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The Research Proposal

83 Components of the Literature Review

Krathwohl (2005) suggests and describes a variety of components to include in a research proposal.  The following sections present these components in a suggested template for you to follow in the preparation of your research proposal.

Introduction

The introduction sets the tone for what follows in your research proposal – treat it as the initial pitch of your idea.  After reading the introduction your reader should:

  • Understand what it is you want to do;
  • Have a sense of your passion for the topic;
  • Be excited about the study´s possible outcomes.

As you begin writing your research proposal it is helpful to think of the introduction as a narrative of what it is you want to do, written in one to three paragraphs.  Within those one to three paragraphs, it is important to briefly answer the following questions:

  • What is the central research problem?
  • How is the topic of your research proposal related to the problem?
  • What methods will you utilize to analyze the research problem?
  • Why is it important to undertake this research? What is the significance of your proposed research?  Why are the outcomes of your proposed research important, and to whom or to what are they important?

Note : You may be asked by your instructor to include an abstract with your research proposal.  In such cases, an abstract should provide an overview of what it is you plan to study, your main research question, a brief explanation of your methods to answer the research question, and your expected findings. All of this information must be carefully crafted in 150 to 250 words.  A word of advice is to save the writing of your abstract until the very end of your research proposal preparation.  If you are asked to provide an abstract, you should include 5-7 key words that are of most relevance to your study. List these in order of relevance.

Background and significance

The purpose of this section is to explain the context of your proposal and to describe, in detail, why it is important to undertake this research. Assume that the person or people who will read your research proposal know nothing or very little about the research problem.  While you do not need to include all knowledge you have learned about your topic in this section, it is important to ensure that you include the most relevant material that will help to explain the goals of your research.

While there are no hard and fast rules, you should attempt to address some or all of the following key points:

  • State the research problem and provide a more thorough explanation about the purpose of the study than what you stated in the introduction.
  • Present the rationale for the proposed research study. Clearly indicate why this research is worth doing.  Answer the “so what?” question.
  • Describe the major issues or problems to be addressed by your research. Do not forget to explain how and in what ways your proposed research builds upon previous related research.
  • Explain how you plan to go about conducting your research.
  • Clearly identify the key or most relevant sources of research you intend to use and explain how they will contribute to your analysis of the topic.
  • Set the boundaries of your proposed research, in order to provide a clear focus. Where appropriate, state not only what you will study, but what will be excluded from your study.
  • Provide clear definitions of key concepts and terms. As key concepts and terms often have numerous definitions, make sure you state which definition you will be utilizing in your research.

Literature Review

This is the most time-consuming aspect in the preparation of your research proposal and it is a key component of the research proposal. As described in Chapter 5 , the literature review provides the background to your study and demonstrates the significance of the proposed research. Specifically, it is a review and synthesis of prior research that is related to the problem you are setting forth to investigate.  Essentially, your goal in the literature review is to place your research study within the larger whole of what has been studied in the past, while demonstrating to your reader that your work is original, innovative, and adds to the larger whole.

As the literature review is information dense, it is essential that this section be intelligently structured to enable your reader to grasp the key arguments underpinning your study. However, this can be easier to state and harder to do, simply due to the fact there is usually a plethora of related research to sift through. Consequently, a good strategy for writing the literature review is to break the literature into conceptual categories or themes, rather than attempting to describe various groups of literature you reviewed.  Chapter V, “ The Literature Review ,” describes a variety of methods to help you organize the themes.

Here are some suggestions on how to approach the writing of your literature review:

  • Think about what questions other researchers have asked, what methods they used, what they found, and what they recommended based upon their findings.
  • Do not be afraid to challenge previous related research findings and/or conclusions.
  • Assess what you believe to be missing from previous research and explain how your research fills in this gap and/or extends previous research

It is important to note that a significant challenge related to undertaking a literature review is knowing when to stop.  As such, it is important to know how to know when you have uncovered the key conceptual categories underlying your research topic.  Generally, when you start to see repetition in the conclusions or recommendations, you can have confidence that you have covered all of the significant conceptual categories in your literature review.  However, it is also important to acknowledge that researchers often find themselves returning to the literature as they collect and analyze their data.  For example, an unexpected finding may develop as one collects and/or analyzes the data and it is important to take the time to step back and review the literature again, to ensure that no other researchers have found a similar finding.  This may include looking to research outside your field.

This situation occurred with one of the authors of this textbook´s research related to community resilience.  During the interviews, the researchers heard many participants discuss individual resilience factors and how they believed these individual factors helped make the community more resilient, overall.  Sheppard and Williams (2016) had not discovered these individual factors in their original literature review on community and environmental resilience. However, when they returned to the literature to search for individual resilience factors, they discovered a small body of literature in the child and youth psychology field. Consequently, Sheppard and Williams had to go back and add a new section to their literature review on individual resilience factors. Interestingly, their research appeared to be the first research to link individual resilience factors with community resilience factors.

Research design and methods

The objective of this section of the research proposal is to convince the reader that your overall research design and methods of analysis will enable you to solve the research problem you have identified and also enable you to accurately and effectively interpret the results of your research. Consequently, it is critical that the research design and methods section is well-written, clear, and logically organized.  This demonstrates to your reader that you know what you are going to do and how you are going to do it.  Overall, you want to leave your reader feeling confident that you have what it takes to get this research study completed in a timely fashion.

Essentially, this section of the research proposal should be clearly tied to the specific objectives of your study; however, it is also important to draw upon and include examples from the literature review that relate to your design and intended methods.  In other words, you must clearly demonstrate how your study utilizes and builds upon past studies, as it relates to the research design and intended methods.  For example, what methods have been used by other researchers in similar studies?

While it is important to consider the methods that other researchers have employed, it is equally important, if not more so, to consider what methods have not been employed but could be.  Remember, the methods section is not simply a list of tasks to be undertaken. It is also an argument as to why and how the tasks you have outlined will help you investigate the research problem and answer your research question(s).

Tips for writing the research design and methods section:

  • Specify the methodological approaches you intend to employ to obtain information and the techniques you will use to analyze the data.
  • Specify the research operations you will undertake and he way you will interpret the results of those operations in relation to the research problem.
  • Go beyond stating what you hope to achieve through the methods you have chosen. State how you will actually do the methods (i.e. coding interview text, running regression analysis, etc.).
  • Anticipate and acknowledge any potential barriers you may encounter when undertaking your research and describe how you will address these barriers.
  • Explain where you believe you will find challenges related to data collection, including access to participants and information.

Preliminary suppositions and implications

The purpose of this section is to argue how and in what ways you anticipate that your research will refine, revise, or extend existing knowledge in the area of your study. Depending upon the aims and objectives of your study, you should also discuss how your anticipated findings may impact future research.  For example, is it possible that your research may lead to a new policy, new theoretical understanding, or a new method for analyzing data?  How might your study influence future studies?  What might your study mean for future practitioners working in the field?  Who or what may benefit from your study?  How might your study contribute to social, economic, environmental issues?  While it is important to think about and discuss possibilities such as these, it is equally important to be realistic in stating your anticipated findings.  In other words, you do not want to delve into idle speculation.  Rather, the purpose here is to reflect upon gaps in the current body of literature and to describe how and in what ways you anticipate your research will begin to fill in some or all of those gaps.

The conclusion reiterates the importance and significance of your research proposal and it provides a brief summary of the entire proposed study.  Essentially, this section should only be one or two paragraphs in length. Here is a potential outline for your conclusion:

  • Discuss why the study should be done. Specifically discuss how you expect your study will advance existing knowledge and how your study is unique.
  • Explain the specific purpose of the study and the research questions that the study will answer.
  • Explain why the research design and methods chosen for this study are appropriate, and why other design and methods were not chosen.
  • State the potential implications you expect to emerge from your proposed study,
  • Provide a sense of how your study fits within the broader scholarship currently in existence related to the research problem.

As with any scholarly research paper, you must cite the sources you used in composing your research proposal.  In a research proposal, this can take two forms: a reference list or a bibliography.  A reference list does what the name suggests, it lists the literature you referenced in the body of your research proposal.  All references in the reference list, must appear in the body of the research proposal.  Remember, it is not acceptable to say “as cited in …”  As a researcher you must always go to the original source and check it for yourself.  Many errors are made in referencing, even by top researchers, and so it is important not to perpetuate an error made by someone else. While this can be time consuming, it is the proper way to undertake a literature review.

In contrast, a bibliography , is a list of everything you used or cited in your research proposal, with additional citations to any key sources relevant to understanding the research problem.  In other words, sources cited in your bibliography may not necessarily appear in the body of your research proposal.  Make sure you check with your instructor to see which of the two you are expected to produce.

Overall, your list of citations should be a testament to the fact that you have done a sufficient level of preliminary research to ensure that your project will complement, but not duplicate, previous research efforts. For social sciences, the reference list or bibliography should be prepared in American Psychological Association (APA) referencing format. Usually, the reference list (or bibliography) is not included in the word count of the research proposal. Again, make sure you check with your instructor to confirm.

An Introduction to Research Methods in Sociology by Valerie A. Sheppard is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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  • How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

  • Search for relevant literature
  • Evaluate sources
  • Identify themes, debates, and gaps
  • Outline the structure
  • Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

  • Quick Run-through
  • Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

  • Demonstrate your familiarity with the topic and its scholarly context
  • Develop a theoretical framework and methodology for your research
  • Position your work in relation to other researchers and theorists
  • Show how your research addresses a gap or contributes to a debate
  • Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

Literature review guide

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essential components of a literature review

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

  • Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
  • Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
  • Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
  • Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

  • Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
  • Body image, self-perception, self-esteem, mental health
  • Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

  • Your university’s library catalogue
  • Google Scholar
  • Project Muse (humanities and social sciences)
  • Medline (life sciences and biomedicine)
  • EconLit (economics)
  • Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

  • What question or problem is the author addressing?
  • What are the key concepts and how are they defined?
  • What are the key theories, models, and methods?
  • Does the research use established frameworks or take an innovative approach?
  • What are the results and conclusions of the study?
  • How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
  • What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

  • Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
  • Themes: what questions or concepts recur across the literature?
  • Debates, conflicts and contradictions: where do sources disagree?
  • Pivotal publications: are there any influential theories or studies that changed the direction of the field?
  • Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

  • Most research has focused on young women.
  • There is an increasing interest in the visual aspects of social media.
  • But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

  • Look at what results have emerged in qualitative versus quantitative research
  • Discuss how the topic has been approached by empirical versus theoretical scholarship
  • Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

  • Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
  • Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
  • Critically evaluate: mention the strengths and weaknesses of your sources
  • Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

  • Sampling methods
  • Simple random sampling
  • Stratified sampling
  • Cluster sampling
  • Likert scales
  • Reproducibility

 Statistics

  • Null hypothesis
  • Statistical power
  • Probability distribution
  • Effect size
  • Poisson distribution

Research bias

  • Optimism bias
  • Cognitive bias
  • Implicit bias
  • Hawthorne effect
  • Anchoring bias
  • Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

  • To familiarize yourself with the current state of knowledge on your topic
  • To ensure that you’re not just repeating what others have already done
  • To identify gaps in knowledge and unresolved problems that your research can address
  • To develop your theoretical framework and methodology
  • To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

  • An introductory paragraph that explains what your working topic and thesis is
  • A forecast of key topics or texts that will appear in the review
  • Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
  • Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
  • Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
  • Critically Evaluate: Mention the strengths and weaknesses of your sources
  • Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

  • Summarize the key findings you have taken from the literature and emphasize their significance
  • Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

  • Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
  • Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
  • Qualitative versus quantitative research
  • Empirical versus theoretical scholarship
  • Divide the research by sociological, historical, or cultural sources
  • Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

  • It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
  • Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
  • Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
  • Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

The Writing Center • University of North Carolina at Chapel Hill

Literature Reviews

What this handout is about.

This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Introduction

OK. You’ve got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a “thumbs up” or “thumbs down” as you leaf through the pages. “Literature review” done. Right?

Wrong! The “literature” of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. “Literature” could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

Let’s get to it! What should I do before writing the literature review?

If your assignment is not very specific, seek clarification from your instructor:

  • Roughly how many sources should you include?
  • What types of sources (books, journal articles, websites)?
  • Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
  • Should you evaluate your sources?
  • Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word “review” in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you’ve already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that’s out there on the topic, but you’ll make your job easier if you first limit your scope.

Keep in mind that UNC Libraries have research guides and to databases relevant to many fields of study. You can reach out to the subject librarian for a consultation: https://library.unc.edu/support/consultations/ .

And don’t forget to tap into your professor’s (or other professors’) knowledge in the field. Ask your professor questions such as: “If you had to read only one book from the 90’s on topic X, what would it be?” Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Strategies for writing the literature review

Find a focus.

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

The current trend in treatment for congestive heart failure combines surgery and medicine. More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

  • Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
  • Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
  • Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

  • Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
  • By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
  • By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
  • Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
  • Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed. Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

  • Current Situation: Information necessary to understand the topic or focus of the literature review.
  • History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
  • Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

Begin composing

Once you’ve settled on a general pattern of organization, you’re ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as “writer,” “pedestrian,” and “persons.” The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine “generic” condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, “Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense,” Women and Language19:2).

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review’s focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton’s study, but then synthesize it by rephrasing the study’s significance and relating it to their own work.

Keep your own voice

While the literature review presents others’ ideas, your voice (the writer’s) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author’s information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil’s. For more information, please see our handout on plagiarism .

Revise, revise, revise

Draft in hand? Now you’re ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you’ve presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you’ve documented your sources and formatted the review appropriately for your discipline. For tips on the revising and editing process, see our handout on revising drafts .

Works consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.

Anson, Chris M., and Robert A. Schwegler. 2010. The Longman Handbook for Writers and Readers , 6th ed. New York: Longman.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. 1997. The Harcourt Brace Guide to Writing in the Disciplines . New York: Harcourt Brace.

Lamb, Sandra E. 1998. How to Write It: A Complete Guide to Everything You’ll Ever Write . Berkeley: Ten Speed Press.

Rosen, Leonard J., and Laurence Behrens. 2003. The Allyn & Bacon Handbook , 5th ed. New York: Longman.

Troyka, Lynn Quittman, and Doug Hesse. 2016. Simon and Schuster Handbook for Writers , 11th ed. London: Pearson.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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How To Structure Your Literature Review

3 options to help structure your chapter.

By: Amy Rommelspacher (PhD) | Reviewer: Dr Eunice Rautenbach | November 2020 (Updated May 2023)

Writing the literature review chapter can seem pretty daunting when you’re piecing together your dissertation or thesis. As  we’ve discussed before , a good literature review needs to achieve a few very important objectives – it should:

  • Demonstrate your knowledge of the research topic
  • Identify the gaps in the literature and show how your research links to these
  • Provide the foundation for your conceptual framework (if you have one)
  • Inform your own  methodology and research design

To achieve this, your literature review needs a well-thought-out structure . Get the structure of your literature review chapter wrong and you’ll struggle to achieve these objectives. Don’t worry though – in this post, we’ll look at how to structure your literature review for maximum impact (and marks!).

The function of the lit review

But wait – is this the right time?

Deciding on the structure of your literature review should come towards the end of the literature review process – after you have collected and digested the literature, but before you start writing the chapter. 

In other words, you need to first develop a rich understanding of the literature before you even attempt to map out a structure. There’s no use trying to develop a structure before you’ve fully wrapped your head around the existing research.

Equally importantly, you need to have a structure in place before you start writing , or your literature review will most likely end up a rambling, disjointed mess. 

Importantly, don’t feel that once you’ve defined a structure you can’t iterate on it. It’s perfectly natural to adjust as you engage in the writing process. As we’ve discussed before , writing is a way of developing your thinking, so it’s quite common for your thinking to change – and therefore, for your chapter structure to change – as you write. 

Need a helping hand?

essential components of a literature review

Like any other chapter in your thesis or dissertation, your literature review needs to have a clear, logical structure. At a minimum, it should have three essential components – an  introduction , a  body   and a  conclusion . 

Let’s take a closer look at each of these.

1: The Introduction Section

Just like any good introduction, the introduction section of your literature review should introduce the purpose and layout (organisation) of the chapter. In other words, your introduction needs to give the reader a taste of what’s to come, and how you’re going to lay that out. Essentially, you should provide the reader with a high-level roadmap of your chapter to give them a taste of the journey that lies ahead.

Here’s an example of the layout visualised in a literature review introduction:

Example of literature review outline structure

Your introduction should also outline your topic (including any tricky terminology or jargon) and provide an explanation of the scope of your literature review – in other words, what you  will   and  won’t   be covering (the delimitations ). This helps ringfence your review and achieve a clear focus . The clearer and narrower your focus, the deeper you can dive into the topic (which is typically where the magic lies). 

Depending on the nature of your project, you could also present your stance or point of view at this stage. In other words, after grappling with the literature you’ll have an opinion about what the trends and concerns are in the field as well as what’s lacking. The introduction section can then present these ideas so that it is clear to examiners that you’re aware of how your research connects with existing knowledge .

