks, 15% less likely to use regional analgesia in labor, 24% less likely to experience pre-term birth, and 16% less likely to have an episiotomy.³⁶
• Women attended at birth by a known midwife report a higher rating of maternal satisfaction with information, advice and explanation, more choice in place of birth and pain relief, and are more likely to feel in control.³⁶
• Reduced intervention rates (more spontanous vaginal deliveries, fewer cesarean sections) for case loaded women compared to standard care and private obstetric care in Australia, also found cost reduction.^60,61
• Women are more likely to disclose potentially harmful behaviors and situations and be prepared to trust advice and accept ongoing referrals.⁶²
• Associated with a number of positive healthcare outcomes in broader healthcare research.⁶³
• Positive experiences of maternity care from socially disadvantaged women are often attributed to higher levels of continuity.^64,65,66
• A trusting relationship between a woman and her healthcare provider leads to increased identification of the needs of women who frequently attend maternity services for no apparent medical reason.⁶⁷
• Culturally competent, safe public health models of care, where midwives work collaboratively with the multidisciplinary team, is crucial to improve women and their baby’s health outcomes.⁶⁸
• Known association between continuity and better birth outcomes for women with social risk factors including less intervention and cesarean section, lower rates of admission to the neonatal unit, and more referrals to support services.^56,69
• Current evidence suggests a cost-saving effect because of shorter hospital stay for mother and baby, fewer tests and interventions, and continuity models of care are more flexible and match input of midwives’ time to women’s needs, especially in labor and birth.^61,36
• Respectful application of evidence-based guidelines with attention to women’s individual, cultural, medical, and personal needs is essential for universal access to quality maternal care.⁵⁸
• Culturally competent and community-based models of care, which adopt a life course approach, might help to reduce maternal health inequalities, enhance care coordination with primary health services, and improve the outcomes and experiences of socially disadvantaged populations and women living socially complex lives.⁶⁸

POLICY

Health policies, in the private and public sector, are a set of strategic decisions made by policy makers relating to the planning, implementation, monitoring, and evaluation of services. Part of this process involves resource allocation, timeline for implementation and budgeting of services.⁷⁰ The model of care offered to women is dependent on a country’s health-system infrastructure. One health system can have multiple models of care integrated into its services. Midwife-led and shared care models of care are common in countries such as, Australia, New Zealand, The Netherlands, and the UK, whereas medical models are common in North America.³⁶

The Lancet series on Midwifery²² provided sustainable evidence-based strategies for policymakers in LMIC and HIC to strengthen the quality maternal and newborn care. Complex interactions and power forces between different policy actors are influential in the achievement of a robust policy. For example, in LMIC, senior political support within government and wider public support is evidenced to be vital for a successful policy.⁷¹

Recommendations from national maternal health policies vary depending on the current health status of the population. Table 2 outlines key policy recommendations from the UK, Australia, and Cambodia, illustrating these different requirements based on their settings. In areas with well-established health systems, economic stability, and regulation of health professionals, its aims focus on improving the experiences of their population groups. Contrastingly, unestablished and lower-income settings establish broad aims to meet the globally acceptable standards of health, such as reducing the maternal mortality ratio (MMR), and investing in quality research to create a body of evidence to inform future policies based on their socio-political context.

Globally, midwives are increasingly recognized as an indispensable workforce for improving the experiences and outcomes of women and babies.^59,74 Midwifery has the potential to avoid approximately 80% of all maternal deaths, neonatal deaths, and stillbirths.²¹ In addition to this, the midwife-led model of care has been shown to be a cost-effective and cost-saving model of care.⁷⁵ Consequently, the WHO recommended midwife-led continuity of care (MLCC) models to support women, in settings where there are appropriately trained midwives that are educated to international standards. This shifts the dynamic of responsibilities from medics to midwives.⁷⁶ In LMIC, like Cambodia, without well-established nor regulated midwifery education^71,77 it would not be appropriate to implement a MLCC model of care. However, the drive towards a solely medical model of care to reduce the rate of mortality and improve access to care can lead to the overmedicalization of maternity care, subsequently increasing interventions like cesarean section.⁷¹ This highlights the necessity and the impact a maternity model of care can have on a population, therefore, consideration of its place in the health sector should be strongly considered.

