Medical-Legal Partnerships for women in the United States: a systematic review protocol.

This protocol conforms to the 2015 protocol reporting guidelines developed by Moher et al., the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement (see Additional File 1), a set of guidelines developed to improve the transparency, accuracy, and completeness of systematic reviews and meta-analyses. The protocol is registered with the Open Science Framework at https://osf.io/wd6t5/?view_only=2d6baf14c7b2408293ac31ee5921c8e3 . To enhance understanding of the effects of MLPs on women, this systematic review has two objectives: (1) compare the impacts of Medical-Legal Partnerships (MLPs) by gender, and (2) identify tailored approaches adopted by MLPs to assist women. For Objective 1, we will use the Population, Intervention, Comparators, and Outcomes (PICO) framework to define eligibility criteria as it is well suited to quantitative questions [ 32 ]. For Objective 2, we will apply the Population, phenomena of Interest, and the Context (PICo) framework, which is adapted to qualitative questions [ 33 ]. It is common to apply both frameworks in a systematic review with both quantitative and qualitative objectives [ 32 , 33 ]. The systematic review will include publications that describe MLPs that serve women in the United States. We take our cues from the MLPs on how they define this population (e.g., inclusion of transgender as well as cisgender women); we will note how MLPs define their service population. The review will exclude articles that (1) only report on men, or (2) do not mention gender, or (3) are based outside of the U.S. MLPs are defined by the presence of eight core elements (see Table  1 ) [ 34 ], but based on our preliminary searches, such criteria are rarely reported upon exhaustively in MLP literature. It is unclear the extent to which most MLPs meet these criteria in practice [ 12 ]. We understand MLPs to entail the institutionalized participation of legal professionals on holistic health care teams [ 11 ]. We will exclude articles that describe medical-legal collaborations in which legal services are not delivered in the partnered clinical setting. These services need not be continuously co-located in the clinical setting for the article to be included. Table 1 Central components of a Medical-Legal Partnership [ 34 ] 1. A formal agreement between the clinical setting and legal services organization that outlines goals, responsibilities and protections for patient privacy and confidentiality 2. A defined patient population (e.g., medical condition and socioeconomic status) 3. A strategy to screen patients for legal needs 4. Dedicated legal professionals to staff the MLP 5. A “lawyer in residence” within the clinical setting or in close proximity to providers 6. Lawyers provide training to providers about identifying health-harming legal needs 7. Screening and referral processes, including information-sharing arrangements 8. Designated budget and resources to support MLP operations Central components of a Medical-Legal Partnership [ 34 ] Objective 1 involves assessing the effectiveness of MLPs by gender. We make use of the traditional Population, Intervention, Comparators, and Outcomes (PICO) approach to frame our eligibility criteria. Population and Intervention are described above. We will include peer-reviewed publications that compare the impact of MLPs by gender and include women as one of the comparators . Following proponents of MLPs who stress their important role in addressing structural problems [ 35 ], we understand outcomes broadly to be measured at the individual, relationship, institution, community, and policy levels. As part of this review, we will consider articles that describe outcomes that affect women across these social-ecological dimensions. For example, individual-level outcomes may include changes to clinically assessed or self-reported health outcomes. Institution-level outcomes may include increased rates of screening for civil legal needs in clinical settings. Policy-level outcomes may include legislative changes. In the case of outcomes on socio-ecological dimensions that extend beyond the individual patient, the