Free Webinar: Literature Review 101

2: The Body Section

The body of your literature review is the centre of your work. This is where you’ll present, analyse, evaluate and synthesise the existing research. In other words, this is where you’re going to earn (or lose) the most marks. Therefore, it’s important to carefully think about how you will organise your discussion to present it in a clear way. 

The body of your literature review should do just as the description of this chapter suggests. It should “review” the literature – in other words, identify, analyse, and synthesise it. So, when thinking about structuring your literature review, you need to think about which structural approach will provide the best “review” for your specific type of research and objectives (we’ll get to this shortly).

There are (broadly speaking)  three options  for organising your literature review.

The body section of your literature review is the where you'll present, analyse, evaluate and synthesise the existing research.

Option 1: Chronological (according to date)

Organising the literature chronologically is one of the simplest ways to structure your literature review. You start with what was published first and work your way through the literature until you reach the work published most recently. Pretty straightforward.

The benefit of this option is that it makes it easy to discuss the developments and debates in the field as they emerged over time. Organising your literature chronologically also allows you to highlight how specific articles or pieces of work might have changed the course of the field – in other words, which research has had the most impact . Therefore, this approach is very useful when your research is aimed at understanding how the topic has unfolded over time and is often used by scholars in the field of history. That said, this approach can be utilised by anyone that wants to explore change over time .

Adopting the chronological structure allows you to discuss the developments and debates in the field as they emerged over time.

For example , if a student of politics is investigating how the understanding of democracy has evolved over time, they could use the chronological approach to provide a narrative that demonstrates how this understanding has changed through the ages.

Here are some questions you can ask yourself to help you structure your literature review chronologically.

  • What is the earliest literature published relating to this topic?
  • How has the field changed over time? Why?
  • What are the most recent discoveries/theories?

In some ways, chronology plays a part whichever way you decide to structure your literature review, because you will always, to a certain extent, be analysing how the literature has developed. However, with the chronological approach, the emphasis is very firmly on how the discussion has evolved over time , as opposed to how all the literature links together (which we’ll discuss next ).

Option 2: Thematic (grouped by theme)

The thematic approach to structuring a literature review means organising your literature by theme or category – for example, by independent variables (i.e. factors that have an impact on a specific outcome).

As you’ve been collecting and synthesising literature , you’ll likely have started seeing some themes or patterns emerging. You can then use these themes or patterns as a structure for your body discussion. The thematic approach is the most common approach and is useful for structuring literature reviews in most fields.

For example, if you were researching which factors contributed towards people trusting an organisation, you might find themes such as consumers’ perceptions of an organisation’s competence, benevolence and integrity. Structuring your literature review thematically would mean structuring your literature review’s body section to discuss each of these themes, one section at a time.

The thematic structure allows you to organise your literature by theme or category  – e.g. by independent variables.

Here are some questions to ask yourself when structuring your literature review by themes:

  • Are there any patterns that have come to light in the literature?
  • What are the central themes and categories used by the researchers?
  • Do I have enough evidence of these themes?

PS – you can see an example of a thematically structured literature review in our literature review sample walkthrough video here.

Option 3: Methodological

The methodological option is a way of structuring your literature review by the research methodologies used . In other words, organising your discussion based on the angle from which each piece of research was approached – for example, qualitative , quantitative or mixed  methodologies.

Structuring your literature review by methodology can be useful if you are drawing research from a variety of disciplines and are critiquing different methodologies. The point of this approach is to question  how  existing research has been conducted, as opposed to  what  the conclusions and/or findings the research were.

The methodological structure allows you to organise your chapter by the analysis method  used - e.g. qual, quant or mixed.

For example, a sociologist might centre their research around critiquing specific fieldwork practices. Their literature review will then be a summary of the fieldwork methodologies used by different studies.

Here are some questions you can ask yourself when structuring your literature review according to methodology:

  • Which methodologies have been utilised in this field?
  • Which methodology is the most popular (and why)?
  • What are the strengths and weaknesses of the various methodologies?
  • How can the existing methodologies inform my own methodology?

3: The Conclusion Section

Once you’ve completed the body section of your literature review using one of the structural approaches we discussed above, you’ll need to “wrap up” your literature review and pull all the pieces together to set the direction for the rest of your dissertation or thesis.

The conclusion is where you’ll present the key findings of your literature review. In this section, you should emphasise the research that is especially important to your research questions and highlight the gaps that exist in the literature. Based on this, you need to make it clear what you will add to the literature – in other words, justify your own research by showing how it will help fill one or more of the gaps you just identified.

Last but not least, if it’s your intention to develop a conceptual framework for your dissertation or thesis, the conclusion section is a good place to present this.

In the conclusion section, you’ll need to present the key findings of your literature review and highlight the gaps that exist in the literature. Based on this, you'll  need to make it clear what your study will add  to the literature.

Example: Thematically Structured Review

In the video below, we unpack a literature review chapter so that you can see an example of a thematically structure review in practice.

Let’s Recap

In this article, we’ve  discussed how to structure your literature review for maximum impact. Here’s a quick recap of what  you need to keep in mind when deciding on your literature review structure:

  • Just like other chapters, your literature review needs a clear introduction , body and conclusion .
  • The introduction section should provide an overview of what you will discuss in your literature review.
  • The body section of your literature review can be organised by chronology , theme or methodology . The right structural approach depends on what you’re trying to achieve with your research.
  • The conclusion section should draw together the key findings of your literature review and link them to your research questions.

If you’re ready to get started, be sure to download our free literature review template to fast-track your chapter outline.

Literature Review Course

Psst… there’s more!

This post is an extract from our bestselling Udemy Course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

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Literature review 101 - how to find articles

27 Comments

Marin

Great work. This is exactly what I was looking for and helps a lot together with your previous post on literature review. One last thing is missing: a link to a great literature chapter of an journal article (maybe with comments of the different sections in this review chapter). Do you know any great literature review chapters?

ISHAYA JEREMIAH AYOCK

I agree with you Marin… A great piece

Qaiser

I agree with Marin. This would be quite helpful if you annotate a nicely structured literature from previously published research articles.

Maurice Kagwi

Awesome article for my research.

Ache Roland Ndifor

I thank you immensely for this wonderful guide

Malik Imtiaz Ahmad

It is indeed thought and supportive work for the futurist researcher and students

Franklin Zon

Very educative and good time to get guide. Thank you

Dozie

Great work, very insightful. Thank you.

KAWU ALHASSAN

Thanks for this wonderful presentation. My question is that do I put all the variables into a single conceptual framework or each hypothesis will have it own conceptual framework?

CYRUS ODUAH

Thank you very much, very helpful

Michael Sanya Oluyede

This is very educative and precise . Thank you very much for dropping this kind of write up .

Karla Buchanan

Pheeww, so damn helpful, thank you for this informative piece.

Enang Lazarus

I’m doing a research project topic ; stool analysis for parasitic worm (enteric) worm, how do I structure it, thanks.

Biswadeb Dasgupta

comprehensive explanation. Help us by pasting the URL of some good “literature review” for better understanding.

Vik

great piece. thanks for the awesome explanation. it is really worth sharing. I have a little question, if anyone can help me out, which of the options in the body of literature can be best fit if you are writing an architectural thesis that deals with design?

S Dlamini

I am doing a research on nanofluids how can l structure it?

PATRICK MACKARNESS

Beautifully clear.nThank you!

Lucid! Thankyou!

Abraham

Brilliant work, well understood, many thanks

Nour

I like how this was so clear with simple language 😊😊 thank you so much 😊 for these information 😊

Lindiey

Insightful. I was struggling to come up with a sensible literature review but this has been really helpful. Thank you!

NAGARAJU K

You have given thought-provoking information about the review of the literature.

Vakaloloma

Thank you. It has made my own research better and to impart your work to students I teach

Alphonse NSHIMIYIMANA

I learnt a lot from this teaching. It’s a great piece.

Resa

I am doing research on EFL teacher motivation for his/her job. How Can I structure it? Is there any detailed template, additional to this?

Gerald Gormanous

You are so cool! I do not think I’ve read through something like this before. So nice to find somebody with some genuine thoughts on this issue. Seriously.. thank you for starting this up. This site is one thing that is required on the internet, someone with a little originality!

kan

I’m asked to do conceptual, theoretical and empirical literature, and i just don’t know how to structure it

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Write a literature review.

  • Examples and Further Information

1. Introduction

Not to be confused with a book review, a literature review surveys scholarly articles, books and other sources (e.g. dissertations, conference proceedings) relevant to a particular issue, area of research, or theory, providing a description, summary, and critical evaluation of each work. The purpose is to offer an overview of significant literature published on a topic.

2. Components

Similar to primary research, development of the literature review requires four stages:

  • Problem formulation—which topic or field is being examined and what are its component issues?
  • Literature search—finding materials relevant to the subject being explored
  • Data evaluation—determining which literature makes a significant contribution to the understanding of the topic
  • Analysis and interpretation—discussing the findings and conclusions of pertinent literature

Literature reviews should comprise the following elements:

  • An overview of the subject, issue or theory under consideration, along with the objectives of the literature review
  • Division of works under review into categories (e.g. those in support of a particular position, those against, and those offering alternative theses entirely)
  • Explanation of how each work is similar to and how it varies from the others
  • Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research

In assessing each piece, consideration should be given to:

  • Provenance—What are the author's credentials? Are the author's arguments supported by evidence (e.g. primary historical material, case studies, narratives, statistics, recent scientific findings)?
  • Objectivity—Is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
  • Persuasiveness—Which of the author's theses are most/least convincing?
  • Value—Are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

3. Definition and Use/Purpose

A literature review may constitute an essential chapter of a thesis or dissertation, or may be a self-contained review of writings on a subject. In either case, its purpose is to:

  • Place each work in the context of its contribution to the understanding of the subject under review
  • Describe the relationship of each work to the others under consideration
  • Identify new ways to interpret, and shed light on any gaps in, previous research
  • Resolve conflicts amongst seemingly contradictory previous studies
  • Identify areas of prior scholarship to prevent duplication of effort
  • Point the way forward for further research
  • Place one's original work (in the case of theses or dissertations) in the context of existing literature

The literature review itself, however, does not present new primary scholarship.

  • Next: Examples and Further Information >>

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How to write a literature review

What is a literature review.

The literature review is a written overview of major writings and other sources on a selected topic. Sources covered in the review may include scholarly journal articles, books, government reports, Web sites, etc. The literature review provides a description, summary and evaluation of each source. It is usually presented as a distinct section of a graduate thesis or dissertation.

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Purpose of the literature review

The purpose of the literature review is to provide a critical written account of the current state of research on a selected topic:

  • Identifies areas of prior scholarship
  • Places each source in the context of its contribution to the understanding of the specific issue, area of research, or theory under review.
  • Describes the relationship of each source to the others that you have selected
  • Identifies new ways to interpret, and shed light on any gaps in, previous research
  • Points the way forward for further research.

Components of the literature review

The literature review should include the following:

  • Objective of the literature review
  • Overview of the subject under consideration.
  • particular position, those opposed, and those offering completely different arguments.
  • Discussion of both the distinctiveness of each source and its similarities with the others.

Steps in the literature review process

Preparation of a literature review may be divided into four steps:

  • Define your subject and the scope of the review.
  • Search the library catalogue, subject specific databases and other search tools to find sources that are relevant to your topic.
  • Read and evaluate the sources and to determine their suitability to the understanding of topic at hand (see the Evaluating sources section).
  • Analyse, interpret and discuss the findings and conclusions of the sources you selected.

Evaluating sources

In assessing each source, consideration should be given to:

  • What is the author's expertise in this particular field of study (credentials)?
  • Are the author's arguments supported by empirical evidence (e.g. quantitative/qualitative studies)?
  • Is the author's perspective too biased in one direction or are opposing studies and viewpoints also considered?
  • Does the selected source contribute to a more profound understanding of the subject?

Examples of a published literature review

Literature reviews are often published as scholarly articles, books, and reports. Here is an example of a recent literature review published as a scholarly journal article:

Ledesma, M. C., & Calderón, D. (2015). Critical race theory in education: A review of past literature and a look to the future. Qualitative Inquiry, 21(3), 206-222. Link to the article

Additional sources on writing literature reviews

Further information on the literature review process may be found below:

  • Booth, A., Papaioannou, D., & Sutton, A. (2012). Systematic approaches to a successful literature review
  • Fink, A. (2010). Conducting research literature reviews: From the Internet to paper
  • Galvin, J. (2006). Writing literature reviews: A guide for students of the social and behavioral sciences
  • Machi, L. A., & McEvoy, B. T. (2012). The literature review: Six steps to success

Adapted with permission and thanks from How to Write a Literature Review originally created by Kenneth Lyons, McHenry Library, University of California, Santa Cruz.

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Components of a Literature Review

Edg 501 literature review: components of a literature review.

  • Structure of a Literature Review
  • Writing the Literature Review
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The works that make up the literature review fall into three categories:  

General theoretical literature

  • This literature establishes the importance of your topic/research.  define abstract concepts, discuss the relationships between abstract concepts, and include statistics about the problem being investigated.  Landmark and classic articles are also included.
  • Encyclopedia of Education
  • Encyclopedia of Curriculum Studies
  • Encyclopedia of Educational Psychology
  • 21st Century Education

Literature on related topic areas

  • These sources identify general themes that run throughout the literature.   For example,  a  search on the topic of high stakes testing will find articles on high stakes testing and gender, socioeconomic status, inclusive education, cheating, and academic achievement.  

Resources for this literature (see below) : 

  • Academic Search Complete This link opens in a new window
  • PsycARTICLES This link opens in a new window
  • PsycINFO This link opens in a new window

Literature specific to your research focus

  • This literature is highly relevant.  The sources isolate the issues and highlight the findings you expected when you articulated your research question or formulated your hypothesis.    

Next Step: See  Writing the Literature Review

Qualitative and Quantitative Research

Qualitative research methods are tools for gathering information that does not take a numerical form that can be counted and otherwise manipulated mathematically. If I live with a group of women and men and observe that males tend to dominate conversations, for example, my results consist of an interpretation based on a set of observations that I summarize in an overall impression. As such, it is a qualitative assessment of what is going on. By contrast, if I systematically count how often men and women interact and then compare the totals, my method is quantitative, because it produces numerical results.

Qualitative methods are most closely associated with  participant observation ,  historical sociology ,  ethnomethodology ,  ethnography and ethnology . Quantitative methods are most closely associated with  surveys ,  experiments , and other forms of numerical  data  gathering. Although quantitative methods are often considered superior to socalled "soft" qualitative methods, most sociologists appreciate that each provides unique and valuable insights into the workings of social life that are beyond the reach of the other.

Qualitative and quantitative research methods. (2000). In A. G. Johnson, 

The Blackwell dictionary of sociology  (2nd ed.). Oxford, UK: Blackwell

Publishers. Retrieved from Credo Reference.

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What is the Purpose of a Literature Review?

What is the Purpose of a Literature Review?

4-minute read

  • 23rd October 2023

If you’re writing a research paper or dissertation , then you’ll most likely need to include a comprehensive literature review . In this post, we’ll review the purpose of literature reviews, why they are so significant, and the specific elements to include in one. Literature reviews can:

1. Provide a foundation for current research.

2. Define key concepts and theories.

3. Demonstrate critical evaluation.

4. Show how research and methodologies have evolved.

5. Identify gaps in existing research.

6. Support your argument.

Keep reading to enter the exciting world of literature reviews!

What is a Literature Review?

A literature review is a critical summary and evaluation of the existing research (e.g., academic journal articles and books) on a specific topic. It is typically included as a separate section or chapter of a research paper or dissertation, serving as a contextual framework for a study. Literature reviews can vary in length depending on the subject and nature of the study, with most being about equal length to other sections or chapters included in the paper. Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let’s look at the overall purpose of a literature review.

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Literature reviews are considered an integral part of research across most academic subjects and fields. The primary purpose of a literature review in your study is to:

Provide a Foundation for Current Research

Since the literature review provides a comprehensive evaluation of the existing research, it serves as a solid foundation for your current study. It’s a way to contextualize your work and show how your research fits into the broader landscape of your specific area of study.  

Define Key Concepts and Theories

The literature review highlights the central theories and concepts that have arisen from previous research on your chosen topic. It gives your readers a more thorough understanding of the background of your study and why your research is particularly significant .

Demonstrate Critical Evaluation 

A comprehensive literature review shows your ability to critically analyze and evaluate a broad range of source material. And since you’re considering and acknowledging the contribution of key scholars alongside your own, it establishes your own credibility and knowledge.

Show How Research and Methodologies Have Evolved

Another purpose of literature reviews is to provide a historical perspective and demonstrate how research and methodologies have changed over time, especially as data collection methods and technology have advanced. And studying past methodologies allows you, as the researcher, to understand what did and did not work and apply that knowledge to your own research.  

Identify Gaps in Existing Research

Besides discussing current research and methodologies, the literature review should also address areas that are lacking in the existing literature. This helps further demonstrate the relevance of your own research by explaining why your study is necessary to fill the gaps.

Support Your Argument

A good literature review should provide evidence that supports your research questions and hypothesis. For example, your study may show that your research supports existing theories or builds on them in some way. Referencing previous related studies shows your work is grounded in established research and will ultimately be a contribution to the field.  

