First, two researchersindependently selected the papers and, at a second point in time, held areconciliation meeting. The Kappa coefficient was used to assess agreement,while the Grading of Recommendations, Assessment, Development and Evaluationwas adopted to assess risk of bias and classify level of evidence. in this review, 42 papers were included, 34 of which addressed producttechnologies, most referred to pharmacological products, while two papersaddressed the use of blood transparent plastic bags collector and thecontribution of birth spacing and prenatal care. The eight papers addressingprocess technologies included the active management of the third stage oflabor, controlled cord traction, uterine massage, and educationalinterventions. product and process technologies presented high and moderate evidenceconfirmed in 61.90% of the papers. The levels of evidence confirm thecontribution of technologies to prevent and control hemorrhaging. Clinicalnurses should provide scientific-based care and develop protocols addressingnursing care actions. PPH is defined as blood loss above 500 ml, measured up to 24 hourspostpartum, while this amount of blood loss after 24 hours is defined as secondary PPH3. Blood loss up to 500ml among healthy women does not lead to negativeconsequences; however, uncontrolled blood loss over 500ml can be fatal1. Primary PPH occurs in the first 24 hours after birth and is more likely toresult in maternal morbidity and mortality, while secondary postpartum hemorrhagerefers to bleeding that occurs from 24 hours up to six weeks after birth3.Postpartum hemorrhage (PPH) is one of the main causes of maternal morbidity andmortality worldwide3. Procedures to prevent PPH are initiated by assessing a patient’s riskprofile and establishing how to respond to complications in order to prevent a smallamount of bleeding from becoming a severe hemorrhage with the risk of death. PPH isone of the complications of the third stage of labor and this stage begins after thefetus is expelled; however, with the detaching of the placenta from the uterine walland its expulsion through the birth canal, greater than expected bleeding may occur.Therefore, it is essential to know the physiology of childbirth and women’s clinicalconditions, as well as intercurrences that took place during the pregnancy-puerperalperiod, which might contribute to the emergence of hemorrhaging4.In general, blood loss is diagnosed as PPH if one or more of the following occur:loss of uterine tone (atony); retention of placental tissue or blood clots;laceration of the genital tract; or coagulopathy5.In order to prevent PPH, the staff needs to be prepared to use protocols with amultidisciplinary approach, which involves maintaining hemodynamic stability while,simultaneously, identifying and treating the cause of bleeding. A combination ofprediction and prevention, early identification and rapid coordinated actions isessential to preventing PPH. Consequently, efficient communication among the membersof the multidisciplinary obstetrical team is paramountPrevention and control of PPH demand technologies that support labor andinterventions in the event unwanted bleeding occurs. Therefore, health workersshould be aware of and implement technologies supported by a higher level ofevidence and with positive outcomes, which represent the least harm to women andbabies. Additionally, for safe and timely care to be provided, services need to havea well-established capacity to coordinate people, equipment and work processes.Hence, having techniques and technologies as well as protocols does not ensure, byitself, the prevention and control of hemorrhaging; personnel of sufficient qualityand number to meet demand is necessary.6. All these aspects a service is required to have are known as healthtechnologies – a term that encompasses every intervention used to promote health.“In this sense, health technologies can be conceived as the practical application ofknowledge, including machines, clinical and surgical procedures, medications,programs and systems intended to promote health care”7.Technologies, evidence-based practice, and interventions proposed by workers havegrown exponentially in importance from the mid-twentieth century, so much so thatproviding quality services without such resources is inconceivable currently, withmany of them being innovative in nature8.Similarly, the literature presents the elements that integrate health technologies,namely any and all methods/devices used to promote health, prevent death, and treatdiseases and improve rehabilitation or the care of individuals or populations10.Traditional product technologies  require intermediatesteps with relatively differentiated processes and actors, although these areincreasingly connected. Note that product technologies such as diagnostic ortherapeutic resources used in healthcare delivery are more effective when combinedwith process technologies. Process technologies, in turn, include operationalprocedures, care, education and management techniques. Thus, one should seek ascientific basis to strengthen healthcare delivery and produce evidence to innovatein regard to product and process technologies11.There are various systematic reviews addressing PPH showing it still accounts forhigh levels of morbidity and mortality, mainly in developing countries. For thisreason, studies need to be conducted regularly, considering that all technologiesshould be revised and updated over time, especially when we consider the applicationof technologies in different contexts and populations11.In order to overcome the causes of PPH and its determinants of a sociocultural,technical and technological nature in different geo-economic contexts, the resultsof systematic reviews should be disseminated among health services in order tocontribute to the development of multidisciplinary protocols. In this context,nurses, especially those in the obstetrical field, can propose care processes, amongothers, such as those associated with patient safety, especially when applyingpharmacological products1, the need to prepare the staff to intervene appropriately, and lack ofinformation regarding existing technologies in the field, the objective of thisstudy was to identify evidence concerning the contribution of health technologiesused to prevent and control hemorrhaging in the third stage of labor.Given the importance of hemorrhaging, which may be associated with diverse eventssuch as uterine atony, uterine rupture, blood dyscrasia, cephalopelvic disproportionand placental abruption12 to present the results. The entire review process was guided by the question:What is the evidence available concerning the contributions of health technologyused to prevent and control hemorrhaging in the third stage of labor?” The PIO support protocol13 was used, in which P  was represented by women withblood loss in the third stage of labor; I (intervention/procedure) was representedby technologies used to prevent PPH; and O (outcome) was the occurrence of PPH,level of blood loss, or success in managing the decrease of harm to women.This Systematic Review adopted the PRISMA  checklistth to December 30th 2016. The searchstrategy included the following descriptors postpartumhemorrhage; hemorrhage;postpartumperiod; labor stage, third, which were adapted for MeSHTerms All Fields -hemorrhage; hemorrhages; hemorrhagic; bleeding; postpartum; puerperal; Third Stage.DeCS terms – postpartumhemorrhage [postpartumhemorrhage]; HemorragiaPós-Parto [Postpartum Hemorrhage]; HemorragiaPuerperal [Puerperal Hemorrhage]; Hemorragia Posparto[Postpartum Hemorrhage]; hemorragia [hemorrhage];sangramento [bleeding]; Período Pós-Parto [Post-partumPeriod]; pos-parto [post-partum]; pós-parto[post-partum]; Terceira Fase do Trabalho de Parto [Third Stageof Labor]. The following key words were used: Terceiro período[Third period]; Terceiro estágio [Third stage]; Terceiraetapa [Third stage]. The Boolean expressions “AND”, “NOT” and “OR” wereused to locate the instances the aforementioned descriptors occurredsimultaneously.Data were collected from July 10 to 12, 2016 from the following databases: LatinAmerican and Caribbean Health Sciences (LILACS), Database of Nursing (BDENF),Scientific Electronic Library Online – Brazil (SciELO - Brazil), National Library ofMedicine (PubMed)/Medical Literature Analysis and Retrieval System on Line (MEDLINE)and Scopus. The period between June 2006 and July 2016 was chosen because we deemedit would contain the most current technologies. Studies, the title or abstract ofwhich addressed the topic and were available in Portuguese, Spanish or English, wereidentified from July 13Two independent researchers selected the papers, examining each paper’s title,abstract and full text according to the following inclusion criteria: studiesaddressing technologies to prevent hemorrhaging in the third stage of labor; homedelivery or hospital delivery; delivery assisted by any birth assistance ortraditional birth assistance; randomized clinical trial (RCT) or quasi-randomized,observational studies, or analytic