publication must make the case that the changes affect health and well-being. To ensure the findings presented on outcomes are as rigorous as possible, the systematic review will only consider peer-reviewed literature for Objective 1, including quantitative studies or mixed method studies with a quantitative aim, that meet the inclusion criteria described above. Objective 2 involves a qualitative assessment of MLPs tailored to women. We make use of the Population, phenomena of Interest, and the Context (PICo) approach, a framework for conducting systematic reviews adapted to qualitative inquiries [ 33 ]. Population is described above. The phenomenon of interest guiding Objective 2 is tailoring. It is common for MLPs to develop novel approaches to specific patient populations (e.g., children, homeless patients) [ 12 , 25 ]. To understand how MLPs tailor services to support women in addressing adverse SDOH, the review will include literature that describes MLP approaches tailored to women. We will include manuscripts that describe tailoring in the context of a clinical setting that hosts a MLP. We will include articles that describe MLPs serving all genders, so long as they describe a tailored approach to women. Literature that propounds the value of MLPs for women’s health in abstract terms, without reference to a particular intervention, will be excluded. For Objective 2, this systematic review will include peer-reviewed and gray literature. The latter category might include practice reports that describe the context of one or more “case studies” of a woman-specific MLP describing multiple such approaches. We will consider qualitative, quantitative, or mixed-method studies that meet these criteria. Such literature need not include comparators or report on outcomes. Because MLPs involve collaborations between clinicians and legal professionals, we will make use of a disciplinary variety of databases, including MEDLINE, Embase, PsycInfo, Web of Science, Scopus, National Bureau of Economic Research, LexisUni, and HeinOnline. Additional studies will be identified from the bibliographies of articles selected for final inclusion and from literature published on the web site of the National Center for Medical Legal Partnerships (NCMLP). We will also connect with legal experts in the MLP field by publicizing this review through the biweekly newsletter operated by the NCMLP and inviting authors and researchers to reach out to the review team with relevant literature. Sources will be searched for English-language manuscripts published after 1993 (the year attributed to the first MLP) [ 11 ]. Our preliminary search strategy was developed iteratively for use in MEDLINE with the assistance of an academic librarian and coauthors with expertise in social needs and women’s health. Search terms for our population were informed by prior systematic reviews on women (see Table  2 ) [ 36 ]. Index articles[ 16 – 19 ] reporting on the health impacts of MLPs were used to identify an initial list of search terms for the intervention, with additional pilot searches generating new keywords, index terms, and Medical Subjects Headings (MeSH) terms (see Table  2 ). Table 2 Search terms Construct Search Term Medical-Legal Partnership “medical-legal partnership*” OR “MLP” OR "medical-legal need*” OR "medical-legal service*” OR “medical-legal intervention*” OR “medico-legal service*” OR “medico-legal intervention*” "medical-legal advocacy" OR "health-justice partnership” OR “health justice advocacy” OR “medical-legal integration” OR “legal service” OR “legal advice” OR “civil rights” OR “socio-legal” AND  Women’s Health (MH "Women + ") OR (MH "Battered Women") OR (MH "Single Women") OR (MH "Trans Women") OR (MH "Expectant Mothers") OR (MH "Intimate Partner Violence") OR (MH "Women's Health") OR (MH "Women's Health Services") OR (MH "Lesbians") OR (MH "Breast + ") OR (MH "Breast Neoplasms + ") OR (MH "Breast Self-Examination") OR (MH "Breast Pumps") OR (MH "Breast Tissue Density") OR (MH "Breast Reconstruction") OR (MH "Breast Examination + ") OR (MH "Breast Implants") OR (MH "Breast Feeding + ") OR (MH "Mammography") OR (MH "Mastectomy + ") OR (MH "Genitalia, Female + ") OR (MH "Genital