Literature Review Editing Services 

Ensure your literature review is polished and ready for submission by having it professionally proofread and edited by our expert team. Our literature review editing services will help your research stand out and make an impact. Not convinced yet? Send in your free sample today and see for yourself! 

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How to write a literature review introduction (+ examples)

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The introduction to a literature review serves as your reader’s guide through your academic work and thought process. Explore the significance of literature review introductions in review papers, academic papers, essays, theses, and dissertations. We delve into the purpose and necessity of these introductions, explore the essential components of literature review introductions, and provide step-by-step guidance on how to craft your own, along with examples.

Why you need an introduction for a literature review

When you need an introduction for a literature review, what to include in a literature review introduction, examples of literature review introductions, steps to write your own literature review introduction.

A literature review is a comprehensive examination of the international academic literature concerning a particular topic. It involves summarizing published works, theories, and concepts while also highlighting gaps and offering critical reflections.

In academic writing , the introduction for a literature review is an indispensable component. Effective academic writing requires proper paragraph structuring to guide your reader through your argumentation. This includes providing an introduction to your literature review.

It is imperative to remember that you should never start sharing your findings abruptly. Even if there isn’t a dedicated introduction section .

Instead, you should always offer some form of introduction to orient the reader and clarify what they can expect.

There are three main scenarios in which you need an introduction for a literature review:

  • Academic literature review papers: When your literature review constitutes the entirety of an academic review paper, a more substantial introduction is necessary. This introduction should resemble the standard introduction found in regular academic papers.
  • Literature review section in an academic paper or essay: While this section tends to be brief, it’s important to precede the detailed literature review with a few introductory sentences. This helps orient the reader before delving into the literature itself.
  • Literature review chapter or section in your thesis/dissertation: Every thesis and dissertation includes a literature review component, which also requires a concise introduction to set the stage for the subsequent review.

You may also like: How to write a fantastic thesis introduction (+15 examples)

It is crucial to customize the content and depth of your literature review introduction according to the specific format of your academic work.

In practical terms, this implies, for instance, that the introduction in an academic literature review paper, especially one derived from a systematic literature review , is quite comprehensive. Particularly compared to the rather brief one or two introductory sentences that are often found at the beginning of a literature review section in a standard academic paper. The introduction to the literature review chapter in a thesis or dissertation again adheres to different standards.

Here’s a structured breakdown based on length and the necessary information:

Academic literature review paper

The introduction of an academic literature review paper, which does not rely on empirical data, often necessitates a more extensive introduction than the brief literature review introductions typically found in empirical papers. It should encompass:

  • The research problem: Clearly articulate the problem or question that your literature review aims to address.
  • The research gap: Highlight the existing gaps, limitations, or unresolved aspects within the current body of literature related to the research problem.
  • The research relevance: Explain why the chosen research problem and its subsequent investigation through a literature review are significant and relevant in your academic field.
  • The literature review method: If applicable, describe the methodology employed in your literature review, especially if it is a systematic review or follows a specific research framework.
  • The main findings or insights of the literature review: Summarize the key discoveries, insights, or trends that have emerged from your comprehensive review of the literature.
  • The main argument of the literature review: Conclude the introduction by outlining the primary argument or statement that your literature review will substantiate, linking it to the research problem and relevance you’ve established.
  • Preview of the literature review’s structure: Offer a glimpse into the organization of the literature review paper, acting as a guide for the reader. This overview outlines the subsequent sections of the paper and provides an understanding of what to anticipate.

By addressing these elements, your introduction will provide a clear and structured overview of what readers can expect in your literature review paper.

Regular literature review section in an academic article or essay

Most academic articles or essays incorporate regular literature review sections, often placed after the introduction. These sections serve to establish a scholarly basis for the research or discussion within the paper.

In a standard 8000-word journal article, the literature review section typically spans between 750 and 1250 words. The first few sentences or the first paragraph within this section often serve as an introduction. It should encompass:

  • An introduction to the topic: When delving into the academic literature on a specific topic, it’s important to provide a smooth transition that aids the reader in comprehending why certain aspects will be discussed within your literature review.
  • The core argument: While literature review sections primarily synthesize the work of other scholars, they should consistently connect to your central argument. This central argument serves as the crux of your message or the key takeaway you want your readers to retain. By positioning it at the outset of the literature review section and systematically substantiating it with evidence, you not only enhance reader comprehension but also elevate overall readability. This primary argument can typically be distilled into 1-2 succinct sentences.

In some cases, you might include:

  • Methodology: Details about the methodology used, but only if your literature review employed a specialized method. If your approach involved a broader overview without a systematic methodology, you can omit this section, thereby conserving word count.

By addressing these elements, your introduction will effectively integrate your literature review into the broader context of your academic paper or essay. This will, in turn, assist your reader in seamlessly following your overarching line of argumentation.

Introduction to a literature review chapter in thesis or dissertation

The literature review typically constitutes a distinct chapter within a thesis or dissertation. Often, it is Chapter 2 of a thesis or dissertation.

Some students choose to incorporate a brief introductory section at the beginning of each chapter, including the literature review chapter. Alternatively, others opt to seamlessly integrate the introduction into the initial sentences of the literature review itself. Both approaches are acceptable, provided that you incorporate the following elements:

  • Purpose of the literature review and its relevance to the thesis/dissertation research: Explain the broader objectives of the literature review within the context of your research and how it contributes to your thesis or dissertation. Essentially, you’re telling the reader why this literature review is important and how it fits into the larger scope of your academic work.
  • Primary argument: Succinctly communicate what you aim to prove, explain, or explore through the review of existing literature. This statement helps guide the reader’s understanding of the review’s purpose and what to expect from it.
  • Preview of the literature review’s content: Provide a brief overview of the topics or themes that your literature review will cover. It’s like a roadmap for the reader, outlining the main areas of focus within the review. This preview can help the reader anticipate the structure and organization of your literature review.
  • Methodology: If your literature review involved a specific research method, such as a systematic review or meta-analysis, you should briefly describe that methodology. However, this is not always necessary, especially if your literature review is more of a narrative synthesis without a distinct research method.

By addressing these elements, your introduction will empower your literature review to play a pivotal role in your thesis or dissertation research. It will accomplish this by integrating your research into the broader academic literature and providing a solid theoretical foundation for your work.

Comprehending the art of crafting your own literature review introduction becomes significantly more accessible when you have concrete examples to examine. Here, you will find several examples that meet, or in most cases, adhere to the criteria described earlier.

Example 1: An effective introduction for an academic literature review paper

To begin, let’s delve into the introduction of an academic literature review paper. We will examine the paper “How does culture influence innovation? A systematic literature review”, which was published in 2018 in the journal Management Decision.

essential components of a literature review

The entire introduction spans 611 words and is divided into five paragraphs. In this introduction, the authors accomplish the following:

  • In the first paragraph, the authors introduce the broader topic of the literature review, which focuses on innovation and its significance in the context of economic competition. They underscore the importance of this topic, highlighting its relevance for both researchers and policymakers.
  • In the second paragraph, the authors narrow down their focus to emphasize the specific role of culture in relation to innovation.
  • In the third paragraph, the authors identify research gaps, noting that existing studies are often fragmented and disconnected. They then emphasize the value of conducting a systematic literature review to enhance our understanding of the topic.
  • In the fourth paragraph, the authors introduce their specific objectives and explain how their insights can benefit other researchers and business practitioners.
  • In the fifth and final paragraph, the authors provide an overview of the paper’s organization and structure.

In summary, this introduction stands as a solid example. While the authors deviate from previewing their key findings (which is a common practice at least in the social sciences), they do effectively cover all the other previously mentioned points.

Example 2: An effective introduction to a literature review section in an academic paper

The second example represents a typical academic paper, encompassing not only a literature review section but also empirical data, a case study, and other elements. We will closely examine the introduction to the literature review section in the paper “The environmentalism of the subalterns: a case study of environmental activism in Eastern Kurdistan/Rojhelat”, which was published in 2021 in the journal Local Environment.

essential components of a literature review

The paper begins with a general introduction and then proceeds to the literature review, designated by the authors as their conceptual framework. Of particular interest is the first paragraph of this conceptual framework, comprising 142 words across five sentences:

“ A peripheral and marginalised nationality within a multinational though-Persian dominated Iranian society, the Kurdish people of Iranian Kurdistan (a region referred by the Kurds as Rojhelat/Eastern Kurdi-stan) have since the early twentieth century been subject to multifaceted and systematic discriminatory and exclusionary state policy in Iran. This condition has left a population of 12–15 million Kurds in Iran suffering from structural inequalities, disenfranchisement and deprivation. Mismanagement of Kurdistan’s natural resources and the degradation of its natural environmental are among examples of this disenfranchisement. As asserted by Julian Agyeman (2005), structural inequalities that sustain the domination of political and economic elites often simultaneously result in environmental degradation, injustice and discrimination against subaltern communities. This study argues that the environmental struggle in Eastern Kurdistan can be asserted as a (sub)element of the Kurdish liberation movement in Iran. Conceptually this research is inspired by and has been conducted through the lens of ‘subalternity’ ” ( Hassaniyan, 2021, p. 931 ).

In this first paragraph, the author is doing the following:

  • The author contextualises the research
  • The author links the research focus to the international literature on structural inequalities
  • The author clearly presents the argument of the research
  • The author clarifies how the research is inspired by and uses the concept of ‘subalternity’.

Thus, the author successfully introduces the literature review, from which point onward it dives into the main concept (‘subalternity’) of the research, and reviews the literature on socio-economic justice and environmental degradation.

While introductions to a literature review section aren’t always required to offer the same level of study context detail as demonstrated here, this introduction serves as a commendable model for orienting the reader within the literature review. It effectively underscores the literature review’s significance within the context of the study being conducted.

Examples 3-5: Effective introductions to literature review chapters

The introduction to a literature review chapter can vary in length, depending largely on the overall length of the literature review chapter itself. For example, a master’s thesis typically features a more concise literature review, thus necessitating a shorter introduction. In contrast, a Ph.D. thesis, with its more extensive literature review, often includes a more detailed introduction.

Numerous universities offer online repositories where you can access theses and dissertations from previous years, serving as valuable sources of reference. Many of these repositories, however, may require you to log in through your university account. Nevertheless, a few open-access repositories are accessible to anyone, such as the one by the University of Manchester . It’s important to note though that copyright restrictions apply to these resources, just as they would with published papers.

Master’s thesis literature review introduction

The first example is “Benchmarking Asymmetrical Heating Models of Spider Pulsar Companions” by P. Sun, a master’s thesis completed at the University of Manchester on January 9, 2024. The author, P. Sun, introduces the literature review chapter very briefly but effectively:

essential components of a literature review

PhD thesis literature review chapter introduction

The second example is Deep Learning on Semi-Structured Data and its Applications to Video-Game AI, Woof, W. (Author). 31 Dec 2020, a PhD thesis completed at the University of Manchester . In Chapter 2, the author offers a comprehensive introduction to the topic in four paragraphs, with the final paragraph serving as an overview of the chapter’s structure:

essential components of a literature review

PhD thesis literature review introduction

The last example is the doctoral thesis Metacognitive strategies and beliefs: Child correlates and early experiences Chan, K. Y. M. (Author). 31 Dec 2020 . The author clearly conducted a systematic literature review, commencing the review section with a discussion of the methodology and approach employed in locating and analyzing the selected records.

essential components of a literature review

Having absorbed all of this information, let’s recap the essential steps and offer a succinct guide on how to proceed with creating your literature review introduction:

  • Contextualize your review : Begin by clearly identifying the academic context in which your literature review resides and determining the necessary information to include.
  • Outline your structure : Develop a structured outline for your literature review, highlighting the essential information you plan to incorporate in your introduction.
  • Literature review process : Conduct a rigorous literature review, reviewing and analyzing relevant sources.
  • Summarize and abstract : After completing the review, synthesize the findings and abstract key insights, trends, and knowledge gaps from the literature.
  • Craft the introduction : Write your literature review introduction with meticulous attention to the seamless integration of your review into the larger context of your work. Ensure that your introduction effectively elucidates your rationale for the chosen review topics and the underlying reasons guiding your selection.

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Essential components of postnatal care - a systematic literature review and development of signal functions to guide monitoring and evaluation

Affiliations.

  • 1 Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK. [email protected].
  • 2 Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK.
  • 3 The Global Fund for Aids Tuberculosis and Malaria, Switzerland, Geneva.
  • 4 Bocconi School of Management, Bocconi University, Milan, Italy.
  • PMID: 35643432
  • PMCID: PMC9148465
  • DOI: 10.1186/s12884-022-04752-6

Background: Postnatal Care (PNC) is one of the healthcare-packages in the continuum of care for mothers and children that needs to be in place to reduce global maternal and perinatal mortality and morbidity. We sought to identify the essential components of PNC and develop signal functions to reflect these which can be used for the monitoring and evaluation of availability and quality of PNC.

Methods: Systematic review of the literature using MESH headings for databases (Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science). Papers and reports on content of PNC published from 2000-2020 were included. Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

Results: Forty-Eight papers and reports are included in the systematic review from which 22 essential components of PNC were extracted and used to develop 14 signal functions. Signal functions are used in obstetrics to denote a list of interventions that address major causes of maternal and perinatal morbidity or mortality. For each signal function we identified the equipment, medication and consumables required for implementation. The prevention and management of infectious diseases (malaria, HIV, tuberculosis) are considered essential components of routine PNC depending on population disease burden or whether the population is considered at risk. Screening and management of pre-eclampsia, maternal anaemia and mental health are recommended universally. Promotion of and support of exclusive breastfeeding and uptake of a modern contraceptive method are also considered essential components of PNC. For the new-born baby, cord care, monitoring of growth and development, screening for congenital disease and commencing vaccinations are considered essential signal functions. Screening for gender-based violence (GBV) including intimate partner- violence (IPV) is recommended when counselling can be provided and/or a referral pathway is in place. Debriefing following birth (complicated or un-complicated) was agreed through consensus-building as an important component of PNC.

Conclusions: Signal functions were developed which can be used for monitoring and evaluation of content and quality of PNC. Country adaptation and validation is recommended and further work is needed to examine if the proposed signal functions can serve as a useful monitoring and evaluation tool.

Trial registration: The systematic review protocol was registered: PROSPERO 2018 CRD42018107054 .

Keywords: Global health; Health services; Maternal morbidity; Neonatal morbidity; Postnatal care; Quality of care.

© 2022. The Author(s).

Publication types

  • Systematic Review
  • Delivery of Health Care
  • Global Health
  • Intimate Partner Violence* / prevention & control
  • Postnatal Care*
  • Case report
  • Open access
  • Published: 17 February 2024

Calcific bursitis of the Gruberi bursa: a case report

  • Nikhil N. Patel   ORCID: orcid.org/0000-0002-3231-3541 1 ,
  • Jean Jose 1 &
  • Cristina Pravia 1  

Journal of Medical Case Reports volume  18 , Article number:  58 ( 2024 ) Cite this article

133 Accesses

1 Altmetric

Metrics details

Bursitis is the inflammation of a synovial bursa, a small synovial fluid-filled sac that acts as a cushion between muscles, tendons, and bones. Further, calcific bursitis results from calcium deposits on the synovial joint that exacerbates pain and swelling. The Gruberi bursa is located dorsolaterally in the ankle, between the extensor digitorium longus and the talus. Despite limited literature on its pathophysiology, the aim of this case is to discuss the bursa’s association with calcific bursitis and its management via a case presented to our clinic.

Case presentation

A 47-year-old Caucasian female with no past medical or family history presents with acute right ankle pain following a minor injury 3 months prior with no improvement on analgesic or steroid therapy. Imaging demonstrated incidental calcium deposits. The day prior to presentation, the patient stated she used 1-pound ankle weights that resulted in mild swelling and gradual pain to the right dorsoanterior ankle. Physical exam findings displayed a significant reduction in the range of motion limited by pain. Imaging confirmed calcification within the capsule of the talonavicular joint, consistent with Gruberi bursitis. Initial management with prednisone yielded minimal improvement, requiring an interventional approach with ultrasound-guided barbotage that elicited immediate improvement.

The presented case report highlights a rare and unique instance of acute ankle pain and swelling caused by calcific Gruberi bursitis in a young female. Although the Gruberi bursa is a relatively new discovery, it contains inflammatory components that may predispose it to calcification and should be considered in the differential of ankle swelling. Therefore, utilizing a systematic approach to a clinical presentation and considering all differential diagnoses is essential.

Peer Review reports

Ankle pain and swelling is a common clinical presentation resulting from various conditions, including sprains, gout, and calcific periarthritis. A synovial bursa is a small sac filled with synovial fluid that acts as a cushion between muscles, tendons, and bones [ 1 ]. Bursitis is a common musculoskeletal presentation of an irritated, swollen, or infected bursa capsule that elicits pain and reduces range of motion [ 2 , 3 ]. The four most common locations for bursitis are prepatellar, olecranon, trochanteric, and retrocalcaneal; typically, these respond to non-surgical management [ 4 ]. Calcific bursitis is the build-up of calcium deposits in soft tissue, which can result in painful swelling of the bursa in synovial joints such as the shoulder, elbow, fingers, wrist, hip, knee, and, less commonly, the ankle [ 5 ]. In this report, we present a case of acute onset ankle pain and swelling secondary to calcific Gruberi bursitis requiring interventional non-operative management.