descriptive studies. Exclusion criteria were:theses, dissertations, editorials, integrative or systematic reviews, descriptiveobservational studies, and qualitative studies.18, with a confidence interval of 95%, was applied to assess inter-rateragreement. This coefficient has the following measure levels: less than zero,“insignificant”; between 0 and 0.2, “weak”; between 0.21 and 0.40, “reasonable”;between 0.41 and 0.60, “moderate”; between 0.61 and 0.80, “strong”; and between 0.81and 1.0, “almost perfect”.After selecting the papers, the researchers held a meeting to reconcile agreementsand disagreements by carefully consulting the full texts. Of the 48 papers selected,the researchers disagreed in regard to 10. After discussion, they decided to includefour of these papers, with 42 papers being included in the final review. The Kappa coefficient20, a system sensitive to rating the quality of evidence. In this system,quality of evidence is classified as: high, moderate, low, or very low very low . Evidenc20.In this study, the classification used (the GRADE system) to assess the quality ofevidence took into account the risk of bias in randomized clinical trials addressingproduct technologies, in terms of methodological limitations concerning the designor implementation of individual studies. Evidence of randomized clinical trials maybe downgraded if allocation is not confidential; absence of blinding; incompletefollow-up; a report of selective outcomes, and other limitations, such as: earlyinterruption of the study due to some benefit or insufficient information to assesswhether there is important risk of bias. Risk of bias was assessed for each of thesedomains and classified as high-risk, uncertain, or low risk of biasIn the third stage of the process, after reading the full texts and excluding thosethat failed to meet the inclusion criteria, according to two independentresearchers, we proceeded to the systematization of studies.In order to compile and synthetize the results of the different studies included inthe review, we organized tables and grouped the technologies into two categories:product technologies and process technologies. Tables are presented in theresults.After applying the search strategies, 6,999 papers were found. Of these, 6,726 wereexcluded due to the following: the titles and/or abstracts of 5,978 papers did notmeet the inclusion criteria; 652 papers were published in more than one database;and 96 were not characterized as papers 18, which was equal to 0.86 in the first stage and equal to 1.00 in the second,revealed a high level of inter-rater agreement.The full texts of 273 papers were read and 42 were included . The KapRegarding the methods used by the papers under study, 39 are RCTs; one is aquasi-experimental study; one is a retrospective cohort; and one is an observationalstudy. The risk of bias was assessed in the 39 randomized clinical trials addressingtechnologies to prevent and control hemorrhaging in the third stage of labor usingthe GRADE system . The fin9. Among the 34 papers classified as product technologies  versus misoprostol; and one compared ZB11  to misoprostol. Product technologies toprevent PPH encompassed studies that presented interventions using uterotonic drugsand transparent plastic collector bag.Thirty, out of the 34 papers classified as product technologies addressedtechnologies directed to the prevention of PPH, including eight papers that accessedthe isolated use of misoprostol; four addressed the use of oxytocin throughdifferent routes and dosages; 12 studies compared misoprostol to oxytocin; twostudies compared carbetocin to syntometrine; one analyzed ergometrineEight papers were classified as process technologies , which iThe evidence supports decision-making concerning clinical practice and gives rise tonew ways to approach a problem over time. Changes in care practice, however, areslow considering that the production of knowledge and its incorporation requirequalified personnel, as the application of evidence in care practice is aresponsibility of not only one profession but of the entire care system; thus, it isa responsibility of all the professionals in institutions and of society itself.Therefore, one has to consider the sociocultural and educational context, as well assafety culture and the innovation taking place in health services concerningpractice, intervention and outcomes. Otherwise, evidence may become innocuous ifprofessionals are mobilized by repetition rather than innovation, commitment andresponsibility to life.It is, therefore, based on this assumption that we present evidence reported by the42 studies that make up this systematic review: 33 of these analyzed the efficacy ofuterotonic drugs to prevent/treat PPH, including studies addressing oxytocin,misoprostol, ergometrine, syntometrine, carbetocin, PGF2α and ZB11. Oxytocin andmisoprostol appear as the most studied drugs, with results for them being presentedin a larger number of publications.31, when compared to other drugs, regardless of the dosage and route ofadministration, with the exception of one study32.In regard to the product technologies, most papers addressed the use of uterotonicsduring the third period of labor and recommend them to prevent PPH. The studiesaddressing the efficacy of different dosages of synthetic oxytocin, report a shorterduration of the third stage of labor35 report that oxytocin presented a mean blood loss. Birth spacing influencesthis result; that is, greater blood loss in found among childbirths with intervalsof less than two years36. Other studies30 did not report significant differences in regard to this aspect.In regard to blood loss, six studies38. Other studies24, however, presented a greater occurrence of PPH in the oxytocin group,requiring a greater use of additional uterotonics in this group. The employment ofoxytocin in intervals shorter than two years between births determined a greateroccurrence of PPH36. Additionally, a drop in the concentration of hematocrit in the oxytocingroup was significant in the postpartum32.Significant differences were not reported by the studies addressing oxytocin in thethird stage of labor in regard to the occurrence of PHH and/or severe PPH and dropin the concentration of hematocrit/hemoglobin39. One study40, however, reports greater amounts of blood loss in the oxytocin group.The administration of oxytocin, even by unskilled individuals, was efficacious tocontrol PPH and also to decrease blood loss, as well as the need to refer patientsto referral units41. These studies show that, regardless of the dosage of misoprostol, theduration of the third stage of the labor did not present significant differences,nor did the drop in the concentration of hematocrit/hemoglobin, except in those papers32 that found a decrease in the concentration of these hematologicalcomponents.The use of misoprostol was analyzed in studies with different compositions andadministration routes to prevent PPH43 and shorter and lower41.The occurrence of PPH and/or severe PPH was greater among women who received misoprostol44. The RCTs46 report that misoprostol was more efficacious in preventing PPH among womenwith inadequate birth spacing, that is, less than two years. This drug/dosage/routewas effective when used in the treatment of primary PPH caused by uterine atony59.Studies report that both that the duration of the third period of labor and mean lossof blood were significantly longer and greater47.When considering the route of administration, sublingual misoprostol was moreefficacious, decreasing the duration of the third stage of labor and mean blood lossin comparison to the rectal and oral routes. Conversely, side effects like fever andtremors were more frequent when the sublingual route was used. The group whoreceived the medication through the oral route presented a greater need foradditional uterotonics. In terms of acceptability, rectal misoprostol was betteraccepted by women and was the one with fewer side effects50, with the exception of one study32 that did not report significant differences. Other symptoms like nausea,vomiting and diarrhea were found, but no significant differences were found between groups50.Side effects were common in all women who received misoprostol. Most studiescomparing oxytocin to misoprostol report significant differences in which groupstreated with misoprostol experienced more side effects, especially tremors and fever45 recommend misoprostol be adopted in areas where routine uterotonics are notavailable, as it is the best option to prevent PPH, given its ease of application,stability at ambient temperature and low cost. This is a safe and efficaciousalternative to be used by midwives and auxiliaries in home births. Misoprostol isthe most viable choice in communities40 and is easy to store42. In areas where there are routine uterotonics available, however, thebenefits of misoprostol might not outweigh the discomfort of side effects49.Seven studies43, though women need to be better educated on when to use misoprostol in regardto placental deconditioning.In regard to