Neoplasms, Female + ") OR (MH "Genital Diseases, Female + ") OR (MH "Female Urogenital Diseases and Pregnancy Complications + ") OR (MH "Sexual Dysfunction, Female + ") OR (MH "Maternal Health Services + ") OR (MH "Prenatal Care") OR (MH "Prenatal Diagnosis + ") OR (MH "Perinatal Period") OR (MH "Perinatal Care") OR (MH "Postnatal Care + ") OR (MH "Postnatal Period + ") OR (MH "Depression, Postpartum") OR (MH "Postpartum Psychosis") OR (MH "Pregnancy + ") OR (MH "Pregnancy Outcomes") OR (MH "Pregnancy Discomforts") OR (MH "Lactation") OR (MH "Lactation Disorders + ") OR (MH "Contraception + ") OR (MH "Hormonal Contraception") OR (MH "Contraceptive Agents + ") OR (MH "Prepregnancy Care") OR (MH "Family Planning + ") OR (MH “Fertility + ") OR (MH "Fertility Preservation") OR (MH "Infertility + ") OR (MH "Obstetric Emergencies") OR (MH "Delivery, Obstetric + ") OR (MH "Obstetric Patients") OR (MH "Obstetric Service") OR (MH "Obstetric Care + ") OR (MH "Surgery, Obstetrical + ") OR (MH "Gynecologic Examination") OR (MH "Surgery, Gynecologic + ") OR (MH "Diagnosis, Gynecologic + ") OR (MH "Gynecologic Care") OR (MH "Abortion, Incomplete") OR (MH "Abortion, Induced + ") OR (MH "Abortion, Spontaneous + ") OR (MH "Menstrual Cycle + ") OR (MH Dysmenorrhea") OR (MH "Menstrual and Perimenopausal Disorders + ") OR (MH "Menstruation Disorders + ") OR (MH "Menstruation") OR (MH "Menstruation Inducing Agents + ") OR (MH "Oligomenorrhea") OR (MH "Menopause + ") OR (MH "Menarche") OR (MH "Menopause, Premature") OR (MH "Premenopause") OR (MH "Postmenopause") OR (MH "Postmenopausal Disorders") OR (MH "Perimenopause") OR (MH "Domestic Violence + ") OR (MH "Rape") OR ((TI woman OR AB woman) OR (TI women OR AB women) OR (TI womens OR AB womens) OR (TI womans OR AB womans) OR (TI "women s" OR AB "womens") OR (TI "woman s" OR AB "woman s") OR (TI female OR AB female) OR (TI females OR AB females) OR (TI "female s" OR AB "female s") OR (TI trans OR AB trans) OR (TI transgender OR AB transgender) OR (TI transgendered OR AB transgendered) OR (TI transfemale OR AB transfemale) OR (TI transfemale OR AB trans-female) OR (TI transman OR AB transman) OR (TI transman OR AB trans-man) OR (TI transmans OR AB transmans) OR (TI"transman s" OR AB "transman s") OR (TI trans-mans OR AB trans-mans) OR (TI "trans-man s" OR AB "trans-man s") OR (TI transmen OR AB transmen) OR (TI trans-men OR AB trans-men) OR (TI transmens OR AB transmens) OR (TI trans-mens OR AB trans-mens) OR (TI "transmen s" OR AB "transmen s") OR (TI "transmen s" OR AB "transmen s") OR (TI transwoman OR AB transwoman) OR (TI trans-woman OR AB trans-woman) OR (TI transwomans OR AB transwomans) OR (TI "transwoman s" OR AB "transwoman s") OR (TI trans-womans OR AB trans-womans) OR (TI "trans-woman s" OR AB "transwoman s") OR (TI trans-women OR AB trans-women) OR (TI transwomen OR AB transwomen) OR (TI transwomens OR AB transwomens) OR (TI "transwomen s" OR AB "transwomen s") OR (TI trans-womens OR AB transwomens) OR (TI "transwomen s" OR AB "transwomen s") OR (TI genderspecific OR AB gender-specific) OR (TI "gender specific" OR AB "gender specific") OR (TI gender-related OR AB gender-related) OR (TI "gender related" OR AB "gender related") OR (TI "gender difference" OR AB "gender difference") OR (TI "gender differences" OR AB "gender differences") OR (TI sex-specific OR AB sex-specific) OR (TI "sex specific" OR AB "sex specific") OR (TI sex-related OR AB sex-related) OR (TI "sex related" OR AB "sex related") OR (TI "sex difference" OR AB "sex difference") OR (TI "sex differences" OR AB "sex differences") OR (TI lesbian OR AB lesbian) OR (TI lesbians OR AB lesbians) OR (TI non-binary OR AB non-binary) OR (TI "non binary" OR AB "non binary") OR (TI abortifacient OR AB abortifacient) OR (TI abortifacients OR AB abortifacients) OR (TI abortion OR AB abortion) OR (TI abortions OR AB abortions) OR (TI amenorrhea OR AB amenorrhea) OR (TI breast OR AB breast) OR (TI breasts OR AB breasts) OR (TI breastfeeding OR AB breastfeeding) OR (TI cervix OR AB cervix) OR (TI cervical OR AB cervical) OR (TI climacteric OR AB climacteric) OR (TI clitoris OR AB clitoris) OR (TI clitoral OR AB clitoral) OR (TI colposcop* OR AB colposcop*) OR (TI