First described by Alexander Monro (1825), the Gruberi bursa is located between the extensor digitorum longus (EDL) tendon and talus [ 6 ]. The Gruberi bursa is found on the dorsolateral ankle. There is limited literature describing its pathophysiology and its relationship with calcific bursitis.

A 47-year-old Caucasian female with no past medical or family history presented to the clinic for evaluation and treatment of 1-day acute right ankle pain. The patient stated that she sustained a minor injury 3 months prior when she tripped and fell, hyper-plantarflexing the right ankle; she endorsed pain toward the base of her toes rather than her ankle. A plain X-ray of the right ankle in anteroposterior (AP) and lateral noted “incidental calcium deposits over the talonavicular region” (Fig. 1 ).

figure 1

A 1.4 × 0.9 × 1.1 cm focus of soft tissue calcification, with juxta-articular deposits of calcium hydroxyapatite along the dorsal aspect of the talus (arrows)

Subsequently, she went to a pilates class and used 1-pound ankle weights for the first time. The next day, she woke up with mild swelling and gradual, progressive pain to the right dorsoanterior ankle. She was unable to ambulate or bear weight on that foot within 24 hours of the pilates session. The patient denied fevers, chills, rashes, or previous history of rheumatological disorders. Upon physical exam, the right ankle showed noticeable swelling to the anterior aspect without erythema or warmth. Dorsalis pedis was palpable, and strength was 4/5 in all muscle groups of the right leg. The pain was localized predominantly to the anterior aspect of the ankle centrally and over the talonavicular region and tender at the extensor digitorum commonness. The Achilles, posterior ankle, tibialis anterior, and extensor hallux longus tendons were non-tender. Sensation was intact to light touch. Range of motion was severely limited by pain.

Repeat X-ray at this acute presentation demonstrated no evidence of fracture or osteochondral pathology but again showed a calcification dorsal to the talonavicular region. This appeared different than an ossicle or osteophyte, providing concern for acute calcific periarthritis. A magnetic resonance imaging (MRI) of her ankle did not show any soft tissue masses but confirmed calcification within the capsule of the talonavicular joint without involvement of the extensor tendons. Using the MRI findings, the precise anatomical location was determined to be consistent with Gruberi bursitis (Fig. 2 ). She was prescribed prednisone 40 mg daily for 4 days without significant improvement.

figure 2

( A ) Sagittal Short Tau Inversion Recovery, ( B ) Sagittal T1, and ( C ) Axial Proton Density Magnetic Resonance Images demonstrate a calcified soft tissue mass with surrounding inflammatory changes along the dorsal aspect of the talus, involving the inferior extensor retinaculum (frondiform ligament) as it passes along the extensor digitorum tendons, reflecting calcific Gruberi bursitis (arrows)

Upon consultation with interventional radiology, an ultrasound (US)-guided barbotage was performed (Fig. 3 ). The inflamed right ankle Gruberi bursa was identified, and amorphous calcifications were noted dorsally to the talus, measuring 1.4 × 0.6 × 1.8 cm, consistent with calcific bursitis (Fig. 4 ). A 20-gauge needle was advanced into the right foot, and a mixture of lidocaine and saline was injected with multiple passes through the amorphous calcifications, breaking them down enough to be lavaged out. Subsequently, a mixture containing 1 cc (40 mg) of Kenalog and lidocaine was injected into the area of calcific bursitis. Within minutes, the ankle pain significantly improved [Numeric Pain Rating Scale (NRS) pain pre-procedure 10/10 and post-procedure 2/10], and the patient immediately returned to baseline ambulation. Rest, ice, and anti-inflammatories were recommended on discharge. Upon 6-month follow-up, this patient is endorsing no pain in her ambulation nor at rest.

figure 3

( A ), ( B ) Longitudinal grayscale ultrasound images of the ankle demonstrate ultrasound-guided calcific bursitis lavage using a 20-gauge spinal needle (arrows)

figure 4

( A ) Longitudinal grayscale and ( B ) color Doppler ultrasound images of the ankle demonstrate hyperechoic foci with acoustic posterior shadowing, internal calcific content, and no appreciable internal vascularity (arrows)

Despite mentions of this anatomical bursa in early twentieth-century anatomy textbooks and multiple reports using MRI or US, extensive debate exists on whether the Gruberi bursa communicates with the talonavicular joint, the tibiotalar joint, and the EDL tendon [ 1 , 7 , 8 , 9 , 10 ].

In this report, we present a unique case of Gruberi bursitis as a rare cause of acute dorsolateral ankle pain and swelling in a young female. While calcific bursitis can affect various bursae in the body, no such literature exists, with only Ragab et al. discussing MRI findings of Gruberi bursitis [ 1 ].

Calcific bursitis presents with localized pain, swelling, tenderness, and reduced range of motion that can worsen with activity, repetitive trauma, or chronic irritation and deposit formation [ 11 , 12 ]. Common management includes rest, immobilization, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy to reduce pain and inflammation [ 13 ]. Ice and compression can further alleviate associated symptoms. In consultation with orthopedic surgery, operative management, including arthroscopic removal of the calcific deposit, excision of the bursa, or performing a bursectomy, can be considered if conservative treatment fails to improve the bursitis. Interventional radiology measures, as in our case, can also be performed to aspirate the calcification and inject corticosteroids for pain and inflammation management. Barbotage is a low-risk procedure requiring local anesthesia and relatively quick recovery. The improvement seen in this patient thus supports the belief that inflammatory bursitis to the Gruberi bursa due to calcific involvement exists.

A common differential diagnosis for calcific bursitis is acute calcific periarthritis [ 14 , 15 , 16 ]. Although periarthritis is also caused by calcium deposits within soft tissue, resulting in rapid onset monoarticular pain, swelling, erythema, or fever, the cardinal difference is the involvement of tendons [ 14 , 17 , 18 , 19 ]. Similarly, calcific periarthritis is found in big joints such as the shoulder and is self-resolving or requires conservative treatment [ 15 ]. Our case represents a unique presentation in the ankle that required alternative therapy. Despite high doses of oral steroids, the patient was non-ambulatory for at least 1 week before the barbotage. Thus, this case is significant in providing support for ultrasound-guided barbotage for patients who do not respond to conservative medical management. Patients of any age who endorse severe pain at rest or ambulation would benefit from this therapy.

Furthermore, it is important to utilize a systematic approach to the clinical presentation due to high misdiagnosis rates for infective or inflammatory pathophysiology, arthropathies, or neoplasia [ 20 , 21 , 22 ]. Diagnosis, including gout, pseudogout, or infectious etiologies such as osteomyelitis, must be considered in acute ankle pain presentations. Laboratory tests such as C-reactive protein, complete blood count, erythrocyte sedimentation rate, and diagnostic imaging such as MRI or US should be considered [ 23 ]. Although our case lacked laboratory testing due to an emergent presentation, it is imperative to consider all differentials.

While it is a relatively new discovery, the Gruberi bursa does contain inflammatory components that predispose it to calcification, as presented in this case. Further research is needed to determine the pathophysiology of calcification in the talonavicular region. Additionally, studies should be performed to identify inclusion criteria and compare the efficacy of ultrasound-guided barbotage to other treatments of calcific Gruberi bursitis. This report demonstrates the value of enhanced MRI and significant improvement using ultrasound-guided barbotage after failed conservative medical management.

Availability of data and materials

The data and materials supporting the findings of this study are available upon reasonable request from the corresponding author.

Abbreviations

Extensor digitorum longus

Anteroposterior

Magnetic resonance imaging

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Patel, N.N., Jose, J. & Pravia, C. Calcific bursitis of the Gruberi bursa: a case report. J Med Case Reports 18 , 58 (2024). https://doi.org/10.1186/s13256-024-04377-7

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Essential components of postnatal care – a systematic literature review and development of signal functions to guide monitoring and evaluation

Hannah mccauley.

1 Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA UK

Kirsty Lowe

Nicholas furtado.

2 The Global Fund for Aids Tuberculosis and Malaria, Switzerland Geneva,

Viviana Mangiaterra

3 Bocconi School of Management, Bocconi University, Milan, Italy

Nynke van den Broek

Associated data.

Postnatal Care (PNC) is one of the healthcare-packages in the continuum of care for mothers and children that needs to be in place to reduce global maternal and perinatal mortality and morbidity. We sought to identify the essential components of PNC and develop signal functions to reflect these which can be used for the monitoring and evaluation of availability and quality of PNC.

Systematic review of the literature using MESH headings for databases (Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science). Papers and reports on content of PNC published from 2000–2020 were included. Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

Forty-Eight papers and reports are included in the systematic review from which 22 essential components of PNC were extracted and used to develop 14 signal functions. Signal functions are used in obstetrics to denote a list of interventions that address major causes of maternal and perinatal morbidity or mortality. For each signal function we identified the equipment, medication and consumables required for implementation. The prevention and management of infectious diseases (malaria, HIV, tuberculosis) are considered essential components of routine PNC depending on population disease burden or whether the population is considered at risk. Screening and management of pre-eclampsia, maternal anaemia and mental health are recommended universally. Promotion of and support of exclusive breastfeeding and uptake of a modern contraceptive method are also considered essential components of PNC. For the new-born baby, cord care, monitoring of growth and development, screening for congenital disease and commencing vaccinations are considered essential signal functions. Screening for gender-based violence (GBV) including intimate partner- violence (IPV) is recommended when counselling can be provided and/or a referral pathway is in place. Debriefing following birth (complicated or un-complicated) was agreed through consensus-building as an important component of PNC.

Conclusions

Signal functions were developed which can be used for monitoring and evaluation of content and quality of PNC. Country adaptation and validation is recommended and further work is needed to examine if the proposed signal functions can serve as a useful monitoring and evaluation tool.

Trial registration

The systematic review protocol was registered: PROSPERO 2018 CRD42018107054 .

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04752-6.

Postnatal Care (PNC) is one of the care packages that make up the continuum of care for mothers and babies globally [ 1 , 2 ]. A significant number of maternal deaths still occur during the postnatal period and an estimated 2.8 million babies die in the first month of life (neonatal death) [ 3 , 4 ]. Neonatal deaths account for up to 52% of all deaths in children under-5 years of age [ 5 ]. The majority of maternal and neonatal deaths are treatable and preventable with timely recognition and good-quality care [ 6 ].

Current guidelines advise that women should have at least eight ANC visits or contacts during pregnancy, a skilled attendant with adequate resources at the time of birth, and PNC immediately after birth and/or on at least four occasions in the subsequent six weeks [ 2 , 7 , 8 ].

Despite the critical importance of the postnatal period for both maternal and child survival and well-being, PNC consistently has the lowest coverage rates [ 9 ]. Postnatal care coverage is not a reported in the annual World Health Statistics reports and nor is it a component of the indicator to assess Universal Health Coverage (UHC). Estimates show that globally far fewer women and newborn babies receive PNC compared to antenatal care (ANC), with less than half of women receiving a postnatal care visit within two days of childbirth [ 10 , 11 ].

It is recommended that women who give birth with a skilled attendant in a healthcare facility receive immediate postnatal care and stay at the healthcare facility for at least 24 hours in case of uncomplicated birth [ 12 ]. However, it has been reported that even when women give birth in a healthcare facility, this may not include PNC as women may only stay at the healthcare facility for a few hours [ 13 ]. Of the 48% of women in sub-Saharan Africa who give birth without a skilled birth attendant only 13% receive a PNC visit [ 14 ].

The importance of PNC for reducing neonatal mortality has been documented with an estimation that if PNC rates were to reach 90% in sub-Saharan Africa, then 10–27% of all neonatal deaths could be averted [ 15 ]. Research has similarly outlined the considerable extent of maternal psychological and physiological morbidity following childbirth especially among vulnerable populations [ 16 , 17 ]. These include maternal anaemia, hypertension, puerperal and other infections as well as the need for increased psychosocial support. Timely identification and management during and after pregnancy can reduce the burden of disease and prevent complications particularly where morbidity and mortality levels among women of reproductive age are high [ 18 ].

In addition to the screening, identification, and management of pregnancy- and birth-related morbidity, the postnatal period and postnatal care package is an opportunity for the promotion and implementation of other components of public health, including the commencing of childhood immunisations, exclusive breastfeeding and uptake of modern contraceptive methods [ 1 ]. Care in the first 1000 days of life is crucially important to ensure that children survive and thrive. Children who are exclusively breastfed are 14 times more likely to survive the first six months of life than non-breastfed children [ 19 ]. Receiving PNC is significantly associated with modern contraception use [ 2 , 20 ].

PNC is also an important platform for programmes that aim to tackle the inequities in HIV, tuberculosis and malaria prevention and treatment [ 21 ]. For example, mother-to-child transmission of HIV (PMTCT) programmes provide treatment and education to HIV positive mothers and treatment for HIV-exposed infants with the aim of preventing newborn infections [ 22 ]. In high-burden settings, nearly half of all new HIV infections among children occur during the postnatal period. However, this is also when many women who are HIV positive fail to attend for ongoing care and treatment and drop out of such programmes. This means that comparatively more infant HIV infections occur during the postnatal period than during pregnancy and labour [ 23 ].

It is important that all components of PNC are provided to the mother and her baby in an integrated holistic manner. Given the low coverage rates and uptake of PNC globally, the attention internationally has been largely on supporting the implementation and uptake of at least the minimum number of PNC visits that are considered effective, and, on where and who can provide PNC at the healthcare facility level as well as in the community [ 24 ]. There has been less emphasis on the essential components or minimum content of the PNC care package required to meet the needs of both mothers and/or babies. Without the right content PNC will largely remain a ‘missed opportunity’. For other care packages that make up the continuum of care including for Emergency Obstetric Care and Antenatal Care ‘signal functions’ have been developed which reflect the essential components of a care package [ 25 , 26 ]. These have however not yet been developed for PNC.

We therefore conducted a systematic review of the literature and consensus-building workshops with a range of key stakeholders to identify the essential components of PNC and develop signal functions to assist in the monitoring and evaluation of availability and quality of PNC.

The PRISMA guidelines were followed for this systematic review and a narrative summary of results is provided [ 27 ]. The World Health Organisation (WHO) definition of postnatal period is ‘postnatal period begins immediately after the birth of the baby and extends up to six weeks (42 days) after birth’. When describing care provision, the postnatal period consists of immediate, early and late periods. The period from days 2 through 7 is defined as the early postnatal period and the period from days 8 through 42 as the late postnatal period [ 2 ].

The review protocol was registered (PROSPERO 2018 CRD42018107054).

Search strategy

A systematic search strategy was developed. Six databases including Cinahl, Cochrane (Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials), Global Health, Medline, PubMed, and Web of Science were searched using MeSH Headings, subheadings, thesaurus, and key word searches. A librarian was involved in developing MeSH terms and selecting relevant databases. Bibliographies from the articles selected for full text retrieval were reviewed to identify additional relevant studies. Key word searches were also conducted in Google Scholar. (Table S 1 - Search Terms).

Inclusion criteria

Articles from indexed journals describing one or more components of the content of PNC were included. As the researchers were English and French speaking, articles were limited to those published in English and French published between January 2000 (to coincide with the development of the postnatal care guidance from WHO) and September 2020.

Exclusion criteria

Studies that did not describe at least one content component of PNC were excluded. Studies were also excluded if they were case studies or research protocols. Finally, studies with no research methods such as journalistic style articles, editorials and individual volunteer accounts including personal reflection accounts were excluded.

Terminology

For this review, we used the term ‘component’ to denote individual interventions or actions that are considered part of the PNC care package. The terms ‘core’, ‘key’, ‘vital’ and ‘essential’ are used interchangeably in the literature. For the purpose of this review, we use the term ‘essential’ to denote a requirement for the PNC care package. In obstetrics ‘signal functions’ are used to denote a representative shortlist of key interventions and activities that address major causes of maternal and perinatal morbidity or mortality [ 25 , 26 ]. These were first used in obstetrics to define Emergency Obstetric Care with nine identified signal functions describing this care package. A list of signal functions does not include every service that may need to be provided but are considered as representative of a minimum essential care package that needs to be in place. The equipment, medication and/or vaccines required to implement each signal function can be identified and must be in place to be able to provide each relevant component of care.

Both the words ‘postpartum’ and ‘postnatal’ are used in the literature and in policy documents sometimes interchangeably. The WHO recommends the adoption of just a single term ‘postnatal’ to be used for all issues pertaining to the mother and the baby after birth up to 6 weeks (42 days) [ 28 ]. A distinction is made between ‘immediate postnatal care’ which is given immediately after birth and in the first 24-h after birth before discharge home (if birth is in a healthcare facility). Subsequent PNC is also referred to as ‘routine’ PNC visits and is recommended on at least three further occasions; day-3, days 7–14 and 6-weeks after birth [ 12 ]. This systematic review and developed signal functions pertain to routine PNC visits.