the viability of using misoprostol in communities, a study thatdistributed it during prenatal care for women to self-administer it at home, nosignificant decrease of PPH was found. Nonetheless, the use of uterotonics increasedas did the return visits of women to the health service. The self-administration ofmisoprostol with little monitoring and supervision was considered safe50 recommending the use of this uterotonic via the oral, sublingual and rectalroutes in different dosages, indicating it is efficacious, economically viable andeasy to administer. Therefore, the use of misoprostol in areas with few resources isa good alternative to oxytocin. Analysis of bias indicated there were nomethodological limitations regarding the design or implementation of the individualpapers presented. The RCTs59 with moderate evidence indicate that oral misoprostol is the onlypharmacological option available in areas with few resources to prevent postpartumhemorrhaging and bleeding. Other studies46 addressed in this review and that address the use of misoprostol also makesimilar recommendations but, in accordance with GRADE , however, was greater in the group receivingergometrine. For this reason, the recommendation to use ergometrine depends on therelevance of risks35.As noted in the previous paragraph, in addition to misoprostol and oxytocin, theefficacy of ergometrine, syntometrine and PGF2α in preventing PPH was also compared.Studies addressing ergometrine46. Significant differences, however, were reported by another study51, in regard to nausea, tremors, vomiting, uterine pain, and sweating.In regard to syntometrine, the studies intending to determine the severity andincidence of this drug’s side effects report no significant differences in terms ofthe duration of the third stage of labor, amount of blood loss, and use ofadditional uterotonics51, carbetocin was more efficacious than syntometrine, though one of the studies51 does not report relevant differences between the efficacies of both. Thestudy with carbetocin identified fewer side effects and, even though an analysis ofcost/efficacy was not performed, the author reports that the cost of carbetocin isten times greater than the cost of syntometrine, while emphasizing that carbetocinwas associated with fewer side effects, so that its use can contribute to reducedcosts and time required for professionals.In the comparison performed between syntometrine and carbetocin in the prevention of PPH42 was more efficacious than misoprostol in decreasing mean blood loss and theduration of the third stage of labor and the drop in hemoglobin levels. Theassociated gastrointestinal side effects, however, were significantly greater andincluded nausea, vomiting, diarrhea and abdominal cramps.PGF2α in one RCT50 conducted in China addressed the ZB11 uterotonic, used in Tibetan traditionalmedicine to prevent PPH. The results show higher rates of PPH in the ZB11 group incomparison to the misoprostol group. No significant differences were found in termsof blood loss. Side effects such as diarrhea, tremors, and fever were lessrecurrent. The authors50 suggest that other studies be undertaken in that geographic area because homebirths performed by the pregnant women themselves, or without the assistance ofqualified workers, is not uncommon. Thus, research addressing efficaciousuterotonics with accessible prices is especially relevant in areas with thesecharacteristics and can contribute to women’s easier access to safe technologies50. This specific RCT was assessed using the GRADE system and was considered tohave a high level of evidence, presenting no methodological limitations.One RCT52. The authors covering this drug report that high dosages of TA can decreaseblood loss and maternal morbidity among women with PPH. Due to moderate qualityevidence, this drug is recommended only in cases in which oxytocin and otheruterotonics are not able to stop hemorrhaging.Another drug that was addressed in order to verify its efficacy and safety inpreventing and treating PPH was tranexamic acid (TA)53.Another product technology that was assessed in European countries was thetransparent plastic collection bag. A multicenter RCT assessed its efficacy inpreventing severe PPH, based on the measurement of blood lost after vaginal birth.The results reveal no significant differences when blood loss was measured using acollector bag or only visually verified. The authors note that more studies areneeded to develop strategies able to decrease severe PPH by improving care management60 and an observational study61 to verify changes in hematological parameters caused by blood loss amongwomen who received AMTSL (Active Management of the Third Stage of Labor) and theexpectant management of the third stage of labor. They concluded that blood loss wasgreater and the level of hemoglobin was lower in the group with expectantmanagement.In regard to process technologies, we initially verified that some authors conducted RCTs60 did not find valid and relevant evidence regarding the efficacy ofphysiological care in the third stage of labor among women at a low risk forPPH.Active management of the third stage of labor is especially indicated for primiparouswomen, but the findings of a systematic review60; however, if active management is the preferred option for AMTSL amonglow-risk women in high-level hospitals in developed countries, the only benefit willbe to decrease drops in hemoglobin caused by childbirth54.Decreased blood loss has a greater impact on the health of women in low-income countries56. Not performing CCT led to an increase in the risk of severe hemorrhaging,especially when compared to the effect of oxytocin, which is the main component ofAMTSL. In regard to this process technology, more clinical studies are needed toverify whether CCT decreases blood loss and prevents PPH among women who receivedprophylactic oxytocin in the third stage of labor56.Another technology used to prevent PPH is the controlled cord traction (CCT) adoptedin vaginal births to superficially decrease blood loss and reduce the duration ofthe third stage of labor. A multicenter RCT investigated the simplified approach ofAMTSL without CCT and its results show that the risk of PPH, rate of manual removalof placenta, mean blood loss, and duration of the third stage of labor were greaterin the group in which CCT was not performed62.Still in regard to the prevention of PPH, the efficacy of skin-to-skin contact andbreastfeeding after birth in decreasing PPH rates were also investigated. Risk forPPH decreased by almost four times among women practicing these. The highest effectin this study was among women at a lower risk of PPH. Both practices, whenimplemented immediately after birth, might be efficacious in decreasing PPH rates,regardless of the already existing risk factors for PPH62. Note, however, these that the application of such practices should include arigorous assessment of the clinical conditions of the women, because such a resourceis not viable for those with at-risk pregnancies.According to the authors, these practices promote the release of endogenous oxytocin,and they emphasize that pregnant women should be educated and supported in theimplementation of these practices during the third and fourth stage of labor57 verified whether this technology can decrease blood loss after vaginal birth.The results show that patients who underwent vaginal birth, having received uterinemassage combined with uterotonics, did not experience a decrease in blood loss whencompared to the administration of uterotonics only. The group of women who receiveduterine massage reported pain and/or discomfort when receiving the massage and askedfor it to be stopped57. Routine uterine massage is not a technology indicated for the prevention ofPPH after vaginal childbirth. It is a time-consuming and painful procedure andeliminating this practice from AMTSL benefits the obstetrical team because, inaddition to saving effort, the time used in its application can be directed to other tasks57.In regard to technology intended to prevent and control severe PPH and maternalmorbidity and mortality, one paper addressed here focuses on sustainedtrans-abdominal uterine massage. The multicenter RCT58. The authors emphasize that educational interventions are increasinglynecessary to improve clinical practices in the face of new technologies and changesimplemented in care components.Another technology addressed is an educational intervention. Whether theimplementation of a protocol of early PPH prevention decreased the incidence ofsevere PPH was assessed. The pregnant women involved were randomly assigned to theeducational intervention (where sensitization meetings were held and the protocolwas discussed) or only received the protocol without interventions. The results showthat the mean rate of severe PPH did not differ in the units that received theeducational intervention. Some elements of the PPH prevention protocol, however,were more frequently used in the units that received the intervention, such asasking for the help of specialized