colpotom* OR AB colpotom*) OR (TI conception OR AB conception) OR (TI contraception OR AB contraception) OR (TI contraceptive OR AB contraceptive) OR (TI contraceptives OR AB contraceptives) OR (TI culdoscop* OR AB culdoscop*) OR (TI dysmenorrhea OR AB dysmenorrhea) OR (TI dyspareunia OR AB dyspareunia) OR (TI endometriosis OR AB endometriosis) OR (TI endometritis OR AB endometritis) OR (TI endometrium OR AB endometrium) OR (TI endometrial OR AB endometrial) OR (TI endometrioid OR AB endometrioid) OR (TI episiotom* OR AB episiotom*) OR (TI fallopian OR AB fallopian) OR (TI fallopians OR AB fallopians) OR (TI "family planning" OR AB "family planning") OR (TI fertility OR AB fertility) OR (TI gynecolog* OR AB gynecolog*) OR (TI "hot flash" OR AB "hot flash") OR (TI "hot flashes" OR AB "hot flashes") OR (TI hymen OR AB hymen) OR (TI hymens OR AB hymens) OR (TI hysterectom* OR AB hysterectom*) OR (TI hysteroscop* OR AB hysteroscop*) OR (TI infertility OR AB infertility) OR (TI "intimate partner violence" OR AB "intimate partner violence") OR (TI "intrauterine device" OR AB "intrauterine device") OR (TI "intrauterine devices" OR AB "intrauterine devices") OR (TI IUD OR AB IUD) OR (TI IUDs OR AB IUDs) OR (TI labia OR AB labia) OR (TI labias OR AB labias) OR (TI labial OR AB labial) OR (TI lactation OR AB lactation) OR (TI lactating OR AB lactating) OR (TI mammaplast* OR AB mammaplast*) OR (TI mammoplast* OR AB mammoplast*) OR (TI mammogra* OR AB mammogra*) OR (TI mastectom* OR AB mastectom*) OR (TI maternal OR AB maternal) OR (TI maternally OR AB maternally) OR (TI menopaus* OR AB menopaus*) OR (TI menorrhagia OR AB menorrhagia) OR (TI menstrua* OR AB menstrua*) OR (TI menses OR AB menses) OR (TI menarche OR AB menarche) OR (TI "military sexual trauma" OR AB "military sexual trauma") OR (TI "military sexual assault" OR AB "military sexual assault") OR (TI "morning after pill" OR AB "morning after pill") OR (TI "morning after pills" OR AB "morning after pills") OR (TI obstetric* OR AB obstetric*) OR (TI oligomenorrhea OR AB oligomenorrhea) OR (TI oophorectom* OR AB oophorectom*) OR (TIoophoritis OR AB oophoritis) OR (TI ovariectom* OR AB ovariectom*) OR (TI ovary OR AB ovary) OR (TI ovaries OR AB ovaries) OR (TI ovarian OR AB ovarian) OR (TI "painful period" OR AB "painful period") OR (TI "painful periods" OR AB "painful periods") OR (TI "irregular period" OR AB "irregular period") OR (TI "irregular periods" OR AB "irregular periods") OR (TI PCOS OR AB PCOS) OR (TI perimenopaus* OR AB perimenopaus*) OR (TI perimenopaus* OR AB peri-menopaus*) OR (TI perinatal OR AB perinatal) OR (TI peri-natal OR AB peri-natal) OR (TI perinatally OR AB perinatally) OR (TI perinatally OR AB peri-natally) OR (TI PMDD OR AB PMDD) OR (TI postmenopaus* OR AB postmenopaus*) OR (TI post-menopaus* OR AB postmenopaus*) OR (TI postnatal OR AB postnatal) OR (TI post-natal OR AB postnatal) OR (TI postnatally OR AB postnatally) OR (TI post-natally OR AB postnatally) OR (TI postpartum OR AB postpartum) OR (TI post-partum OR AB post-partum) OR (TI preconception OR AB preconception) OR (TI preconception OR AB pre-conception) OR (TI pregnancy OR AB pregnancy) OR (TI pregnancies OR AB pregnancies) OR (TI pregnant OR AB pregnant) OR (TI pregnancy-induced OR AB pregnancy-induced) OR (TI pregnancy-associated OR AB pregnancy-associated) OR (TI prepregnancy OR AB prepregnancy) OR (TI premenstrual OR AB premenstrual) OR (TI pre-menstrual OR AB premenstrual) OR (TI prenatal OR AB prenatal) OR (TI pre-natal OR AB pre-natal) OR (TI prenatally OR AB prenatally) OR (TI pre-natally OR AB pre-natally) OR (TI puerperium OR AB puerperium) OR (TI rape OR AB rape) OR (TI rapes OR AB rapes) OR (TI raped OR AB raped) OR (TI "reproductive health" OR AB "reproductive health") OR (TI "reproductive care" OR AB "reproductive care") OR (TI "reproductive healthcare" OR AB "reproductive healthcare") OR (TI "reproductive plan" OR AB "reproductive plan") OR (TI "reproductive planning" OR AB “reproductive planning") OR (TI salpingectom* OR AB salpingectom*) OR (TI salpingo-oophorectom* OR AB salpingo-oophorectom*) OR (TI uterus OR AB uterus) OR (TI uterine OR AB uterine) OR (TI vagina OR AB vagina) OR (TI vaginas OR AB