Study selection

Papers identified from the electronic searches were imported into Endnote and duplicates were removed. Three independent researchers reviewed all titles and abstracts to determine if papers met the inclusion criteria. Where inclusion/exclusion criteria could not be determined from the titles and abstracts alone and/or for papers without an abstract, full articles were retrieved and reviewed for relevance. In case of uncertainty or discordance between reviewers the full text was reviewed again by all three and consensus reached to include or exclude.

Quality assessment was undertaken on all included papers using The Hawker et al. Critical Appraisal Tool. The checklist is used to assess nine areas of the research article. The maximum score an article can score is 36 for fulfilling all the items on the checklist while a minimum score of 9 can be scored for a very poor article.

Data extraction

Using a pre-designed data extraction form, information for each study was extracted by two independent researchers to include type of study, population, and the individual components of PNC recommended or assessed. Any disagreement was resolved by discussion with a third researcher. Information obtained from studies that reported on more than one component of PNC was recorded in a central summary table. Studies that reported on only one component of PNC were summarised in separate tables by themes which were identified during review.

Data synthesis

A narrative synthesis was used to summarise findings. All identified individual components of PNC were listed and were categorised to develop a draft list of 25 signal functions with identification of the equipment, medication and consumables required to deliver each. A series of consensus-building workshops were held (3 international and 4 national) with a range of stakeholders (184 in total) including researchers, clinicians, health service managers from low- and middle-income countries (Afghanistan, Chad, Ghana, Togo, Nigeria) as well as high income settings (Europe, USA, UK) and key representatives from UN partners (UNFPA, WHO, UNICEF, and the Global Fund). Workshops were organised to allow for examination of each recommendation for content of PNC in small working groups followed by plenary discussion, consensus agreement leading to adoption or not of proposed content, signal function, equipment, medication and consumables required for each. Consensus-building workshops were conducted alongside and during the ongoing systematic review with evidence obtained from review of documents (policy, guidelines) and peer reviewed papers presented at time of the workshops. Adaptation or not of any component as discussed during any workshop was based on evidence where available with practices for which there was evidence of non-effectiveness or harmful practices agreed as needing to be discarded. After synthesis of all workshop feedback and the literature review a comprehensive list of 15 proposed signal functions were developed.

Description of studies

Database searches revealed 1213 potentially applicable publications. Duplicates were removed and abstracts reviewed. Exclusion and inclusion criteria was applied and 92 papers were included for full text review. After review 44 papers were excluded and 48 studies included in this review (Fig.  1 – Prisma Diagram). The main exclusion reasons were the policy or study papers were not reporting on content of PNC or were case studies.

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Study selection- PRISMA Flow Diagram (Moher et al., 2009)

Of the 48 included papers 14 reported on multiple components of PNC. This included a systematic review [ 29 ], 6 sets of guidelines or policy papers [ 1 , 2 , 4 , 30 – 32 ] and 7 studies or non-systematic reviews [ 33 – 39 ]. (Supplementary Table 2 – Summary of Included studies reporting on multiple components of PNC).

All other papers included (34 papers) reported on only one single component of PNC and were subsequently grouped by 6 themes identified following review including (in order of number of papers included) mental health- postnatal depression (10) [ 40 – 49 ] breastfeeding [ 8 ], preventing mother to child transmission of HIV (PMTCT) (4) [ 50 – 57 ], family planning (3) [ 58 – 61 ], care of the pre-term newborn (2) [ 62 – 64 ] and Kangaroo Mother Care (KMC) (2) [ 67 , 68 ], maternal anaemia (2) [ 69 , 70 ] and Miscellaneous (3) [ 71 – 73 ] including screening for congenital hip dysplasia, and newborn hip screening and pelvic floor exercises. (Summary Tables available on request).

Quality assessment was performed on the 14 papers (Supplementary table 2 ), nine were graded as good quality and five assessed to be fair quality. The studies rated fair reported detailed study design methods but not the sampling methods and implications of the study, which compromised their quality. However, all included studies had areas of good quality making them suitable for data extraction.

Synthesis for papers reporting on single components of PNC

Mental health.

The largest number of included papers pertained to screening and management of maternal mental health and focused on Postnatal Depression (PND). Several papers report on the effectiveness and/or feasibility of introducing screening for PND. The introduction of screening in India (using the Edinburgh Postnatal Depression Screening- EPDS tool) immediately postpartum and at 6–8 weeks was found to be beneficial in identifying women at risk [ 40 ] as did a study in Ethiopia using the WHO self-reporting questionnaire [ 41 ]. Similarly, a study in Nepal reported highlighted the need for routine screening for PPD and reported that pregnancy complications and health problems in the baby were risk factors for PND [ 42 ].

A systematic review on the effectiveness of psychosocial assessment for the detection and management of PND concluded that assessment helps detect risk factors but those who screen positive and received prevention care for PND did not do better than those who screened positive and received no additional care [ 43 ].

A self-care programme consisting of two sessions covering physical and psychosocial wellbeing based on the teach-back method resulted in improved in quality of life during the postnatal period including with regard to improved positive feelings of the mother towards herself and towards her child as well as improved physical health [ 44 ]. Women in Australia who had received a short motivational interviewing intervention (including discussion of risk factors for PND, anxiety, low self-esteem) in the postnatal period were four times more likely to seek help for PND in the 12 months after birth [ 45 ].

In Iran, weekly support sessions provided by telephone over a period of eight weeks did not result in fewer women screening positive for PND using the EPDS [ 46 ] whereas in an RCT lifestyle-based education reduced anxiety and EPDS scores at six weeks postnatally [ 47 ]. Educational counselling in additional to routine care (debriefing) for women with adverse birth events did not result in better scores for quality of life, anxiety or depression at six weeks to six months postnatally [ 48 ]. Therapist-supported iCBT significantly improves stress, anxiety, and depressive symptoms among postpartum women with small to large effects [ 49 ].

Breastfeeding

Eight included papers reported on a range of approaches to support breastfeeding. An RCT in the UK examined the effect of skin-to-skin contact care versus none. Although initiation and duration of breastfeeding at four months was not improved, concerns regarding a drop in temp with skin-to-skin care were negated with good maintenance of temperature for the neonate. Both groups got breastfeeding education and support [ 50 ]. In a controlled intervention study in Turkey one-to one demonstration using models on how to breastfeed was more effective in preventing cracked nipples than providing an information brochure only [ 51 ]. Similarly, in Sweden midwives offered training and support to women at three days, three and nine months postpartum which was reported to result in women enjoying breastfeeding as well as a strengthened maternal relationship with the baby [ 52 ]. A one-hour workshop and one-hour counselling session in the first 24 h after birth was reported as effective and beneficial when breast feeding was assessed at four and eight weeks postpartum [ 53 ]. In the Gambia women who reported having received counselling, a supportive partner, from a more educated and wealthier background were more likely to intend to practice exclusive breastfeeding [ 54 ].

In contrast in another study in the UK support and education counselling after teaching the mother to position the baby herself there was no difference regarding whether the midwife provided further support or was ‘hands-off’ when breastfeeding was assessed at 17 weeks [ 55 ]. Evaluation of the effect of peer-to-peer counselling per telephone on breastfeeding duration showed no difference [ 56 ]. In an exploratory qualitative study, supporting mother-infant bonding increased the duration of breastfeeding in mothers with babies admitted to a neonatal intensive care unit in Malawi [ 57 ].

Diagnosis and management of HIV

A study from South Africa [ 58 ] highlighted missed opportunities for PMTCT with failure to attend for HIV treatment and FP, lack of TB screening, and women not receiving consistent messages and highlighted the need to address this. In Malawi the need for continued follow -up and care was highlighted through a cohort study with adherence to HIV treatment adequate for 73% or women during pregnancy, 66% in the first 3 months postnatally and 75% during months 4–21 postnatal [ 59 ]. The importance of early diagnosis and management of HIV infection in the neonate was demonstrated in Malawi and Thailand [ 60 , 61 ].

Family Planning (FP)

Offering FP as part of immediate PNC was associated with high rates of uptake in a study by Duncan et al. among HIV positive women [ 62 ]. In a large study from India women who had received a postpartum Intra uterine contraceptive device (IUCD) reported a high level of satisfaction and low level of expulsion (4% at 6 weeks) [ 63 ]. In an RCT in the USA contraceptive education by phone, insurance coverage and appointment scheduling did not influence the uptake or not of LARC [ 64 ].

Preterm and/or LBW babies

A Cochrane review by Mc Call et al. looking at thermo-regulation for preterm or low birth weight (LBW) babies reports that using plastic wraps or bags and/or thermo mattresses leads to higher temperature on admission to neonatal units (25 studies included) but that skin-to- skin care remains effective when compared to traditional incubator care [ 65 ].  Sun et al. recommend the use of a screening algorithm for the prediction of retinopathy of prematurity [ 66 ].

Prevention of hypothermia

An RCT demonstrated that helping mothers via one-on-one teaching and demonstration of skin-to-skin contact and Kangaroo Mother Care (KMC) improved mother to infant attachment and reduced maternal anxiety [ 67 ]. Nahidi et al. developed a mother to infant skin to skin contact questionnaire to improve implementation and factors associated [ 68 ].

Maternal anaemia

The importance of having guidelines for the management of anaemia was reported in a paper from New Zealand with a wide range of approaches noted among midwives especially regarding assessment of iron status [ 69 ]. Although two thirds (64.4%) of postnatal women had anaemia in a study from Uganda, the healthcare system had missed the opportunities to effectively address it, such as through the implementation of the policy recommendation for iron and folic acid supplementation [ 70 ].

Miscellaneous

A systematic review recommends the use of pulse-oximetry screening (POS) to check blood flow in the feet and hands during examination of the newborn baby in the immediate postpartum period for early detection of congenital cardiac heart disease. The reduction in neonatal morbidity and mortality is likely to be more pronounced in low-resource settings where most of these babies are born without a prenatal diagnosis. [ 71 ]. A systematic review to examine early dynamic ultrasound (eDUS) screening for hip instability in the first 6 weeks after birth suggests that this could be more effective than clinical examination alone [ 72 ]. A systematic review on the effect of pelvic floor muscle exercise reported that this improved sexual desire, arousal, orgasm, and satisfaction in the postpartum period [ 73 ].

Synthesis for papers reporting on multiple components of PNC [ 14 ]

Lassi et al. included 148 Cochrane and other systematic reviews which identified 61 RMNCH interventions which included eight for routine PNC including: prevention and management of anaemia in the mother, hygienic cord care, prevention of hypothermia with KMC for Low-Birth-Weight babies, newborn immunisation, breastfeeding, family planning, bed nets (ITN) for prevention of malaria, PMTCT for women who are HIV positive. Prevention and management of eclampsia was mentioned as part of ANC only. Home care was mentioned as an approach to delivery of PNC [ 29 ].

In a cross-sectional survey among 320 HIV positive postnatal women in Zambia, uptake of infant testing for HIV in the first six weeks was positively associated with maternal uptake of ARVs and, HIV status disclosure to the male partner. Women who reported intimate partner violence (IPV, 40% of the women included in the study) were less likely to have infants tested. Overall, 73% of infants had a test for HIV by 6 weeks. The paper highlights the importance of integration and linking of HIV prevention and management in both the mother and baby and the importance of screening for IPV during PNC [ 38 ].

A cluster RCT conducted in Ghana to assess effect of postnatal home visits vs routine PNC available at a healthcare facility and assessed breastfeeding (initiation and exclusive BF), thermoregulation (skin to skin contact, first bath delayed), sleeping under ITN, weighing of the baby and awareness of danger signs to identify the sick baby. Home visits were associated with improved coverage with increased care seeking at the facility in case the baby showed signs of illness (77% in intervention vs 55% in control) [ 33 ] .

A WHO Technical Working Group reviewed the evidence and reached consensus regarding indicators to assess coverage of key newborn interventions—on two additional indicators for care of the newborn in the immediate postpartum period including regarding; i) thermoregulation recommending drying, delayed bathing, skin-to-skin contact and checking temperature, and ii) cord care—keeping the cord dry versus application of 4% chlorhexidine -with the consensus being the latter needed further research. Additionally, weighing of the baby, breastfeeding and counselling on danger signs in the newborn were agreed as being essential components of PNC [ 34 ].

Several studies assessed the availability of quality of PNC. For a comprehensive healthcare facility assessment in Ghana components of (mainly immediate) PNC focused on the newborn and assessed- drying the baby after birth, delaying bathing the baby, prophylactic eye ointment for the baby, initiation of breast feeding, skin to skin contact and KMC for preterm and/or LBW babies [ 35 ]. In a before-after study to improve the uptake of intra-partum and postnatal care in Uganda components assessed for PNC included thermo-regulation for the newborn (immediate drying, external warming, skin to skin contact) promotion and provision of hygienic cord care early initiation of breastfeeding and KMC [ 39 ].

Two studies looked specifically at care provided in the community or home setting. A study in Iran reported on the effectiveness of community-based PNC which included uptake of PNC in the first week, weight gain during the first 3–7 days, hospitalization rate and management of the sick neonate mainly highlighting the importance of awareness of the danger signs and recognition of the sick baby [ 37 ]. Interviews exploring routine practices of home delivery and immediate PNC with women in Ethiopia assessed PNC components including tying the cord immediately after birth, dry cord care, bathing and cleaning the baby birth, and giving the baby water and sugar before initiation of breastfeeding (as non-recommended practice) [ 36 ].

Interventions identified to be essential in the postnatal period for the mother were described in 2011 by the Partnership for Maternal, Newborn and Child Health (PMNCH) and included family planning, prevention and treatment of maternal anaemia, detection and management of postpartum sepsis, PMTCT, immediate thermal care of the baby, initiation of exclusive breastfeeding, hygienic cord and skin care, KMC for preterm and LBW newborns and management of newborns with jaundice. These guidelines also highlighted the level and organisation of care required to provide PNC to women and their newborns [ 1 ].

In preparation for the Every Newborn Action Plan (ENAP) 70 indicators were assessed resulting in 10 core and 10 additional indicators being adopted; core indicators were considered those that impact the maternal and/or neonatal morality rate and/or stillbirth rate and include intrapartum skilled birth attendance, early PNC and essential Newborn Care. For PNC treatment of neonatal infections, chlorhexidine for cord care for babies at risk of complications and KMC were identified as essential [ 31 ].

The latest WHO Guidelines specifically for PNC [ 2 , 12 ] address the timing frequency place and content for PNC during the 6 weeks after to birth for mothers and babies and were developed on all available evidence focused on LMICs. Recommended content includes newborn examination, exclusive BF, cord care, delay in bathing, mother and baby staying together, immunisations, examination of the mother (general wellbeing micturition – urinary incontinence, bowel function, perineal care, headache, fatigue, back pain, uterine tenderness and lochia), iron and folic acid supplementation to prevent or manage anaemia in the mother.

Global guidelines for pregnancy, childbirth, postpartum and newborn care include recommendations regarding screening and management of pre-eclampsia and eclampsia; prevention of mother-to-child transmission of HIV; HIV and infant feeding; post-partum depression, and post-partum family planning [ 12 ]. The guidelines provide evidence-based recommendations including for the management of endemic diseases like malaria, HIV/AIDS, TB and anaemia. The PNC guidelines recommend administration of Vit K to the newborn and thermal regulation.

The main objective of Salam et al.’s paper was to review the evidence-base for interventions that have a proven positive impact on newborn and maternal health outcomes. In this non-systematic review, for PNC interventions that impacted positively on maternal and neonatal morbidity and mortality included education and provision of family planning, early initiation of and support for exclusive breastfeeding; thermal care or KMC for preterm and/or LBW babies, and hygienic skin and umbilical cord care after birth [ 30 ].

In the UK, NICE guidelines [ 32 ] outline the care that should be given to women and their babies up to eight weeks after birth. Individual components of clinical care include (but are not limited to) monitoring of blood pressure in the mother, cord care in the baby, administration of Vit K, breastfeeding support. These guidelines also highlight the need to listen to women, be responsive to their needs, taking into consideration the individual needs and preferences of each woman and debriefing after birth.

Essential Components of PNC and development of signal functions.

From the included papers a total of 22 components of PNC identified as essential were extracted. Results are presented in Table ​ Table1 1 – Components of PNC identified and number of papers supporting each component.

Components of PNC identified and number of papers supporting each component

Peer review and consensus building workshops validated, detailed, and grouped the components which were then developed as developed as proposed signal functions of PNC (Table 2 - Proposed signal functions for PNC with components and outline of required equipment, medication and consumables). Screening for and management of tuberculosis although not identified by the systematic review of the literature was considered a vital and essential component of PNC across all consensus-building workshops along with screening for and management of HIV.

Proposed signal functions for PNC with essential content and components to be assessed and outline of required equipment drugs and consumables

a Assumes availability of essential consumables such as non-sterile gloves, needles, syringes or capillary tubes, skin swabs, tourniquet and cotton wool.

b All drugs as per national protocol – can vary and needs to be specified for each country.