personnel and asking for specialized servicewithin 15 minutes of PPH being diagnoseda priori, one assumes these present equivalentscientific rigor and evidence. After applying the GRADE system, however, a lack ofmethodological rigor was identified in 13 studies, which were classified aspresenting low level evidence. Additionally, among the 34 papers classified asproduct technology, most is represented by pharmacological products.Some limitations were identified in this systematic review. A total of 39 RCTs werefound and, Still, the knowledge gathered here regarding the health technologies used to preventand control hemorrhaging in the third stage of labor contributes to the developmentof evidence-based instruments and protocols intended to prevent and control PPH.Moreover, studies conducted by nurses in the context of clinical practice can leadto new technological developments, whether product or process technologies, in orderto meet the needs of women and to reduce avoidable deaths.Cross-referencing with other descriptors should also be considered in futurestudies.Product technologies of a pharmacological nature, especially uterotonics such asmisoprostol and oxytocin, the studies of which compose the body of analysis,presented high and moderate evidence on the prevention and control PPH in the thirdstage of labor, in addition to contributing to decreased blood loss, shorterduration of the third stage of labor, improved concentration ofhematocrit/hemoglobin and a reduced need for additional uterotonics.Among the studies addressing process technologies, the active management of the thirdstage of labor presented high, moderate and low evidence level, while controlledcord traction presented a high level of evidence. When product technology (oxytocin)was associated with process technology (uterine massage), the level of evidence wasmoderate.Therefore, the prevention and control of hemorrhaging in the third stage of laborrequires studies addressing the association of product and process technologies,considering the evidence found so far concerning the contributions of thesetechnologies. Clinical nurses should incorporate scientific evidence, conduct newsystematic reviews and develop nursing protocols to provide women with the bestpossible care practices.


Rural Australian populations experience an increased burden of ischaemic heart disease (IHD) compared to their metropolitan counterparts, similar to other developed countries, globally. Policy and other efforts need to address and acknowledge these differences in order to reduce inequalities in health burden. This paper examines rural health policy makers’ perceptions and use of evidence in efforts to reduce the burden of IHD in rural areas.Policy makers and government advisors (n = 21) who worked with, or advised on, rural health policy at local, state and federal government levels, with specific focus on the state of Victoria (n = 9) were identified from publicly available documents and subsequent snowball sample. Semi-structured qualitative interviews were conducted in regards to the use of evidence in policy to prevent IHD and thematic analysis undertaken applying two theoretical perspectives: context-based evidence-based policy making and the conceptual framework for understanding rural and remote health.The rural context, particularly low resourcing, was seen as limiting potential for evidence based policy at local government (LG) level. Lower levels of political pressure and education were seen as constraints to evidence-based policy in rural communities. Participants described the potential for policy to have a greater impact on reducing heart disease in rural areas though they felt under-resourced and out of touch with the scientific evidence. Scientific studies were less valued than local anecdote to prioritise specific policy. At all levels  low self-efficacy in interpreting evidence and perceived lack of relevance inhibited development of evidence informed policy.The rural context constrains the use of scientific evidence in policy making for the prevention of heart disease in rural areas in Australia with multiple factors influencing the capacity for evidenced based health policy. This is similar to findings at the international scale and is for consideration across other developed countries that experience inequalities in IHD disease burden between rural and urban populations. Cardiovascular diseases (CVD), including ischaemic heart disease (IHD) are the leading causes of death in Australia,2. RuralA large inequality in CVD burden persists between rural and metropolitan Australia, and in 2015, rural Australians were reported to be between 1.15 and 1.3 times more likely to die from CVD than their metropolitan counterparts . Rural pThe persistent inequity in disease burden between rural and metropolitan areas is in part due to current and historical public health policies serving metropolitan populations more effectively than rural Australians ,8–11. InThe use of evidence in policy has been encouraged in light of ‘evidence based practice’ (EBP) which forms the basis and justification of strategies for clinical health interventions in modern medicine. However, this practice is much less common in the practice of health policy and decision making at the population level ,15. In tThe Conceptual Framework of Context-Based Evidence-based Decision Making by Dobrow et al (2004) [The Conceptual Framework for Understanding Rural and Remote Health by Bourke et al (2012)[Conceptual Framework of Context-Based Evidence-Based Decision Making has been used to guide qualitative analysis to better understand evidence use in the development of breast cancer screening[Conceptual Framework for Understanding Rural and Remote Health[There are many external factors  that ultimately influence how and if evidence is used to justify health policy decisions. To undel (2004)  combinedal (2012). The Conscreening and coloscreening in varyite Health provideste Health. Bringinte Health, the terte Health is any ite Health.The aims of the study were to:Describe the perceptions of evidence showing the increased IHD disease burden, among rural health policy makers and advocates in Victoria and compare these to views among their state and federal counterparts, andIdentify the extent to which there is adoption of evidence in Australian health policy in the unique rural context, and facilitators and barriers to adoption and implementation.Consider the influence of the rural context over the use of scientific evidence to drive policy in rural Australia through the lens of two published conceptual frameworks ,21.This research was conducted with assumptions informed by a post-positivist stance (26). Post-positivism argues that the truth can be uncovered and described, but never completely understood (26). Semi-structured qualitative interviews (n = 21) were conducted with policy makers and government advisors, working with or advising on rural health policy at local, state and federal levels, with specific focus at local level in Victoria (n = 9). Perspectives of those working at local government (LG) level in the state of Victoria were compared with Victorian state government and federal perspectives on the issue of IHD and rural health policy. See Participants were identified purposefully and via a snowball sampling method. To be eligible, participants had to have been working with health policy in a rural area for at least 1 year at either local or state level in Victoria, or at a federal level. Roles of participants included health policy makers, politicians, academics and leaders of relevant health advocacy organisations (e.g. NGOs) who worked directly with government policy makers see . The staInterviews were conducted either in person at the participant’s workplace, or via telephone by the lead researcher (LA) and audio-recorded. An interview schedule was developed using open ended questions around the following domains:Perceptions of the increased burden of CVD/IHD in rural areas and barriers to effective policy actionsPriorities for health in rural areasThe use and perceptions of scientific evidence in the rural health policy making processBarriers to using the scientific evidence in the policy and priority setting processInterview times ranged from 25 minutes to 1 hour. All interviews were recorded and transcribed, and the interviewer also took notes throughout the interview process on additional observations.Interviews were transcribed and checked for accuracy by LA. Transcripts were thematically analysed using a theoretical thematic analysis technique  which inConceptual Framework for Understanding Rural and Remote Health [Two theoretical frameworks were used to guide the thematic analysis of participant responses. All questions that focussed on understanding the participant’s perception of the increased burden of IHD in rural areas and how this translated into actions relevant to health policy were analysed using the lens of the e Health . This fre Health .The Conceptual framework for Context-based Evidence-Based Decision-Making [This framework used to define the context of rurality Australia and its influence over the use of scientific evidence in health policy. n-Making  was usedTo ensure the specific rural context could be analysed in terms of its influence over the use of scientific evidence in health policy, these two frameworks were combined to create 18 possible themes that could be analysed within the data, using a deductive analysis approach. Fig 1 sNVivo software version 11 , was used to generate, organise and analyse themes that emerged from the transcript data. Firstly transcripts were read in full by the researcher using an open coding process. Axial coding was thenNo differences were observed in the participant responses between those working at either state or national level and so they are referred to as collectively ‘higher level’ (HL) government.The summary of findings from each theme derived from the frameworks is summarised in The context of the ‘rural locale’  had implThe participants at LG level described how the rural locale may play a role in likelihood of them identifying and accessing the scientific evidence on IHD in rural areas during the policy writing process. For example, in one rural area, the community felt that the high burden of IHD was a prominent issue which then led to action and evidence informed policy within the community.