vaginas) OR (TI vaginal* OR AB vaginal*) OR (TI transvaginal* OR AB transvaginal*) OR (TI vaginismus OR AB vaginismus) OR (TI vulva OR AB vulva) OR (TI vulvas OR AB vulvas) OR (TI vulvar OR AB vulvar) OR (TI vulvectom* OR AB vulvectom*) OR (TI vulvitis OR AB vulvitis) OR (TI vulvodynia OR AB vulvodynia)) OR (((TI dilatation OR AB dilatation) OR (TI vacuum OR AB vacuum)) N2 (TI curettage OR AB curettage)) OR (((TI sex OR AB sex) OR (TI sexual OR AB sexual) OR (TI sexually OR AB sexually) OR (TI domestic OR AB domestic) OR (TI partner OR AB partner) OR (TI spouse OR AB spouse) OR (TI spousal OR AB spousal) OR (TI physical OR AB physical) OR (TI physically OR AB physically)) N3 ((TI abuse OR AB abuse) OR (TI abuses OR AB abuses) OR (TI abused OR AB abused) OR (TI abuser OR AB abuser) OR (TI abusers OR AB abusers) OR (TI abusive OR AB abusive) OR (TI violence OR AB violence) OR (TI violent OR AB violent) OR (TI assault OR AB assault) OR (TI assaults OR AB assaults) OR (TI assaulted OR AB assaulted))) OR ((TI tubal OR AB tubal) N2 ((TI ligation* OR AB ligation*) OR (TI sterilization* OR AB sterilization*) OR (TI sterilisation* OR AB sterilisation*))) Search terms We will initially assemble all articles into EndNote v.21 reference software before transferring them to Covidence, an online review management software designed to facilitate collaborative literature reviews. We will select, review, and code literature using Covidence. The selection process will be documented in Covidence. Data from publications selected in Covidence will be extracted and entered in an Excel matrix. Findings will be presented in narrative and tabular forms. In Covidence, SR and EF will remove duplicates and engage in study selection. We will review titles and abstracts (or full texts, in the case of articles without available abstracts) and exclude articles based on the aforementioned criteria. We will pilot test the first 10 articles to ensure the inclusion and exclusion criteria are being applied consistently. For the pilot testing, SR and EF will independently screen 10 articles and then meet to ensure consistent application of inclusion/exclusion criteria, develop rules for applying criteria, and identify inductive themes. Unresolved conflicts will be presented to the larger study team. Thereafter, SR and EF will continue to screen titles and abstracts independently. After reviewing all titles and abstracts, SR and EF will screen the full text of potentially relevant articles against all inclusion and exclusion criteria. Included studies will be tagged for relevance for Objective 1, Objective 2, or both. The bibliographies of publications included for full text review will be screened and tagged in Covidence to identify additional articles for further screening. We will meet regularly to discuss any conflicts identified in Covidence, consulting a third team member on any decisions where we cannot achieve consensus. Data extraction will involve a process of deductive and inductive analysis. First, we will develop a data extraction template in Covidence to deductively extract the data items defined below. SR and EF will review each article independently. After completing data extraction for the first 20% of articles, we will meet to verify deductive categories are being applied consistently, discuss differences in coding, and establish rules to ensure consistency. We will also consider additional data items that emerge inductively as part of the pilot review to incorporate in subsequent reviews and to guide additional data collection from previously reviewed articles. We will repeat this process for the next 20% of articles and again for the remaining articles until we have completed data collection. If necessary, a third team member will resolve any discrepancies in coding. For each article, we will collect high-level Study Characteristics, including author(s), publication date, state(s) where MLP operates, clinical setting of MLP, a description of the MLP’s target patient population, whether the eight core elements of a MLP are satisfied [ 12 ], whether the article evaluates outcomes by gender (Objective 1), describes one or more case studies of MLPs tailored to women (Objective 