Throughout the workshops it was highlighted that drug regimens for treatment and prevention of malaria, tuberculosis and HIV should be setting specific and dependent on country practice and policy. Hepatitis B vaccination of the newborn baby is now almost universally recommended but may depend on a country’s national policy and incidence or disease and/or identification of at-risk population. Workshop participants agreed that the proposed PNC signal functions could be used as an important monitoring and evaluation tool including for healthcare facility assessments e.g., to identify the number of healthcare facilities across all levels of care that can provide each of these components and also identify barriers to implementation e.g. lack of human resources, drugs, consumables and equipment The signal functions can also be used as an assessment of service delivery e.g., identification of the proportion of women who received each component during an PNC visit or contact.

Main findings

As a result of a systematic review of the literature 22 essential components of postnatal care (PNC) were identified of which 12 relate directly to the mother and 10 to the baby. These were synthesised and, following consensus-building with a wide range of stakeholders, were developed into 14 proposed signal functions with the identification of the required equipment, drugs vaccines and consumables to implement each component. As for other care packages in the continuum of care for mothers and children, signal functions of PNC can be used to guide monitoring and evaluation of PNC availability and quality.

We note that in the peer-reviewed literature, guidelines and policy documents the focus has frequently been on components related specifically to neonatal rather than maternal health care. This may be in response to the comparatively high burden of global perinatal and neonatal mortality. However, the health of the baby is directly linked to that of the mother. PNC seeks to address the well-being and health needs of both the mother and her baby during one combined visit or consultation. The proposed signal functions highlight this and do not make a distinction between those that are for the baby and those that are more specifically for the mother. The identified essential components and signal functions include prevention recognition and management of general wellbeing, obstetric complications, medical and infectious diseases that are prevalent as well as social and mental health. Postnatal care is also an important platform to promote exclusive breastfeeding and family planning. It is expected that these essential components of PNC are provided as ‘routine’ for women and babies in the postnatal period to support an optimum recovery for the mother, growth and development of the newborn baby and promote health seeking behaviour for the family. Adaptations can be made where needed depending on the burden of disease in any particular setting and emphasis of focus e.g., for the signal functions pertaining to malaria, TB and HIV. Guidelines for practice will depend on the estimated overall incidence in the population served.

Strengths and limitations

Postnatal Care is provided as two separate care packages 1) immediate postnatal care at the time of birth and 2) subsequent postnatal care. Postnatal care immediately after birth (in the first few hours) could more logically be considered part of the skilled birth attendance care package or part of intra-partum care and has been described as including prevention of postpartum haemorrhage through active management of the third stage and resuscitation of the newborn if required. Secondly, the care a woman and her baby require at the time of birth and/or immediately after this is very much dependent on the type of birth (vaginal or operative) and whether there are any complications for either the mother or her baby, making it more difficult to define a ‘standard’ or routine care package that would be applicable to all women and babies during the subsequent postnatal period which is commonly defined as the first 42 days after birth.

To the best of our knowledge this is the first systematic review examining specifically what should be considered as the essential content of PNC for the mother and baby to be provided in the first six weeks following birth. The included components are those that are considered part of a comprehensive care package for all women and babies i.e. as part of ‘routine’ PNC. For women and babies with specific complications or underlying morbidity additional PNC components will be required.

Context in relation to other studies

There is still relatively scant epidemiological information on the specific pregnancy-related burden of disease in the postnatal period. However, this is recognised as a period of risk as well as opportunity for screening, prevention, and management of health problems and to support the wellbeing of the mother and baby. There is emerging evidence that in low-and middle- income settings the burden of morbidity is significant [ 16 , 17 ]. In high-income settings where the burden of disease is smaller, the emphasis of PNC provision has more recently been on ensuring general well-being of the woman and her baby. This includes and emphasis on social and mental health and debriefing after either complicated or uncomplicated birth, rather than on prevention and management of pregnancy complications or infectious diseases.

For the purpose of developing globally relevant signal functions and, based on the results of our systematic review of the literature, the signal functions proposed in this study seek to be comprehensive and recognise the need to address three major infectious diseases (HIV, tuberculosis and malaria) as well as obstetric conditions, medical conditions, mental and social health. For those populations with a low prevalence of HIV, tuberculosis and/or malaria country adaptations can be made. It would be helpful to have agreed international cut-off points of prevalence above which screening for, and management of certain infectious diseases should be included as essential components of PNC. A useful comparison is the recommendations regarding whether or not to screen for tuberculosis as part of antenatal care which is guided by estimated country level prevalence of tuberculosis [ 8 ]. Screening for HIV is almost universally recommended as part of ANC and may not have to be repeated as part of PNC in countries with a low prevalence.

Examination of the baby to check for any congenital abnormalities and/or illness is an important part of PNC. In many settings an anomaly ultrasound scan is routinely offered as part of ANC. Whether or not this is provided, it remains important to ensure a full body examination of the baby as part of PNC. In high income settings additionally laboratory testing is carried out (e.g. a Guthrie or ‘heel prick’ test to check for phenylketonuria) and a routine hearing test is carried out on all newborn babies to identify deafness.

Discussion regarding the need for and/or effectiveness of de-briefing after traumatic birth as well as general de-briefing and information sharing after uncomplicated birth have informed the development of the relevant proposed signal function and was recognised by stakeholders during consultation to be a new and emerging component of PNC which requires further attention [ 74 , 75 ].

We conducted an earlier and separate systematic review and consensus-building to identify the essential components of ANC with the development of 15 proposed signal functions [ 26 ]. We note that there is an overlap in content and therefore the signal functions developed for both ANC and PNC and we recommend these are combined for the purposes of monitoring and evaluation as well as training of healthcare providers. In most setting ANC and PNC are provided in similar settings and by the same cadres of healthcare providers including for the main part community- and/or facility-based nurse-midwives.

Implications for policy and practice

It is recognised that PNC is being delivered by a wide range of healthcare providers, including those at facility- and community-level. For a full content of effective PNC to be delivered these healthcare providers need to have the necessary equipment, dugs, consumables as well as up-to-date knowledge and skills in all aspects of PNC. As it can be expected that many women are home-bound especially in the early postnatal period, there is a need to provide care at home or very close to home and models for this may require further development [ 76 ]. Recently there have been suggestions that community-based healthcare workers and/or volunteers may be better placed to provide PNC. However, an initial mapping shows that few of such cadres are adequately trained for, competent in, legislated and supported to provide all of the essential components of either ANC or PNC [ 77 ]. Other forms of community support are effective such as mother to mother support for continuation of exclusive breastfeeding, practical and emotional support from partners, family and the wider community to enhance wellbeing and promote a positive experience of the postnatal period [ 78 , 79 ].

The importance of screening for social (including gender-based violence) as well as mental health problems (including depression) during the antenatal as well as postnatal period is recognised globally [ 17 , 80 ]. A variety of screening tools is available currently to assess wellbeing and mental health and it will be important to establish which is most effective and feasible to use in each specific setting. In some cases, translation into a local language and/or socio-cultural adaptation of tools is still needed. However, our systematic review highlighted several studies from countries where such screening has now been successfully introduced. Screening for GBV and/or intimate partner violence (IPV) is problematic in many settings and not accepted practice either for the healthcare provider or the woman attending for care [ 81 , 82 ]. WHO guidelines for ANC recommend screening for GBV/IPV in settings where women can receive care and a referral pathway is established [ 8 ]. However, although recommended practice, we note that the current WHO guidelines for PNC make no specific recommendation regarding GBV [ 12 ].

Future research and unanswered questions

PNC coverage is defined as the number of women aged 15–49 years with a live birth who have postnatal contact with a health-care provider within two days of birth as a proportion of the total number of women aged 15–49 with a live birth. This information is collected from Demographic Health Surveys (DHS), Reproductive Health Surveys (RHS), Multiple Indicator Cluster Surveys (MICS), or other types of household surveys that collect data using nationally representative population samples and standardised questionnaires. Population-based household surveys are the preferred data source in settings that have a low utilization of healthcare facility services. However, such surveys are generally expensive and may be difficult to conduct.

The availability and uptake of essential health services coverage (SDG indicator 3.8.1) is an important measurement [ 83 ]. Thus, the Universal Health Coverage (UHC) index includes 16 essential health services as indicators of the equity and level of UHC. For reproductive, maternal, neonatal and child health (RMNCH) these are: family planning, antenatal care, delivery care, full child immunisation, and care for pneumonia in children [ 83 ]. We note that unlike ANC coverage, PNC coverage is not reported as an indicator in the annual World Health Statistics reports.

The available indicators for PNC are obtained for populations through a variety of different data sources, the most important of which are household surveys. Regarding PNC coverage, in both the MICS and DHS what is measured is; 1) the proportion of women who recall having received PNC within 2 days of giving birth and 2) who (which type of healthcare provider) provided PNC. Since 2013, in DHS (phase 7) what is asked is: did the woman receive PNC in the 2 days after birth, who provided this and where. For content what is included is: if the healthcare provider examined the cord, measured the baby’s temp, counselled on danger signs and observed breastfeeding [ 84 ] .

Given the importance of PNC as a key healthcare package for the prevention and management of morbidity and mortality in women of reproductive age and in the newborn, it will be important to reach global consensus on more effective routine monitoring of PNC coverage and content. The signal functions developed could be used: 1) for health facility assessment; 2) to identify health system barriers to implementation; 3) as a component of the service delivery assessment and, 4) for assessment of quality of care. Further research regarding the acceptability and feasibility of the application of the signal functions proposed in this study for the effective monitoring and evaluation of availability and quality of PNC is needed.

Globally the proportion of mothers and babies who receive PNC is significantly lower than those who receive ANC and this constitutes a missed opportunity. Reasons for this could be that PNC is not accessible, not available and/or not of good quality. The focus has to date been mainly on the number and timing of PNC visits rather than what is provided to the mother and baby during these visits or contacts. More attention should be given to content if PNC is to have the required impact on maternal and neonatal morbidity and mortality. We propose a set of signal functions that could be used to monitor and evaluate content of PNC. There is ample evidence for the urgent need to address aspects of care that are disrespectful and of poor quality and that are likely to contribute significantly to the current low uptake of postnatal care globally. Similarly, without the required essential content for the mother and her baby quality of care cannot be provided.

Acknowledgements

We would like to thank all the participants of the workshops for their considered inputs. In addition thanks to Dr A Miller and Dr A Traore for support with screening of papers.

Abbreviations

Authors’ contributions.

HMcC, KL and NvdB conducted the systematic review. HMcC, VM, NF and NvdB facilitated consensus building workshops. All authors (VM, NF, HMcC, Kl, NvdB) contributed to the analysis of the data and writing of the paper. The author(s) read and approved the final manuscript.

The Global Fund for Aids Tuberculosis and Malaria (GFATM).

Availability of data and materials

Declarations.

None declared.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Hannah McCauley, Email: [email protected] .

Kirsty Lowe, Email: moc.liamtoh@ewoL_ytsriK .

Nicholas Furtado, Email: [email protected] .

Viviana Mangiaterra, Email: [email protected] .

Nynke van den Broek, Email: moc.tenretnitb@keorbdvn .

  • Open access
  • Published: 28 May 2022

Essential components of postnatal care – a systematic literature review and development of signal functions to guide monitoring and evaluation

  • Hannah McCauley 1 ,
  • Kirsty Lowe 1 ,
  • Nicholas Furtado 2 ,
  • Viviana Mangiaterra 2 , 3 &
  • Nynke van den Broek 1  

BMC Pregnancy and Childbirth volume  22 , Article number:  448 ( 2022 ) Cite this article

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Postnatal Care (PNC) is one of the healthcare-packages in the continuum of care for mothers and children that needs to be in place to reduce global maternal and perinatal mortality and morbidity. We sought to identify the essential components of PNC and develop signal functions to reflect these which can be used for the monitoring and evaluation of availability and quality of PNC.

Systematic review of the literature using MESH headings for databases (Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science). Papers and reports on content of PNC published from 2000–2020 were included. Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

Forty-Eight papers and reports are included in the systematic review from which 22 essential components of PNC were extracted and used to develop 14 signal functions. Signal functions are used in obstetrics to denote a list of interventions that address major causes of maternal and perinatal morbidity or mortality. For each signal function we identified the equipment, medication and consumables required for implementation. The prevention and management of infectious diseases (malaria, HIV, tuberculosis) are considered essential components of routine PNC depending on population disease burden or whether the population is considered at risk. Screening and management of pre-eclampsia, maternal anaemia and mental health are recommended universally. Promotion of and support of exclusive breastfeeding and uptake of a modern contraceptive method are also considered essential components of PNC. For the new-born baby, cord care, monitoring of growth and development, screening for congenital disease and commencing vaccinations are considered essential signal functions. Screening for gender-based violence (GBV) including intimate partner- violence (IPV) is recommended when counselling can be provided and/or a referral pathway is in place. Debriefing following birth (complicated or un-complicated) was agreed through consensus-building as an important component of PNC.

Conclusions

Signal functions were developed which can be used for monitoring and evaluation of content and quality of PNC. Country adaptation and validation is recommended and further work is needed to examine if the proposed signal functions can serve as a useful monitoring and evaluation tool.

Trial registration

The systematic review protocol was registered: PROSPERO 2018 CRD42018107054 .

Peer Review reports

Postnatal Care (PNC) is one of the care packages that make up the continuum of care for mothers and babies globally [ 1 , 2 ]. A significant number of maternal deaths still occur during the postnatal period and an estimated 2.8 million babies die in the first month of life (neonatal death) [ 3 , 4 ]. Neonatal deaths account for up to 52% of all deaths in children under-5 years of age [ 5 ]. The majority of maternal and neonatal deaths are treatable and preventable with timely recognition and good-quality care [ 6 ].

Current guidelines advise that women should have at least eight ANC visits or contacts during pregnancy, a skilled attendant with adequate resources at the time of birth, and PNC immediately after birth and/or on at least four occasions in the subsequent six weeks [ 2 , 7 , 8 ].

Despite the critical importance of the postnatal period for both maternal and child survival and well-being, PNC consistently has the lowest coverage rates [ 9 ]. Postnatal care coverage is not a reported in the annual World Health Statistics reports and nor is it a component of the indicator to assess Universal Health Coverage (UHC). Estimates show that globally far fewer women and newborn babies receive PNC compared to antenatal care (ANC), with less than half of women receiving a postnatal care visit within two days of childbirth [ 10 , 11 ].

It is recommended that women who give birth with a skilled attendant in a healthcare facility receive immediate postnatal care and stay at the healthcare facility for at least 24 hours in case of uncomplicated birth [ 12 ]. However, it has been reported that even when women give birth in a healthcare facility, this may not include PNC as women may only stay at the healthcare facility for a few hours [ 13 ]. Of the 48% of women in sub-Saharan Africa who give birth without a skilled birth attendant only 13% receive a PNC visit [ 14 ].

The importance of PNC for reducing neonatal mortality has been documented with an estimation that if PNC rates were to reach 90% in sub-Saharan Africa, then 10–27% of all neonatal deaths could be averted [ 15 ]. Research has similarly outlined the considerable extent of maternal psychological and physiological morbidity following childbirth especially among vulnerable populations [ 16 , 17 ]. These include maternal anaemia, hypertension, puerperal and other infections as well as the need for increased psychosocial support. Timely identification and management during and after pregnancy can reduce the burden of disease and prevent complications particularly where morbidity and mortality levels among women of reproductive age are high [ 18 ].

In addition to the screening, identification, and management of pregnancy- and birth-related morbidity, the postnatal period and postnatal care package is an opportunity for the promotion and implementation of other components of public health, including the commencing of childhood immunisations, exclusive breastfeeding and uptake of modern contraceptive methods [ 1 ]. Care in the first 1000 days of life is crucially important to ensure that children survive and thrive. Children who are exclusively breastfed are 14 times more likely to survive the first six months of life than non-breastfed children [ 19 ]. Receiving PNC is significantly associated with modern contraception use [ 2 , 20 ].

PNC is also an important platform for programmes that aim to tackle the inequities in HIV, tuberculosis and malaria prevention and treatment [ 21 ]. For example, mother-to-child transmission of HIV (PMTCT) programmes provide treatment and education to HIV positive mothers and treatment for HIV-exposed infants with the aim of preventing newborn infections [ 22 ]. In high-burden settings, nearly half of all new HIV infections among children occur during the postnatal period. However, this is also when many women who are HIV positive fail to attend for ongoing care and treatment and drop out of such programmes. This means that comparatively more infant HIV infections occur during the postnatal period than during pregnancy and labour [ 23 ].

It is important that all components of PNC are provided to the mother and her baby in an integrated holistic manner. Given the low coverage rates and uptake of PNC globally, the attention internationally has been largely on supporting the implementation and uptake of at least the minimum number of PNC visits that are considered effective, and, on where and who can provide PNC at the healthcare facility level as well as in the community [ 24 ]. There has been less emphasis on the essential components or minimum content of the PNC care package required to meet the needs of both mothers and/or babies. Without the right content PNC will largely remain a ‘missed opportunity’. For other care packages that make up the continuum of care including for Emergency Obstetric Care and Antenatal Care ‘signal functions’ have been developed which reflect the essential components of a care package [ 25 , 26 ]. These have however not yet been developed for PNC.