“We’ve had an initiative that’s been going for 10 years which is a preventative health collaboration initiative, which it was called (omitted) … It’s called that because it was about heart disease.”—Local Government Community Services Manager and health policy writerOther LG participants working in different rural settings thought that focussing on IHD in their policies was not useful as this was not perceived as an issue within the social norm of their community. As a result of the conditions within these settings there was unlikely to be IHD specific policy, and therefore policy makers would be even less likely to be accessing the relevant scientific evidence on the issue.We know that what we’re doing is to eventually prevent chronic disease, but focusing on the chronic disease itself, we haven’t found it’s particularly effective when it comes to communicating with the community.” -Social planner responsible for public health and health policy“One LG participant highlighted how within their rural locale, using scientific evidence in their policy work was atypical.“Probably the short answer is no. I probably don’t chase any of that sort of stuff (scientific intervention studies).”- Environmental Officer responsible for public health and health policyAt the HL, the ‘rural locale’ was also acknowledged as having influence over whether or not there would be pressure on the LG to develop evidence based policy and strategies for reducing IHD. The following quote is a reflection of how the perceptions of the community can influence risk behaviours, or make them socially acceptable and therefore reducing pressure on LG to form policy related to preventable diseases such as IHD.So, each of those towns have its own cultural identity and people in those towns, you know, to a greater or lesser extent operate within a unique cultural environment, if you like. So, an environment where it's, you know, if you’re not smoking what's wrong with you?”–Rurally-based National Policy Advisor“The social norms within the rural locale of LG participants had a direct effect on how the scientific evidence is interpreted and considered as relevant to health policy action. LG participants working within the rural locale are influenced by the social norms and structures within their rural area, as they interact with their unique surroundings. If the evidence doesn’t feel right, or fit in with the perceived culture then it was less likely to be interpreted as valuable and required for the progression of policy work around IHD prevention.If you present me with something and I don’t think that that makes intuitive sense, I’m going to be sceptical about using it as—as evidence, which is, I know, completely unscientific…….Then you see, you’ve always got to be a little bit careful about studies and—and research”–Director of Community Services responsible for designing public health and health policy.“The influence of the rural locale is evident in the view that if scientific studies are not generated from within the rural community then they are interpreted as less relevant than the local community stories when justifying policy actions around preventable conditions such as IHD.It’s international, or it’s, you know, it’s urban or something like that… you think well, it does really have to be relevant to the area. And as I said, communities are all different, and even though a lot of the health issues and cardiovascular issues in (name) Shire are quite similar to (neighbouring shire), you know, it’s completely different local government area. So I would be needing to know that actually that scientific study is going to be relevant for our community.”–Director of Community Services with experience in multiple rural local governments in policy formulation“In contrast, a senior government data analyst felt there was not a need for small area level data to support policy action in rural areas. The participant felt that despite spatial heterogeneity across rural communities, the evidence on disease burden in rural Australia would be generalizable to most of these communities and therefore should be applied to policy.“Most of the time that you can use stuff at a much higher level than people want; the exception to that is if you want to investigate where an area has put in place a particular practise.”-Senior Government Data AnalystThe next quote captures the influence of a rural locale over the interpretation of scientific data. Anecdotal stories from the community are seen as ‘real data’ that is relevant to them, when compared to scientific studies:“I would probably say case studies are a good one…because they’re real life studies, usually. It’s real data. It focuses on a specific… like, a lot of time, a case study might focus on a specific group of people, or a specific person. It’s a case study about their experiences and the outcomes, and those sort of things”- Director of Community Services responsible for health policy formulationHL participants agreed that the rural context has strong influence over the interpretation of the evidence within policy teams. There was agreement with the LG that evidence had to be palatable to the rural locale involved, and that people working in rural environments with access to context-specific evidence were in a position to develop more innovative and potentially effective responses.“I think that often, some of the best new pilots, and looking at things to do differently come from local people who’ve put the effort in to get that evidence–as opposed to ideas that come out of Melbourne from the departments.”–State Member of Parliament Due to barriers related to the rural locale, such as the lack of pressure to access and use the evidence in justifying policy around IHD prevention, application of the scientific evidence was viewed as rare, and in some cases had not been used at all at the local level.“It hasn’t happened before” -Social Planner and Health Policy WriterAt the higher level, one participant suggested that the current system within LG should change to align with the evidence around IHD and despite the effect of the rural locale, be applying evidenced-based policy and taking direct action that is less general and more disease specific.“Well there is a kind of wishy-washy school of health promotion that thinks we shouldn't mention diseases. It seems to me a bizarre notion.”–Senior National Policy AdvisorOne participant felt that the rural locale held back communities from being seen as a political priority because rural populations were generally predictable voters; which relates back to culture, social norms and social rules within rural communities. Without political focus on the issue there would be less motivation to generate and apply the scientific evidence to the policy, if no policy was likely to form in the first place.“I don't think rural health is a—is an electoral agenda at all. And—and the—and the raw calculus of it is that you, you know, most rural areas vote conservatively and so, again, you know, if that seat's not within—if you're polling and it tells you that the swing—the swing is on or it's too tight, then do what you have to hold it, but, geez, don't—don't go wasting time and money and resources in a seat that's already safe.”-National Senior Policy AdvisorOn a similar theme to the quote above, another participant acknowledged how the characteristics of rural communities also did not encourage evidence based policy generation in these areas, due to little direction or knowledge of adequate evidence based solutions:“We find that people in rural areas tend to have lower incomes, have lower levels of educational attainment…… and no one's really nailed it in terms of how you can sort of level the playing field for rural and remote populations versus urban populations.”