DISCUSSION

This chapter provides a brief overview of the current context of models of midwifery care across the globe. The vast differences in the care available and experienced by women in LMIC and HIC has been highlighted and discussed in relation to maternal and neonatal mortality and morbidity. There is a clear correlation between a lack of maternity care and unacceptably high maternal morbidity, and regardless of the country in which a woman lives, she is still at greater risk depending on her socioeconomic status and ethnicity.^{2,6,7,15,16,17,18,19} The Lancet series on "Syndemics"⁷⁸ explores these health inequalities in greater detail giving specific examples of how disease, environment and socioeconomic status interact to further accentuate health inequalities. "Syndemic care" has been put forward as a way of considering these interactions when designing health services and has been described in the models of care highlighted earlier in this chapter. For example, continuity of care models for women with identified social risk factors have been shown to reduce the health inequalities seen in this group. This may be because interacting contexts are being addressed in a more holistic manner than care that focuses only on the pregnancy. Let us take an example from a HIC: a single mother who is struggling financially, feeling exhausted from working two poorly paid jobs, and has gestational diabetes in her current pregnancy that she is struggling to control. If she were to access standard maternity care, she is unlikely to see the same healthcare professional for her antenatal appointments, appointments will be made at a time and setting set by the system, the time she has with a healthcare professional is likely to be short and rushed. The woman is less likely to attend her appointment as it may be at a time that is difficult to do with her complex, stressful responsibilities, if she does attend, she may lose money. If the women does attend her appointment but does not know the healthcare professional she is seeing, she will be less likely to disclose concerns or articulate her needs as she has not been able to develop trust, this could be compounded if she feels the healthcare professional is short of time. As a result, the healthcare professional is unaware of the stress the woman is experiencing, her financial hardship, and how this is affecting her mental health, wellbeing, and diet, thus underlying her poorly controlled gestational diabetes. It is easy to imagine how the story unfolds and how these individual factors interact and impact on clinical outcomes for the woman and her baby. If we think beyond the period of maternity care, we might also begin to see how maternity care can fail women and their children in the years after pregnancy. Despite regular interaction with services, if women’s individual needs are not realized and acted upon, social conditions may worsen, physical and mental health can deteriorate, the ability to parent impacted, children’s development affected, the cycle of poverty persists. The continuity model of care for women with social risk factors, an example of syndemic care, allows for the ideal context for the woman and healthcare professional to develop a trusting relationship. This might include flexible times for appointments, not during work hours or at school pick up times, appointments carried out in her home or a community setting to facilitate engagement and give the healthcare professional an insight into the woman’s environment, time to allow trust to build. If the woman’s trusts her healthcare professional and believes that they are able to help, she is more likely to disclose her individual needs. The healthcare professional can then use this information to offer individualized support that might include access to financial and legal support, introduction to community services, food banks, free childcare and equipment, interaction with peers. A support network can be put in place that ensures a smooth transition from maternity to early years services that may reduce the impact of deprivation and break the cycle. The healthcare professional can offer individualized advice on lifestyle, for example, diet and exercise, to improve health outcomes for the family. The impact of trust and community integration may have a protective effect on stress and anxiety, improving long-term mental health outcomes. This is one small example of how integrated, person-centered, respectful and compassionate care can have long-term benefits and reduce health inequalities. These considerations are relevant to both LMIC and HIC settings.

"Although there may be little that clinical practitioners and public health interventionists can do about the presence of social and political circumstances that might negatively affect health, the syndemic framework allows for the potential to mitigate those effects by appreciating the complex nature of certain diseases and conditions and for addressing the array of factors that give rise to them. In the pursuit of practising more socially conscious medicine, syndemics suggest that context is key."⁷⁸

PRACTICE RECOMMENDATIONS