2), or does both (Objectives 1 and 2). For each article, we will extract data to make determinations about risks of biases. For publications tagged “Objective 1,” or “Objectives 1 and 2,” we will extract data on the study design, total sample size, genders compared with sub-sample sizes, type of outcomes, and effect size. For publications tagged “ Objective 2 ” or “Objectives 1 and 2,” we will also describe how the intervention is tailored to women. As data collection progresses, we will develop new codes to represent inductively identified data items. MLPs affect health indirectly by addressing adverse SDOH. For that reason, we are interested in a broad array of outcomes. No one outcome will be given priority in data analysis and synthesis. Because different data for Objectives 1 and 2 may be extracted from a single publication, multiple types of assessments may be conducted for a single publication. We will make use of different risk of bias assessment tools for Objective 1. Randomized controlled trials (RCTs) will be assessed with the Risk-of-Bias 2 (RoB-2) tool [ 37 , 38 ], developed for use in systematic reviews to evaluate biases in RCTs across a variety of domains. Because the RoB-2 is used for individual RCT outcomes, several RoB-2 assessments may need to be completed for each RCT. For non-randomized studies, we will use the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool, which evaluates biases in studies that report estimates of comparative effectiveness but do not use randomization. Judgements about bias will be accompanied by written justifications. For the review of qualitative data about MLP tailoring, we will make use of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research [ 33 ]. This JBI checklist of ten items captures multiple domains of validity and has the added benefit of focusing on whether a given study demonstrates congruity between its stated philosophical perspective and its research methodology, a critical feature given the diversity of epistemological assumptions undergirding different qualitative research approaches [ 39 ]. Checklist items will be accompanied by written justification. Preliminary searches suggest that existing literature varies widely in the types of outcomes reported [ 40 ].As such, we do not plan to conduct meta-analyses. Data synthesis will be qualitative and narrative. We will export extracted data from Covidence into an Excel spreadsheet. We will conduct two qualitative matrix analyses to identify themes in deductive and inductive data items pertaining to outcomes (Objective 1) and MLP tailoring (Objective 2). For the outcomes analysis (Objective 1), special attention will be paid to the relationship between outcome and tailoring, if relevant. Drawing on our qualitative analyses, we will summarize our findings on the gendered effects of MLPs and how MLPs tailor their services to women, identifying gaps in the literature and implications for future research. We will report the results of the data screening and review using PRISMA guidelines. For Objective 1, we will evaluate the strength of the body of evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of rating the quality of evidence [ 41 ]. The GRADE system delineates five criteria that can reduce the quality rating: study limitations, imprecision, inconsistency of results, indirectness of evidence, and likely publication bias. GRADE further delineates three criteria that can increase the rating of the quality of a given study’s evidence: large magnitude of effect, dose response, and confounders that likely minimize the effect. Research on MLPs is limited. To date, only three RCTs on MLPs have been completed [ 19 ]. Because the GRADE system weights RCTs as high-quality study designs, we do not anticipate identifying multiple high-quality studies. Following the GRADE scale, we will rank the studies as high, moderate, low, or very low. The review will include a table documenting the factors that went into our assessment of each study. We plan to complete this review within 1 year. The search will take 1–2 months. Data extraction and synthesis will take 6–8 months. We will complete data summarization and presentation in 1–2 months.