- Senior National Policy AdvisorThe influence of the broader health system was evident in the participants’ responses about the use of evidence in policy relating to IHD prevention in rural areas, predominantly in relation to a lack of funding and resources to generate evidence-based policy.The ability of policy makers working at LG level to access the scientific evidence in rural areas was limited by a lack of resources and funding specific to reduced/ or no access to scientific databases and therefore the scientific evidence. This makes the development of rural health policy that incorporates scientific evidence specific to rural communities difficult to achieve.“Studies are obviously like pay for—like you need to pay to access the article and stuff like that….which is a pretty massive, um, barrier for an organisation that has really low resourcing levels.” -Social Planner and Health Policy writer.At the HL, the opposite situation was observed as funding for such staff in advocacy and advisory roles did not appear to be an issue as these participants worked in larger organisations with higher levels of resourcing. It was obvious to participants at the HL that the rural LG policy makers were under-funded and under-resourced in terms of being able to access evidence, and one HL policy maker agreed:if the political process is what allocates resources for the management, care and prevention of heart disease in rural areas, then you work backwards and go, "Well, why isn't there? Why isn't there more funding, more resources, you know, um, you know, a better workforce?"- National Senior Policy Advisor“As well as having limited or no access to scientific literature, there were also no identified funding mechanisms for staff to interpret and analyse the evidence related to IHD prevention in rural areas. Due to the lack of funding around training and support, LG participants felt low confidence in interpreting the evidence accurately. When asked if they felt confident interpreting the scientific evidence one participant said:“I could be left red faced if somebody put a very scientific study in front of me”- Environmental Planner and Health Policy WriterAgain, at the HL there did not appear to be barriers to interpreting the evidence, especially in regards to funding and resources to develop advocacy or policies that incorporated scientific evidence.Application of the evidence was reduced by the influence of broader health systems at LG, however this was not a prominent issue at HL. There was potential for broader health systems to contribute to improving access to evidence on IHD in rural areas for LG participants. One participant suggested that there was a lack of data sharing and an improved system to encourage better data keeping and streamlined data collection between local governments and health services could assist with the generation of rural-specific scientific evidence on issues such as IHD. Generation of such evidence would be viewed as more applicable to their work as it would account for heterogeneity between rural areas.“We’ve just got an extraordinary amount of information. The problem is, is that I don't know what the local hospital has got. They don't know what the shire has got. They don't know what the community health service has?”–Community Services Director and Health Policy WriterExamples of power influencing each stage of the evidence use process were evident in this study, and are summarised together due to the closeness of the rural context interactions at each stage.At LG, rural communities demonstrate power through participating in the community consultation processes. Policy makers at the LG felt that community consultation was more of a priority than using scientific evidence, as the issue had to be marketable to their local community. Views within the community collectively have the power to inhibit the use of scientific evidence, and especially around accessing evidence on the issue of preventing IHD. The following quote captures the perspectives of the participant in feeling that the evidence is not necessarily worth accessing if the community decides that the issue is not one of concern.“How do you market the issue? If you're saying we have a death rate higher from heart disease than most other townships, people are going to say, "Well, I'm not old yet so it doesn't impact on me."…..But if we're talking about obesity …..You don't see a heart ready to have a heart attack in the street.”-Local Government Health policy writerParticipants at LG did however feel they could have the power to take actions and develop evidence-based policy to reduce the burden of IHD in rural areas.“I think local government has the opportunity to have a big impact over the longer term.”- Health policy developerAt the HL, politicians were viewed as having significant power over the interpretation and application of evidence in policy in rural areas. Participants shared the view that regularly, despite the best available evidence and advocacy around heart disease, rural communities missed out due to the influence of power in political circles. This participant sums up how power in politics has a big influence over how the evidence is accessed, interpreted and applied, and in this quote implied that evidence has little power at all.“Academics and political scientists may as well be talking about the lifecycles of grasshoppers for all the influence it has in a prime minister's office.”-Senior National Policy AdvisorThere was discussion around a lack of power for politicians who do have a personal background in rural health, and despite having extensive knowledge of rural health issues and barriers to reducing the IHD burden, still had very little power to create change within the current political environment.“I just don't think she’s  ever been given any resources to do anything. Nor is it filling the mail bags as they say. People are not filling MP's mailbags saying, "Look, we've got a higher rate of this that and the next thing in rural areas and we ought to do something about it…” At the higher policy level there's at best inertia and at worst vested interests at work which are operating against the things which would have—would be bringing benefit to rural areas in terms of reducing the heart attack rates, i.e. preventative activities”- Senior National Policy AdvisorPower in rural areas, in a political sense, was also perceived to be reducing over time as metropolitan areas were expanding, creating stronger centres of power in capital cities. This therefore would reduce the likelihood of a government focus on rural health and the development of evidence-based policy to reduce IHD in rural Australia.“We lost one seat–one country seat–in country Victoria. So as a result, we’ve got one fewer, one less voice in parliament that’s advocating for investment in rural health, for example.”- State Member of Parliament This research set out to understand the perceptions of rural policy makers on the use of evidence in their efforts to set policy to reduce heart disease in rural and remote populations. The rural Australian context appears to be a key variable reducing the likelihood of the development of evidence-based policy to reduce the high burden of IHD experienced by rural communities. The data collected here suggest that the lack of resources available to rural policy makers prevent meaningful use of scientific evidence in policy making. Specifically, lack of access to data relevant to their community, social norms within the rural locale, limited funding and lack of skilled staff in rural settings have inhibited their ability to apply scientific evidence to the policy making process.At a national level the resources to support rural and remote health allow for the rapid creation of evidence briefs and background summaries to support policy making at national and state level. However, political processes and the perceived lack of power of rural populations in parliament mean that focus on the specific needs of rural populations the adoption of scientific evidence-based policy is limited at the federal level.This study used a purposive sampling approach to identify key people in rural policy making and seek their perspectives on the role of evidence in rural policy making. We applied a snowball sampling approach whereby This is the first study to interview rural policy makers with a heart disease focus at all three levels of government and this has demonstrated a fundamental difference in perspective and approach between the State/ Federal level of government and the local rural level. The application of the rural health framework  in conjuA potential limitation of this study is that the sampling approach relied on the potential key informant being accessible on the internet in the first instance, and recall of their colleagues skill set or experience in the case of the snowball sampling. The rural informants to this study were Victorian based and this may limit the generalisability of these findings to others states of