We therefore conducted a systematic review of the literature and consensus-building workshops with a range of key stakeholders to identify the essential components of PNC and develop signal functions to assist in the monitoring and evaluation of availability and quality of PNC.

The PRISMA guidelines were followed for this systematic review and a narrative summary of results is provided [ 27 ]. The World Health Organisation (WHO) definition of postnatal period is ‘postnatal period begins immediately after the birth of the baby and extends up to six weeks (42 days) after birth’. When describing care provision, the postnatal period consists of immediate, early and late periods. The period from days 2 through 7 is defined as the early postnatal period and the period from days 8 through 42 as the late postnatal period [ 2 ].

The review protocol was registered (PROSPERO 2018 CRD42018107054).

Search strategy

A systematic search strategy was developed. Six databases including Cinahl, Cochrane (Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials), Global Health, Medline, PubMed, and Web of Science were searched using MeSH Headings, subheadings, thesaurus, and key word searches. A librarian was involved in developing MeSH terms and selecting relevant databases. Bibliographies from the articles selected for full text retrieval were reviewed to identify additional relevant studies. Key word searches were also conducted in Google Scholar. (Table S 1 - Search Terms).

Inclusion criteria

Articles from indexed journals describing one or more components of the content of PNC were included. As the researchers were English and French speaking, articles were limited to those published in English and French published between January 2000 (to coincide with the development of the postnatal care guidance from WHO) and September 2020.

Exclusion criteria

Studies that did not describe at least one content component of PNC were excluded. Studies were also excluded if they were case studies or research protocols. Finally, studies with no research methods such as journalistic style articles, editorials and individual volunteer accounts including personal reflection accounts were excluded.

Terminology

For this review, we used the term ‘component’ to denote individual interventions or actions that are considered part of the PNC care package. The terms ‘core’, ‘key’, ‘vital’ and ‘essential’ are used interchangeably in the literature. For the purpose of this review, we use the term ‘essential’ to denote a requirement for the PNC care package. In obstetrics ‘signal functions’ are used to denote a representative shortlist of key interventions and activities that address major causes of maternal and perinatal morbidity or mortality [ 25 , 26 ]. These were first used in obstetrics to define Emergency Obstetric Care with nine identified signal functions describing this care package. A list of signal functions does not include every service that may need to be provided but are considered as representative of a minimum essential care package that needs to be in place. The equipment, medication and/or vaccines required to implement each signal function can be identified and must be in place to be able to provide each relevant component of care.

Both the words ‘postpartum’ and ‘postnatal’ are used in the literature and in policy documents sometimes interchangeably. The WHO recommends the adoption of just a single term ‘postnatal’ to be used for all issues pertaining to the mother and the baby after birth up to 6 weeks (42 days) [ 28 ]. A distinction is made between ‘immediate postnatal care’ which is given immediately after birth and in the first 24-h after birth before discharge home (if birth is in a healthcare facility). Subsequent PNC is also referred to as ‘routine’ PNC visits and is recommended on at least three further occasions; day-3, days 7–14 and 6-weeks after birth [ 12 ]. This systematic review and developed signal functions pertain to routine PNC visits.

Study selection

Papers identified from the electronic searches were imported into Endnote and duplicates were removed. Three independent researchers reviewed all titles and abstracts to determine if papers met the inclusion criteria. Where inclusion/exclusion criteria could not be determined from the titles and abstracts alone and/or for papers without an abstract, full articles were retrieved and reviewed for relevance. In case of uncertainty or discordance between reviewers the full text was reviewed again by all three and consensus reached to include or exclude.

Quality assessment was undertaken on all included papers using The Hawker et al. Critical Appraisal Tool. The checklist is used to assess nine areas of the research article. The maximum score an article can score is 36 for fulfilling all the items on the checklist while a minimum score of 9 can be scored for a very poor article.

Data extraction

Using a pre-designed data extraction form, information for each study was extracted by two independent researchers to include type of study, population, and the individual components of PNC recommended or assessed. Any disagreement was resolved by discussion with a third researcher. Information obtained from studies that reported on more than one component of PNC was recorded in a central summary table. Studies that reported on only one component of PNC were summarised in separate tables by themes which were identified during review.

Data synthesis

A narrative synthesis was used to summarise findings. All identified individual components of PNC were listed and were categorised to develop a draft list of 25 signal functions with identification of the equipment, medication and consumables required to deliver each. A series of consensus-building workshops were held (3 international and 4 national) with a range of stakeholders (184 in total) including researchers, clinicians, health service managers from low- and middle-income countries (Afghanistan, Chad, Ghana, Togo, Nigeria) as well as high income settings (Europe, USA, UK) and key representatives from UN partners (UNFPA, WHO, UNICEF, and the Global Fund). Workshops were organised to allow for examination of each recommendation for content of PNC in small working groups followed by plenary discussion, consensus agreement leading to adoption or not of proposed content, signal function, equipment, medication and consumables required for each. Consensus-building workshops were conducted alongside and during the ongoing systematic review with evidence obtained from review of documents (policy, guidelines) and peer reviewed papers presented at time of the workshops. Adaptation or not of any component as discussed during any workshop was based on evidence where available with practices for which there was evidence of non-effectiveness or harmful practices agreed as needing to be discarded. After synthesis of all workshop feedback and the literature review a comprehensive list of 15 proposed signal functions were developed.

Description of studies

Database searches revealed 1213 potentially applicable publications. Duplicates were removed and abstracts reviewed. Exclusion and inclusion criteria was applied and 92 papers were included for full text review. After review 44 papers were excluded and 48 studies included in this review (Fig.  1 – Prisma Diagram). The main exclusion reasons were the policy or study papers were not reporting on content of PNC or were case studies.

figure 1

Study selection- PRISMA Flow Diagram (Moher et al., 2009)

Of the 48 included papers 14 reported on multiple components of PNC. This included a systematic review [ 29 ], 6 sets of guidelines or policy papers [ 1 , 2 , 4 , 30 , 31 , 32 ] and 7 studies or non-systematic reviews [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. (Supplementary Table 2 – Summary of Included studies reporting on multiple components of PNC).

All other papers included (34 papers) reported on only one single component of PNC and were subsequently grouped by 6 themes identified following review including (in order of number of papers included) mental health- postnatal depression (10) [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ] breastfeeding [ 8 ], preventing mother to child transmission of HIV (PMTCT) (4) [ 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ], family planning (3) [ 58 , 59 , 60 , 61 ], care of the pre-term newborn (2) [ 62 , 63 , 64 ] and Kangaroo Mother Care (KMC) (2) [ 67 , 68 ], maternal anaemia (2) [ 69 , 70 ] and Miscellaneous (3) [ 71 , 72 , 73 ] including screening for congenital hip dysplasia, and newborn hip screening and pelvic floor exercises. (Summary Tables available on request).

Quality assessment was performed on the 14 papers (Supplementary table 2 ), nine were graded as good quality and five assessed to be fair quality. The studies rated fair reported detailed study design methods but not the sampling methods and implications of the study, which compromised their quality. However, all included studies had areas of good quality making them suitable for data extraction.

Synthesis for papers reporting on single components of PNC

Mental health.

The largest number of included papers pertained to screening and management of maternal mental health and focused on Postnatal Depression (PND). Several papers report on the effectiveness and/or feasibility of introducing screening for PND. The introduction of screening in India (using the Edinburgh Postnatal Depression Screening- EPDS tool) immediately postpartum and at 6–8 weeks was found to be beneficial in identifying women at risk [ 40 ] as did a study in Ethiopia using the WHO self-reporting questionnaire [ 41 ]. Similarly, a study in Nepal reported highlighted the need for routine screening for PPD and reported that pregnancy complications and health problems in the baby were risk factors for PND [ 42 ].

A systematic review on the effectiveness of psychosocial assessment for the detection and management of PND concluded that assessment helps detect risk factors but those who screen positive and received prevention care for PND did not do better than those who screened positive and received no additional care [ 43 ].

A self-care programme consisting of two sessions covering physical and psychosocial wellbeing based on the teach-back method resulted in improved in quality of life during the postnatal period including with regard to improved positive feelings of the mother towards herself and towards her child as well as improved physical health [ 44 ]. Women in Australia who had received a short motivational interviewing intervention (including discussion of risk factors for PND, anxiety, low self-esteem) in the postnatal period were four times more likely to seek help for PND in the 12 months after birth [ 45 ].

In Iran, weekly support sessions provided by telephone over a period of eight weeks did not result in fewer women screening positive for PND using the EPDS [ 46 ] whereas in an RCT lifestyle-based education reduced anxiety and EPDS scores at six weeks postnatally [ 47 ]. Educational counselling in additional to routine care (debriefing) for women with adverse birth events did not result in better scores for quality of life, anxiety or depression at six weeks to six months postnatally [ 48 ]. Therapist-supported iCBT significantly improves stress, anxiety, and depressive symptoms among postpartum women with small to large effects [ 49 ].

Breastfeeding

Eight included papers reported on a range of approaches to support breastfeeding. An RCT in the UK examined the effect of skin-to-skin contact care versus none. Although initiation and duration of breastfeeding at four months was not improved, concerns regarding a drop in temp with skin-to-skin care were negated with good maintenance of temperature for the neonate. Both groups got breastfeeding education and support [ 50 ]. In a controlled intervention study in Turkey one-to one demonstration using models on how to breastfeed was more effective in preventing cracked nipples than providing an information brochure only [ 51 ]. Similarly, in Sweden midwives offered training and support to women at three days, three and nine months postpartum which was reported to result in women enjoying breastfeeding as well as a strengthened maternal relationship with the baby [ 52 ]. A one-hour workshop and one-hour counselling session in the first 24 h after birth was reported as effective and beneficial when breast feeding was assessed at four and eight weeks postpartum [ 53 ]. In the Gambia women who reported having received counselling, a supportive partner, from a more educated and wealthier background were more likely to intend to practice exclusive breastfeeding [ 54 ].

In contrast in another study in the UK support and education counselling after teaching the mother to position the baby herself there was no difference regarding whether the midwife provided further support or was ‘hands-off’ when breastfeeding was assessed at 17 weeks [ 55 ]. Evaluation of the effect of peer-to-peer counselling per telephone on breastfeeding duration showed no difference [ 56 ]. In an exploratory qualitative study, supporting mother-infant bonding increased the duration of breastfeeding in mothers with babies admitted to a neonatal intensive care unit in Malawi [ 57 ].

Diagnosis and management of HIV

A study from South Africa [ 58 ] highlighted missed opportunities for PMTCT with failure to attend for HIV treatment and FP, lack of TB screening, and women not receiving consistent messages and highlighted the need to address this. In Malawi the need for continued follow -up and care was highlighted through a cohort study with adherence to HIV treatment adequate for 73% or women during pregnancy, 66% in the first 3 months postnatally and 75% during months 4–21 postnatal [ 59 ]. The importance of early diagnosis and management of HIV infection in the neonate was demonstrated in Malawi and Thailand [ 60 , 61 ].

Family Planning (FP)

Offering FP as part of immediate PNC was associated with high rates of uptake in a study by Duncan et al. among HIV positive women [ 62 ]. In a large study from India women who had received a postpartum Intra uterine contraceptive device (IUCD) reported a high level of satisfaction and low level of expulsion (4% at 6 weeks) [ 63 ]. In an RCT in the USA contraceptive education by phone, insurance coverage and appointment scheduling did not influence the uptake or not of LARC [ 64 ].

Preterm and/or LBW babies

A Cochrane review by Mc Call et al. looking at thermo-regulation for preterm or low birth weight (LBW) babies reports that using plastic wraps or bags and/or thermo mattresses leads to higher temperature on admission to neonatal units (25 studies included) but that skin-to- skin care remains effective when compared to traditional incubator care [ 65 ].  Sun et al. recommend the use of a screening algorithm for the prediction of retinopathy of prematurity [ 66 ].

Prevention of hypothermia

An RCT demonstrated that helping mothers via one-on-one teaching and demonstration of skin-to-skin contact and Kangaroo Mother Care (KMC) improved mother to infant attachment and reduced maternal anxiety [ 67 ]. Nahidi et al. developed a mother to infant skin to skin contact questionnaire to improve implementation and factors associated [ 68 ].

Maternal anaemia

The importance of having guidelines for the management of anaemia was reported in a paper from New Zealand with a wide range of approaches noted among midwives especially regarding assessment of iron status [ 69 ]. Although two thirds (64.4%) of postnatal women had anaemia in a study from Uganda, the healthcare system had missed the opportunities to effectively address it, such as through the implementation of the policy recommendation for iron and folic acid supplementation [ 70 ].

Miscellaneous

A systematic review recommends the use of pulse-oximetry screening (POS) to check blood flow in the feet and hands during examination of the newborn baby in the immediate postpartum period for early detection of congenital cardiac heart disease. The reduction in neonatal morbidity and mortality is likely to be more pronounced in low-resource settings where most of these babies are born without a prenatal diagnosis. [ 71 ]. A systematic review to examine early dynamic ultrasound (eDUS) screening for hip instability in the first 6 weeks after birth suggests that this could be more effective than clinical examination alone [ 72 ]. A systematic review on the effect of pelvic floor muscle exercise reported that this improved sexual desire, arousal, orgasm, and satisfaction in the postpartum period [ 73 ].

Synthesis for papers reporting on multiple components of PNC [ 14 ]

Lassi et al. included 148 Cochrane and other systematic reviews which identified 61 RMNCH interventions which included eight for routine PNC including: prevention and management of anaemia in the mother, hygienic cord care, prevention of hypothermia with KMC for Low-Birth-Weight babies, newborn immunisation, breastfeeding, family planning, bed nets (ITN) for prevention of malaria, PMTCT for women who are HIV positive. Prevention and management of eclampsia was mentioned as part of ANC only. Home care was mentioned as an approach to delivery of PNC [ 29 ].

In a cross-sectional survey among 320 HIV positive postnatal women in Zambia, uptake of infant testing for HIV in the first six weeks was positively associated with maternal uptake of ARVs and, HIV status disclosure to the male partner. Women who reported intimate partner violence (IPV, 40% of the women included in the study) were less likely to have infants tested. Overall, 73% of infants had a test for HIV by 6 weeks. The paper highlights the importance of integration and linking of HIV prevention and management in both the mother and baby and the importance of screening for IPV during PNC [ 38 ].

A cluster RCT conducted in Ghana to assess effect of postnatal home visits vs routine PNC available at a healthcare facility and assessed breastfeeding (initiation and exclusive BF), thermoregulation (skin to skin contact, first bath delayed), sleeping under ITN, weighing of the baby and awareness of danger signs to identify the sick baby. Home visits were associated with improved coverage with increased care seeking at the facility in case the baby showed signs of illness (77% in intervention vs 55% in control) [ 33 ] .

A WHO Technical Working Group reviewed the evidence and reached consensus regarding indicators to assess coverage of key newborn interventions—on two additional indicators for care of the newborn in the immediate postpartum period including regarding; i) thermoregulation recommending drying, delayed bathing, skin-to-skin contact and checking temperature, and ii) cord care—keeping the cord dry versus application of 4% chlorhexidine -with the consensus being the latter needed further research. Additionally, weighing of the baby, breastfeeding and counselling on danger signs in the newborn were agreed as being essential components of PNC [ 34 ].

Several studies assessed the availability of quality of PNC. For a comprehensive healthcare facility assessment in Ghana components of (mainly immediate) PNC focused on the newborn and assessed- drying the baby after birth, delaying bathing the baby, prophylactic eye ointment for the baby, initiation of breast feeding, skin to skin contact and KMC for preterm and/or LBW babies [ 35 ]. In a before-after study to improve the uptake of intra-partum and postnatal care in Uganda components assessed for PNC included thermo-regulation for the newborn (immediate drying, external warming, skin to skin contact) promotion and provision of hygienic cord care early initiation of breastfeeding and KMC [ 39 ].

Two studies looked specifically at care provided in the community or home setting. A study in Iran reported on the effectiveness of community-based PNC which included uptake of PNC in the first week, weight gain during the first 3–7 days, hospitalization rate and management of the sick neonate mainly highlighting the importance of awareness of the danger signs and recognition of the sick baby [ 37 ]. Interviews exploring routine practices of home delivery and immediate PNC with women in Ethiopia assessed PNC components including tying the cord immediately after birth, dry cord care, bathing and cleaning the baby birth, and giving the baby water and sugar before initiation of breastfeeding (as non-recommended practice) [ 36 ].

Interventions identified to be essential in the postnatal period for the mother were described in 2011 by the Partnership for Maternal, Newborn and Child Health (PMNCH) and included family planning, prevention and treatment of maternal anaemia, detection and management of postpartum sepsis, PMTCT, immediate thermal care of the baby, initiation of exclusive breastfeeding, hygienic cord and skin care, KMC for preterm and LBW newborns and management of newborns with jaundice. These guidelines also highlighted the level and organisation of care required to provide PNC to women and their newborns [ 1 ].