Women confront a unique set of social determinants of poor health (SDOH), those health-impacting “conditions in which people are born, grow, live, work and age” [ 1 ]. It has been well established that adverse SDOH arise from “the inequitable distribution of power, money, and resources” [ 1 ]. Social roles, discrimination, violence, and inequality are patterned in gendered ways. As a result, the quantity, type, and impact of SDOH differs by gender [ 2 , 3 ]. Women are more likely to live on lower incomes than men, and single women are more likely to head low-income households with children [ 4 ]. These economic forms of hardship are associated with high rates of morbidity and mortality [ 5 ]. Further, roughly one in four women experience intimate partner violence (IPV) in their lifetimes [ 6 ], the health effects of which are devastating and persistent [ 7 , 8 ]. Gender inequality profoundly shapes the conditions in which different women live, with significant health impacts [ 9 ]. Gender’s influence on health is mediated and moderated by other intersecting forms of systemic discrimination, like classism, racism, homophobia, and transphobia. Adverse SDOH tend to operate synergistically. For example, the health of women who experience violence is worsened by the effects of housing instability and economic hardship [ 10 ]. Medical-Legal Partnerships (MLP) involve collaborations between clinicians and legal professionals to address adverse SDOH. The MLP movement is said to have started in its current form in 1993, the year Boston Medical Center began offering medical-legal services to low-income families [ 11 ]. The movement’s goal was to improve children’s health and wellness by using the law to ensure educational access (e.g., disability accommodations) or households free of environmental hazards (e.g., lead, asbestos) [ 11 ]. Other pediatric settings followed suit [ 11 ]. While doctor-lawyer alliances have a long history, what distinguishes the MLP model from civil rights-era predecessors [ 11 ] is the MLP’s high level of integration with clinical institutions [ 12 ]. In its ideal form, MLPs invite legal professionals into clinical settings to provide patients with legal assistance. MLPs further provide clinicians with training in identifying adverse SDOH that have legal remedies. Hundreds of hospitals have embraced this MLP model as a way of meaningfully adopting a holistic, person-centered approach to health care [ 13 ]. Early evidence suggests the great promise of MLPs in addressing adverse SDOH. Observational studies find that patients who receive MLP services have improvements in housing stability, access to financial resources, and mental health [ 14 – 17 ]. Much of this research has taken place in pediatric settings, where MLPs got their start [ 13 ]. Three trials have used randomization to test the efficacy of MLPs. Two reported on MLPs serving pediatric populations and found increased use of preventative services, decreases in emergency care utilization, and improved diabetes control [ 16 , 18 ]. A third recruited low-income adults from an urban primary care clinic to be referred to a MLP and found mixed results [ 19 ]. While measures of stress and emergency department utilization showed improvement, outcomes in anxiety and hospitalization worsened [ 19 ]. In interpreting their findings, investigators noted that medical-legal integration may have been too shallow [ 19 , 20 ]. However, an alternative interpretation might be that the efficacy of MLPs is limited to certain populations. Most research on the effects of MLPs on populations of women comes from case studies describing MLPs based in reproductive health clinics that serve cisgender women who are pregnant or postpartum. This literature demonstrates the important role MLPs play in enhancing access to safe and stable housing, reproductive healthcare coverage, public benefits, and restraining orders against abusive partners [ 21 – 24 ]. Little is known about the effects of these services on women beyond individual reproductive care settings. A search of Systematic Reviews, Cochrane Library, and JBI Evidence Synthesis produced no reviews related to MLPs and this patient population. Given the gendered impacts of adverse SDOH, this is a critical gap. The social identity of woman includes great heterogeneity (e.g., cis versus transgender women, racialization, citizenship status, socioeconomic status). Nevertheless, many MLPs with a defined patient population specialize in serving women [ 25 ]. This focus is justified on the grounds that this population confronts unique adverse SDOH and has different experiences accessing aid from the legal sector [ 26 , 27 ]. Indeed, a recent study suggests that women Veterans have significantly higher legal needs than Veteran men [ 28 ]. Women’s legal problems may arise from medical conditions that disproportionately affect women (e.g., abortion access) [ 29 ]. Or they may arise from gendered adverse SDOH (e.g., intimate partner violence, needs related to single parenting) [ 2 , 3 ]. Intersecting adverse SDOH may in turn affect the legal mechanisms more commonly needed by women. For example, compared to men, women are more likely to be single-parenting in poverty, a condition that puts them at heightened risk of having their children taken into foster care on grounds of neglect [ 30 ] and means they may have greater need for support in petitioning Child Protective Services or family court [ 24 , 31 ]. Understanding the outcomes of MLPs on this population and how implementation of this intervention could be tailored to this population has the potential to improve women’s health and wellness by addressing adverse SDOH. This study seeks to review and report on MLPs providing services to women to answer these questions using the Population, Intervention, Comparators, and Outcomes (PICO) [ 32 ] and Population, phenomena of Interest, and the Context (PICo) [ 33 ] frameworks.

In randomized controlled trials, MLPs have had positive effects on health and healthcare utilization in pediatric populations [ 16 , 18 ], but mixed results in low-income adults [ 19 ]. Taken together, these findings raise questions about the efficacy of this intervention across populations and of different implementation strategies tailored to distinct populations [ 20 ]. Women confront a host of unique needs arising from adverse SDOH. And yet, little is known about how best to implement Medical-Legal Partnerships for this group. The proposed systemic review will provide invaluable evidence about whether and how best to implement MLPs for women.

Additional file 1. Additional file 1.