Australia. Indeed, the policy context would be different in other states; of the eight Australian states and territories only New South Wales is similarly mandated as Victoria to create health and wellbeing plans at a local government level. Replication of this work in other states and territories might expect to find far fewer people working in rural IHD health policy with perhaps even fewer resources at their command.Application of the conceptual framework for understanding rural health has demonstrated how the rural context affects the policy making process. A possible reason that current health policy is not meeting the needs of rural Australians emerged in the perspectives of higher level government participants. The majority of respondents suggested that reduced political power in rural areas makes effective and specific rural health policy a low political priority. Participants perceived that political pressure is lacking from rural Australia and therefore politics is becoming increasingly ‘metro-centric’ in part due to expanding urban populations, which is also echoed in the Australian literature ,21. BaseRural Australia is no exception to observations in the current international literature that evidence is only a small influence on the decision making processes, with many other factors having more dominant influence, such as political pressures ,18,20,32The most recent rural specific policy in Australia is the National Framework for Rural and Remote Health  to include considerations for rurality, could indeed be beneficial in assisting local rural governments to improve the poorer health outcomes experienced by rural communities, and would assist with the recognition that there is a unique rural distinction in policy making, as acknowledged within the conceptual framework for context based evidence-based decision making (15).Despite large advances in heart disease prevention globally this remains a key area of inequality between urban and rural dwelling Australians. The use of scientific evidence in health policy is influenced by multiple factors which is recognised on an international scale, and our findings show that the rural context leads to conditions which constrain the ability of the Australian government to focus on these inequalities and subsequently to apply evidence to their efforts in prevention. If these contextual inequalities are not addressed, the inequities in morbidity and mortality will persist for future rural-dwelling communities.S1 File(DOCX)Click here for additional data file.


Electronic cigarettes (e-cigs) are an increasingly popular alternative to smoking, helping to prevent relapse in those trying to quit and with the potential to reduce harm as they are likely to be safer than standard cigarettes. Many women return to smoking in the postpartum period having stopped during pregnancy, and while this can affect their decisions about breastfeeding, little is known about women’s opinions on using e-cigs during this period.The aim of this study is to explore online forum users’ current attitudes, motivations, and barriers to postpartum e-cig use, particularly as a breastfeeding mother.a priori codes identified. All transcripts were entered into NVivo for analysis, with a template approach to thematic analysis being used to code all transcripts from which themes were derived.Data were collected via publicly accessible (identified by Google search) online forum discussions, and Four themes were identified: use, perceived risk, social support and evidence, with a number of subthemes identified within these. Women were using e-cigs to prevent postpartum return to smoking, but opinions on their safety were conflicting. They were concerned about possible transfer of harmful products from e-cigs via breastmilk and secondhand exposure, so they were actively seeking and sharing information on e-cigs from a variety of sources. Although some women were supportive of e-cig use, others provided harsh judgement for mothers who used them.E-cigs have the potential to reduce the number of women who return to smoking in the postpartum period and potentially improve breastfeeding rates, if breastfeeding mothers have access to relevant and reliable information. Health care providers should consider discussing e-cigs with mothers at risk of returning to smoking in the postpartum period. Maternal smoking and low breastfeeding rates are both major public health concerns relating to the postpartum period, with health implications for both the mother and her child -8. WhileStudies have consistently reported associations between smoking behavior (abstinence) and breastfeeding patterns -15, withA relatively new product that may be useful for preventing return to smoking or supporting cessation of smoking is the electronic cigarette (e-cig) . E-cigs Online forums are a popular and accessible community for mothers to discuss, debate and share opinions on anything relating to motherhood . A methoVery little research thus far has examined the use of e-cigs amongst postpartum women, with the current research available focusing on the use of e-cigs in pregnancy. Therefore, we aimed to explore online forum users’ current attitudes, motivators and barriers to using e-cigs as a breastfeeding mother through the analysis of data extracted from online parenting forums.This was an infodemiological study  using onDue to varying guidelines between countries on e-cig use, only UK-based forums were used as the United Kingdom already has guidance recommending the use of e-cigs rather than traditional cigarettes during pregnancy . The eliAND with key words for breastfeeding, and then searched using the search operator (a Google-based command to filter results) site: sampleforum.co.uk via Google search engine.The key words for e-cigs  were comKey words: electronic cigaretteE-Cig(s)E-cig(s)Electronic cigarette(s)VapingVape(s)ANDKey words: breastfeedingBreastfeedingBF(ing)Nurse/NursingBreastmilkFeedingThe use of search operators was the most effective and thorough way to ensure relevant discussions were obtained while ignoring forums owned by specific groups who may have had competing interests, such as e-cig manufacturers or tobacco companies. These sites were identified by screening the URL name and home page.pregnancy and trying to conceive, in line with the aims of the research. The threads used in analysis were then transcribed for NVivo11.A total of 597 Google results were returned using the above search terms, and searches were then adapted to exclude In the analysis, abbreviations within quotes were expanded in squared brackets, and the data source was identified by the thread (T) and the numbered data set.Informed individual consent was not obtained as the data were publicly posted on a large forum -52. The Ethical approval was obtained from the University of Nottingham Medical School Research Ethics Committee.a priori codes, this permits the analysis of the textual data that had been produced for “a different purpose in a different context”  but then I remember how pregnant you are.Xanthe, T7Finally, five subthemes were identified for the main theme of evidence, which included professional, non-professional, anecdotal, lack of evidence and mistrust or uncertainty of evidence. This theme showed that women accessed a wide variety of sources of information to inform their arguments and opinions, and then interpreted and communicated their understanding of this evidence on forums (sometimes inaccurately).Professional evidence came from academic articles or via professional websites such as the National Health Service (NHS) and Public Health England (PHE). This evidence was often misinterpreted, particularly by those who were opposed to vaping. One example was an article available on the NHS website about popcorn lung that was incorrectly cited several times across transcripts as evidence of e-cigs being harmful. A further example of using professional evidence is the following poster, who linked a paper by Farsalinos and Polosa :If you want decent info on the risks and benefits of vaping this is a good place to start. You can access the whole paper for free if you create an account.Jael, T4The most frequently quoted evidence was from nonprofessional sources. This included media articles such as blog posts and newspaper articles, but also links to social media profiles and discussions. There were also examples of websites, like Wikipedia, being cited as sources of evidence against vaping, which was met with ridicule by some provape forum users. The nonprofessional evidence was mostly quoted by those opposed to vaping, whereas professional evidence was equally shared by those both for and against vaping.Anecdotal evidence was also shared by both sides and appeared to be the most substantial form of evidence accepted by women. The women were often more responsive to the experiences and stories from other forum users than they were to other forms of evidence available, and these forms of evidence often appeared to be more persuasive:Anecdotally I can tell you that when my ExH [Ex-husband] vaped, our cats fled from the vapour and I hated the idea of him vaping inside near the cats. I'd be even more concerned about a baby.Grace, T4I do, I feel so much better too, no coughs or colds. I am positive that e cigs are much much less dangerous than cigarettes and think maybe you're being a bit over anxious.Jonquil, T7As well as sharing, quoting and interpreting evidence, there was also a general discussion on the lack of evidence available about the safety of e-cigs. This was most often attributed to a lack of empirical evidence of the long-term effects of vaping. Women were anxious to read information that related specifically to their situation and talked about lack of evidence on vaping and breastfeeding or vaping around young children.This lack of evidence specific to new mothers was also displayed in the final subtheme of mistrust and uncertainty. In the following quote a forum user highlights the use of thalidomide in pregnancy, and how this was perceived as safe:95% safer, Not 100% safe then? Not that long ago the NHS also said Thalidomide was safe. Look how that ended.Camelia, T7This is evidence of women looking for evidence that relates to their specific circumstances by using the comparison of a professional recommendation that resulted in infant harm. It wasn’t just mistrust at the science itself, but also the institutions that make the recommendations:And PHE [Public Health England] have been criticised for their supportive stance on e-cigs. They are very keen to get tobacco smoking down so I can see why they would be supportive.Joy, T6An infodemiologiocal approach was taken for this research, which is the analysis of data on internet forum sites for public health research ,31. ThisThe themes show that women are accessing both lay and professional information on e-cig safety and their use via multiple sources, but this information is not necessarily being interpreted correctly, or it is being met with a degree of mistrust and uncertainty. There are conflicting opinions on the use of e-cigs while breastfeeding, mainly due to health concerns regarding what may be transferred from e-cig to the breastmilk, and then to the infant, as well as concerns about harm from secondhand vapor exposure.There are limitations to this form of infodemiological research, with the use of online forum data forgoing the possibility of following up with individual users or seeking clarification on the meaning of their words, which increases the risk of bias during coding. It is also impossible to establish the validity of posts, like being completely confident that a user who identifies as a breastfeeding mother is, in fact, a breastfeeding mother. The transferability of these themes to the general postpartum population is limited due to both the exclusive participation of forum users and also that all the transcripts came from only two parenting forums. There is also no way to completely establish the authenticity of the users on the forum or whether they have connections within the e-cig or tobacco industry. On the other hand, the use of online data has several strengths, like that discussions are free from the response bias that may be present within interviews, and that forum data provides discourse that has been written with the intention of expressing and debating opinion for the purposes of discussion rather than research. The use of forum data provides in-depth qualitative data, and in other research, the use of a discussion analysis tool found that online interactions involving conflicting viewpoints promoted more discussion and critical thinking . Our resThis work has improved our understanding of how and why women use e-cigs in the postpartum. For the first time we are able to understand and explore what evidence women are accessing to inform themselves about e-cigs and how this information is then interpreted. It also provides the first evidence of women perceiving their use of e-cigs postpartum to be preventative of a return to smoking. We are also better able to understand the concerns women have around the impact of e-cigs on infant health, in particular that a misattribution of nicotine as the most harmful substance transferred to infants via a smoking mother’s milk is sometimes an obstacle to the use of e-cigs postpartum.Previous research has highlighted that some women perceive that smoking affects the quality of their breastmilk in a way that is detrimental to their infant’s health ,60 despiPrior work using forum data considering e-cig use during pregnancy  identifiIn our study, women also displayed mixed views on e-cig safety. The majority of users accepted that e-cigs were probably safer than cigarettes; however, there was a lot of skepticism and mistrust of the evidence for this. Health bodies such as PHE and the NHS were classed as biased due to their targets of reducing cigarette smoking, and comparisons were made regarding previous health recommendations that have since proven to be detrimental. Women were accessing scientific journals to learn more about e-cigs; however, it was often mistranslated. News media stories are often shared among online groups if a headline is particularly provocative, and even when these stories were discredited users felt that these fears must be based on something. Lack of evidence or mistrust of the current evidence appears to be a barrier for the use of e-cigs as a harm reduction tool during the postpartum period, which often gives rise to the thought process that it is better to deal with the familiar than risk the unknown. This skepticism is not confined to e-cigs, as previous research has identified that some women believe NRT patches to be harmful and that smoking is preferable to using them .Uncertainty regarding e-cig safety often led to women discussing the concept of risk either in terms of comparison to smoking or in justifying the perceived risk. This individual assessment of risk is not unique to e-cig use and is attributed to a knowledge deficit between professionals and the lay public . The risThis knowledge deficit could explain the reliance on unverified evidence from social media, news publications or web content found within this study. These sources of information are written to inform a general population but are also written to be read with ease, so this may be why women are engaging more with this type of evidence. There is also a reliance on others for information, with women seeking support and advice from health care professionals but also from other mothers. It is unsurprising that new mothers would seek information that is easy to access and easy to read, but the use of online forums also provides anonymity, which provides some form of protection of self while receiving or giving information . TherefoThe concept of risk is a subjective one, and while there was much discussion of it, this risk was not defined apart from discussions on nicotine. There were suggestions of harm drawn from media conclusions, but risk itself was often discussed as a general term. Other lifestyle behaviors such as alcohol and caffeine consumption were often used as a comparison to justify this risk concept, with forum users suggesting that if these behaviors were acceptable for mothers then vaping was also acceptable. However, the risks of nicotine exposure to the baby were one of the defined examples of risk. There were unsubstantiated attributions that nicotine caused SIDS, fears of infants becoming addicted to nicotine and being forced to experience withdrawal once breastfeeding ceased, and concerns that using e-cigs to manage the mother’s mental health needs (such as stress) would lead to children who grew up exposed to unhealthy coping mechanisms. The exposure of infants to nicotine was also the subject of judgement. Some women would argue that a mother asking if it was acceptable to vape was actually asking if it was acceptable to feed her baby nicotine, suggesting that the nicotine became a deliberate exposure rather than a byproduct of the breastmilk. This concern regarding nicotine acted as a barrier to the use of e-cigs postpartum, and although some women acknowledged the known harmful substances in cigarettes, their primary concern seemed to be nicotine. Harmful effects from nicotine are not fully understood but are likely to be minimal compared to the effect of other compounds. Although it is accepted as an extremely addictive substance , there aThis research closely relates to the “good mother” social construct , as showIn conclusion, this study has shown women hold a mixture of views on the acceptability of vaping as a mother, but some women are using (or are interested in using) e-cigs in the postpartum period. They are seeking, and need, more reliable information to facilitate their use, especially when breastfeeding. Therefore, we need further research that considers how women could have opportunities to ask and receive advice, perhaps by opening a dialogue on e-cigs between mothers and health care providers which could potentially reduce rates of maternal smoking and increase breastfeeding rates.