In preparation for the Every Newborn Action Plan (ENAP) 70 indicators were assessed resulting in 10 core and 10 additional indicators being adopted; core indicators were considered those that impact the maternal and/or neonatal morality rate and/or stillbirth rate and include intrapartum skilled birth attendance, early PNC and essential Newborn Care. For PNC treatment of neonatal infections, chlorhexidine for cord care for babies at risk of complications and KMC were identified as essential [ 31 ].

The latest WHO Guidelines specifically for PNC [ 2 , 12 ] address the timing frequency place and content for PNC during the 6 weeks after to birth for mothers and babies and were developed on all available evidence focused on LMICs. Recommended content includes newborn examination, exclusive BF, cord care, delay in bathing, mother and baby staying together, immunisations, examination of the mother (general wellbeing micturition – urinary incontinence, bowel function, perineal care, headache, fatigue, back pain, uterine tenderness and lochia), iron and folic acid supplementation to prevent or manage anaemia in the mother.

Global guidelines for pregnancy, childbirth, postpartum and newborn care include recommendations regarding screening and management of pre-eclampsia and eclampsia; prevention of mother-to-child transmission of HIV; HIV and infant feeding; post-partum depression, and post-partum family planning [ 12 ]. The guidelines provide evidence-based recommendations including for the management of endemic diseases like malaria, HIV/AIDS, TB and anaemia. The PNC guidelines recommend administration of Vit K to the newborn and thermal regulation.

The main objective of Salam et al.’s paper was to review the evidence-base for interventions that have a proven positive impact on newborn and maternal health outcomes. In this non-systematic review, for PNC interventions that impacted positively on maternal and neonatal morbidity and mortality included education and provision of family planning, early initiation of and support for exclusive breastfeeding; thermal care or KMC for preterm and/or LBW babies, and hygienic skin and umbilical cord care after birth [ 30 ].

In the UK, NICE guidelines [ 32 ] outline the care that should be given to women and their babies up to eight weeks after birth. Individual components of clinical care include (but are not limited to) monitoring of blood pressure in the mother, cord care in the baby, administration of Vit K, breastfeeding support. These guidelines also highlight the need to listen to women, be responsive to their needs, taking into consideration the individual needs and preferences of each woman and debriefing after birth.

Essential Components of PNC and development of signal functions.

From the included papers a total of 22 components of PNC identified as essential were extracted. Results are presented in Table 1 – Components of PNC identified and number of papers supporting each component.

Peer review and consensus building workshops validated, detailed, and grouped the components which were then developed as developed as proposed signal functions of PNC (Table 2 - Proposed signal functions for PNC with components and outline of required equipment, medication and consumables). Screening for and management of tuberculosis although not identified by the systematic review of the literature was considered a vital and essential component of PNC across all consensus-building workshops along with screening for and management of HIV.

Throughout the workshops it was highlighted that drug regimens for treatment and prevention of malaria, tuberculosis and HIV should be setting specific and dependent on country practice and policy. Hepatitis B vaccination of the newborn baby is now almost universally recommended but may depend on a country’s national policy and incidence or disease and/or identification of at-risk population. Workshop participants agreed that the proposed PNC signal functions could be used as an important monitoring and evaluation tool including for healthcare facility assessments e.g., to identify the number of healthcare facilities across all levels of care that can provide each of these components and also identify barriers to implementation e.g. lack of human resources, drugs, consumables and equipment The signal functions can also be used as an assessment of service delivery e.g., identification of the proportion of women who received each component during an PNC visit or contact.

Main findings

As a result of a systematic review of the literature 22 essential components of postnatal care (PNC) were identified of which 12 relate directly to the mother and 10 to the baby. These were synthesised and, following consensus-building with a wide range of stakeholders, were developed into 14 proposed signal functions with the identification of the required equipment, drugs vaccines and consumables to implement each component. As for other care packages in the continuum of care for mothers and children, signal functions of PNC can be used to guide monitoring and evaluation of PNC availability and quality.

We note that in the peer-reviewed literature, guidelines and policy documents the focus has frequently been on components related specifically to neonatal rather than maternal health care. This may be in response to the comparatively high burden of global perinatal and neonatal mortality. However, the health of the baby is directly linked to that of the mother. PNC seeks to address the well-being and health needs of both the mother and her baby during one combined visit or consultation. The proposed signal functions highlight this and do not make a distinction between those that are for the baby and those that are more specifically for the mother. The identified essential components and signal functions include prevention recognition and management of general wellbeing, obstetric complications, medical and infectious diseases that are prevalent as well as social and mental health. Postnatal care is also an important platform to promote exclusive breastfeeding and family planning. It is expected that these essential components of PNC are provided as ‘routine’ for women and babies in the postnatal period to support an optimum recovery for the mother, growth and development of the newborn baby and promote health seeking behaviour for the family. Adaptations can be made where needed depending on the burden of disease in any particular setting and emphasis of focus e.g., for the signal functions pertaining to malaria, TB and HIV. Guidelines for practice will depend on the estimated overall incidence in the population served.

Strengths and limitations

Postnatal Care is provided as two separate care packages 1) immediate postnatal care at the time of birth and 2) subsequent postnatal care. Postnatal care immediately after birth (in the first few hours) could more logically be considered part of the skilled birth attendance care package or part of intra-partum care and has been described as including prevention of postpartum haemorrhage through active management of the third stage and resuscitation of the newborn if required. Secondly, the care a woman and her baby require at the time of birth and/or immediately after this is very much dependent on the type of birth (vaginal or operative) and whether there are any complications for either the mother or her baby, making it more difficult to define a ‘standard’ or routine care package that would be applicable to all women and babies during the subsequent postnatal period which is commonly defined as the first 42 days after birth.

To the best of our knowledge this is the first systematic review examining specifically what should be considered as the essential content of PNC for the mother and baby to be provided in the first six weeks following birth. The included components are those that are considered part of a comprehensive care package for all women and babies i.e. as part of ‘routine’ PNC. For women and babies with specific complications or underlying morbidity additional PNC components will be required.

Context in relation to other studies

There is still relatively scant epidemiological information on the specific pregnancy-related burden of disease in the postnatal period. However, this is recognised as a period of risk as well as opportunity for screening, prevention, and management of health problems and to support the wellbeing of the mother and baby. There is emerging evidence that in low-and middle- income settings the burden of morbidity is significant [ 16 , 17 ]. In high-income settings where the burden of disease is smaller, the emphasis of PNC provision has more recently been on ensuring general well-being of the woman and her baby. This includes and emphasis on social and mental health and debriefing after either complicated or uncomplicated birth, rather than on prevention and management of pregnancy complications or infectious diseases.

For the purpose of developing globally relevant signal functions and, based on the results of our systematic review of the literature, the signal functions proposed in this study seek to be comprehensive and recognise the need to address three major infectious diseases (HIV, tuberculosis and malaria) as well as obstetric conditions, medical conditions, mental and social health. For those populations with a low prevalence of HIV, tuberculosis and/or malaria country adaptations can be made. It would be helpful to have agreed international cut-off points of prevalence above which screening for, and management of certain infectious diseases should be included as essential components of PNC. A useful comparison is the recommendations regarding whether or not to screen for tuberculosis as part of antenatal care which is guided by estimated country level prevalence of tuberculosis [ 8 ]. Screening for HIV is almost universally recommended as part of ANC and may not have to be repeated as part of PNC in countries with a low prevalence.

Examination of the baby to check for any congenital abnormalities and/or illness is an important part of PNC. In many settings an anomaly ultrasound scan is routinely offered as part of ANC. Whether or not this is provided, it remains important to ensure a full body examination of the baby as part of PNC. In high income settings additionally laboratory testing is carried out (e.g. a Guthrie or ‘heel prick’ test to check for phenylketonuria) and a routine hearing test is carried out on all newborn babies to identify deafness.

Discussion regarding the need for and/or effectiveness of de-briefing after traumatic birth as well as general de-briefing and information sharing after uncomplicated birth have informed the development of the relevant proposed signal function and was recognised by stakeholders during consultation to be a new and emerging component of PNC which requires further attention [ 74 , 75 ].

We conducted an earlier and separate systematic review and consensus-building to identify the essential components of ANC with the development of 15 proposed signal functions [ 26 ]. We note that there is an overlap in content and therefore the signal functions developed for both ANC and PNC and we recommend these are combined for the purposes of monitoring and evaluation as well as training of healthcare providers. In most setting ANC and PNC are provided in similar settings and by the same cadres of healthcare providers including for the main part community- and/or facility-based nurse-midwives.

Implications for policy and practice

It is recognised that PNC is being delivered by a wide range of healthcare providers, including those at facility- and community-level. For a full content of effective PNC to be delivered these healthcare providers need to have the necessary equipment, dugs, consumables as well as up-to-date knowledge and skills in all aspects of PNC. As it can be expected that many women are home-bound especially in the early postnatal period, there is a need to provide care at home or very close to home and models for this may require further development [ 76 ]. Recently there have been suggestions that community-based healthcare workers and/or volunteers may be better placed to provide PNC. However, an initial mapping shows that few of such cadres are adequately trained for, competent in, legislated and supported to provide all of the essential components of either ANC or PNC [ 77 ]. Other forms of community support are effective such as mother to mother support for continuation of exclusive breastfeeding, practical and emotional support from partners, family and the wider community to enhance wellbeing and promote a positive experience of the postnatal period [ 78 , 79 ].

The importance of screening for social (including gender-based violence) as well as mental health problems (including depression) during the antenatal as well as postnatal period is recognised globally [ 17 , 80 ]. A variety of screening tools is available currently to assess wellbeing and mental health and it will be important to establish which is most effective and feasible to use in each specific setting. In some cases, translation into a local language and/or socio-cultural adaptation of tools is still needed. However, our systematic review highlighted several studies from countries where such screening has now been successfully introduced. Screening for GBV and/or intimate partner violence (IPV) is problematic in many settings and not accepted practice either for the healthcare provider or the woman attending for care [ 81 , 82 ]. WHO guidelines for ANC recommend screening for GBV/IPV in settings where women can receive care and a referral pathway is established [ 8 ]. However, although recommended practice, we note that the current WHO guidelines for PNC make no specific recommendation regarding GBV [ 12 ].

Future research and unanswered questions

PNC coverage is defined as the number of women aged 15–49 years with a live birth who have postnatal contact with a health-care provider within two days of birth as a proportion of the total number of women aged 15–49 with a live birth. This information is collected from Demographic Health Surveys (DHS), Reproductive Health Surveys (RHS), Multiple Indicator Cluster Surveys (MICS), or other types of household surveys that collect data using nationally representative population samples and standardised questionnaires. Population-based household surveys are the preferred data source in settings that have a low utilization of healthcare facility services. However, such surveys are generally expensive and may be difficult to conduct.

The availability and uptake of essential health services coverage (SDG indicator 3.8.1) is an important measurement [ 83 ]. Thus, the Universal Health Coverage (UHC) index includes 16 essential health services as indicators of the equity and level of UHC. For reproductive, maternal, neonatal and child health (RMNCH) these are: family planning, antenatal care, delivery care, full child immunisation, and care for pneumonia in children [ 83 ]. We note that unlike ANC coverage, PNC coverage is not reported as an indicator in the annual World Health Statistics reports.

The available indicators for PNC are obtained for populations through a variety of different data sources, the most important of which are household surveys. Regarding PNC coverage, in both the MICS and DHS what is measured is; 1) the proportion of women who recall having received PNC within 2 days of giving birth and 2) who (which type of healthcare provider) provided PNC. Since 2013, in DHS (phase 7) what is asked is: did the woman receive PNC in the 2 days after birth, who provided this and where. For content what is included is: if the healthcare provider examined the cord, measured the baby’s temp, counselled on danger signs and observed breastfeeding [ 84 ] .

Given the importance of PNC as a key healthcare package for the prevention and management of morbidity and mortality in women of reproductive age and in the newborn, it will be important to reach global consensus on more effective routine monitoring of PNC coverage and content. The signal functions developed could be used: 1) for health facility assessment; 2) to identify health system barriers to implementation; 3) as a component of the service delivery assessment and, 4) for assessment of quality of care. Further research regarding the acceptability and feasibility of the application of the signal functions proposed in this study for the effective monitoring and evaluation of availability and quality of PNC is needed.

Globally the proportion of mothers and babies who receive PNC is significantly lower than those who receive ANC and this constitutes a missed opportunity. Reasons for this could be that PNC is not accessible, not available and/or not of good quality. The focus has to date been mainly on the number and timing of PNC visits rather than what is provided to the mother and baby during these visits or contacts. More attention should be given to content if PNC is to have the required impact on maternal and neonatal morbidity and mortality. We propose a set of signal functions that could be used to monitor and evaluate content of PNC. There is ample evidence for the urgent need to address aspects of care that are disrespectful and of poor quality and that are likely to contribute significantly to the current low uptake of postnatal care globally. Similarly, without the required essential content for the mother and her baby quality of care cannot be provided.

Availability of data and materials

Abbreviations.

Antenatal Care

Gender-based violence

Intimate Partner Violence

Postnatal Care

Postnatal Depression

Universal Health Coverage

Randomised controlled trial

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We would like to thank all the participants of the workshops for their considered inputs. In addition thanks to Dr A Miller and Dr A Traore for support with screening of papers.

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HMcC, KL and NvdB conducted the systematic review. HMcC, VM, NF and NvdB facilitated consensus building workshops. All authors (VM, NF, HMcC, Kl, NvdB) contributed to the analysis of the data and writing of the paper. The author(s) read and approved the final manuscript.

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Additional file 1:.

Table S1. Search Strategy.

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Supplementary Table 2.  Summary of included studies reporting on multiple components of Postnatal Care (PNC).

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McCauley, H., Lowe, K., Furtado, N. et al. Essential components of postnatal care – a systematic literature review and development of signal functions to guide monitoring and evaluation. BMC Pregnancy Childbirth 22 , 448 (2022). https://doi.org/10.1186/s12884-022-04752-6

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  14. EDG 501 Literature Review: Components of a Literature Review

    Components of a Literature Review The works that make up the literature review fall into three categories: General theoretical literature This literature establishes the importance of your topic/research. define abstract concepts, discuss the relationships between abstract concepts, and include statistics about the problem being investigated.

  15. Approaching literature review for academic purposes: The Literature

    A sophisticated literature review (LR) can result in a robust dissertation/thesis by scrutinizing the main problem examined by the academic study; anticipating research hypotheses, methods and results; and maintaining the interest of the audience in how the dissertation/thesis will provide solutions for the current gaps in a particular field.

  16. Literature review as a research methodology: An ...

    In addition, a literature review is an excellent way of synthesizing research findings to show evidence on a meta-level and to uncover areas in which more research is needed, which is a critical component of creating theoretical frameworks and building conceptual models.

  17. Critical Analysis: The Often-Missing Step in Conducting Literature

    Literature reviews are essential in moving our evidence-base forward. "A literature review makes a significant contribution when the authors add to the body of knowledge through providing new insights" (Bearman, 2016, p. 383).Although there are many methods for conducting a literature review (e.g., systematic review, scoping review, qualitative synthesis), some commonalities in ...

  18. What is the Purpose of a Literature Review?

    Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let's look at the overall purpose of a literature review. Find this useful? Subscribe to our newsletter and get writing tips from our editors straight to your inbox.

  19. How to write a literature review introduction (+ examples)

    In academic writing, the introduction for a literature review is an indispensable component. Effective academic writing requires proper paragraph structuring to guide your reader through your argumentation. This includes providing an introduction to your literature review.

  20. Literature Reviews, Theoretical Frameworks, and Conceptual Frameworks

    Clarifying these different components of educational research studies can be helpful to new biology education researchers and the biology education research community at large in situating their work in the broader scholarly literature. ... Each offers a different perspective on the problem of study and is an essential element in all forms of ...

  21. Essential components of postnatal care

    We sought to identify the essential components of PNC and develop signal functions to reflect these which can be used for the monitoring and evaluation of availability and quality of PNC. Methods: Systematic review of the literature using MESH headings for databases (Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science). Papers ...

  22. Calcific bursitis of the Gruberi bursa: a case report

    Background Bursitis is the inflammation of a synovial bursa, a small synovial fluid-filled sac that acts as a cushion between muscles, tendons, and bones. Further, calcific bursitis results from calcium deposits on the synovial joint that exacerbates pain and swelling. The Gruberi bursa is located dorsolaterally in the ankle, between the extensor digitorium longus and the talus. Despite ...

  23. Essential components of postnatal care

    Background. Postnatal Care (PNC) is one of the care packages that make up the continuum of care for mothers and babies globally [1, 2].A significant number of maternal deaths still occur during the postnatal period and an estimated 2.8 million babies die in the first month of life (neonatal death) [3, 4].Neonatal deaths account for up to 52% of all deaths in children under-5 years of age [].

  24. Essential components of postnatal care

    Essential components of postnatal care - a systematic literature review and development of signal functions to guide monitoring and evaluation Hannah McCauley, Kirsty Lowe, Nicholas Furtado, Viviana Mangiaterra & Nynke van den Broek BMC Pregnancy and Childbirth 22, Article number: 448 ( 2022 ) Cite this article 9223 Accesses 8 Citations