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Table 1 Findings of the effective non-drug interventions for improving outcomes and quality of care in maternal health in sub-Saharan Africa (n = 73)

From: Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review

Intervention Studies analyzed IOM aspect of quality of care addressed Method of implementation Impact and effect of the intervention on beneficiaries Remark Limitations and strengths
1. Mobile and electronic health interventions. 1. Ngabo et al. 2012 [24]; (level III);
2. Lund et al. 2014 [21]; (level II);
3. Oyeyemi et al. 2014 [23] (level IV);
4. Horner et al. 2013 [26]; (level III);
5. Dalaba et al. 2015 [25]; (level III);
Patient centeredness; equitability; timeliness; efficiency; safety 1. Provision of mobile phones to pregnant women;
2. Implementing an SMS-alert program;
3. Provision of mobile phone to CHWs and service vouchers to pregnant mothers;
4. Use of electronic decision support system to improve compliance of health workers to the existing maternity care protocols;
5. Interactive communication systems between a community health worker (CHW) following mother-infant pairs in their community, a national centralized database, and the health facility and in case of an emergency alert, an ambulance operator.
Provides two and three-way communication for action between women and the health system;
Increased uptake of primary health care services;
Increased number of women receiving preventive health services;
Increase in antenatal care attendance;
Increased number of women attending ANC late into pregnancy;
Improved ambulance requests and referral system;
Increased facility-based deliveries;
Overall improvement in compliance to maternity care guidelines.
Mobile phone interventions may contribute towards increased access to maternal health services and facility utilization which is essential for improved maternal and newborn health. Use of electronic health interventions is effective in improving health workers’ compliance to maternity care protocols. Lack or interrupted electricity and mobile network failure were the major challenges to mHealth use. The paper by Oyeyemi et al. (2014) [23] was based on a case control study thus limited in strength of its evidence;
The interventions were often small in scale and at high risk of possible dilution effect between intervention facilities and controls which were not controlled for in these studies.
2. Financial incentives including user fee exemptions, payment for performance, vouchers and community-based insurance schemes. 1. Bellows et al. 2012 [32]; (level III);
2. Fournier et al. 2014 [34]; (level II);
3. Richard et al. 2008 [58]; (level II);
4. Watts et al. 2015 [37] ; (level II);
5. Amendah et al. 2013 [33]; (level V);
6. Obare et al. 2013 [36]; (level V);
7. Obare et al. 2014 [35]; (level V);
8. Adinma et al. 2011 [40]; (level V);
9. Ezugwu et al. 2011 [41]; (level III);
10. Frimpong et al. 2014 [38]; (level III);
11. Smith et al. 2008 [43]; (level II);
12. Basinga et al. 2011 [44]; (level II);
13. Bonfrer et al. 2014 [42]; (level V);
14. Alfonso et al. 2015 [39]; (level II);
Equitability; effectiveness; safety; efficiency; timeliness; patient centeredness 1. Output-based approach voucher (covering ANC visits, facility-based delivery including caesarean section (CS) and postnatal care for mother and child);
2. Fee exemption (including for caesarean sections);
3. Cost-sharing programs between the community and the health care system/facilities;
4. Community-based insurance schemes;
5. Exemptions from premiums payable to CBHI;
6. Payment for performance (P4P);
7. Performance-based financing (PBF).
Incentivizes patients and health care workers;
Improves quality of services provided;
Increase access to spectrum of services available at the health facilities;
Enhances facility-based deliveries;
Increase in caesarean deliveries (mostly in cities than rural settings);
Reduction in maternal morbidity and mortality;
Voucher program improved poor women access to facility-based delivery;
Births occurring at home declined;
Premium exemptions led to increased registration with CBHI;
ANC attendance;
institutional deliveries;
PBF improved the utilization and quality of maternal and child care in Burundi;
PBF improves quality of maternal care without additional costs to the patients.
Financial incentives can enhance demand for facility-based maternal deliveries and also provide a platform for supply of quality maternal health services. Evidence on the effects of financial incentives on maternal outcomes and equity is weak. Some of the studies were based on population-based cohort data, others have small sample sizes and were without a comparison or control.
3. Clinical audits, maternal death reviews and feedback 1. Browne et al. 2015 [126]; (level V);
2. Hunyinbo et al. 2008 [49]; (level II);
3. Pirkle et al. 2013 [111]; (level II);
4. Zongo et al. 2015 [50]; (level II);
5. Kongnyuy et al. 2008 [57]; (level III);
6. Kongnyuy et al. 2009a [55]; (level III);
7. Kongnyuy et al. 2009b [56]; (level III);
8. Igwegbe et al. 2012 [127]; (level III);
9. Ediau et al. 2013 [54]; (level II);
10. Strand et al. 2009 [128]; (level III);
11. Dumont et al. 2005 [53]; (level III);
12. Dumont et al. 2006 [59]; (level III);
13. van der Akker et al. 2009 [52]; (level III);
14. van der Akker et al. 2011 [51]; (level III).
Safety; efficiency; effectiveness; timeliness; patient centeredness 1. Criterion-based clinical audits (CBCA);
2. Maternal death reviews (MDR) and feedback.
Greater clinical examination and postpartum monitoring practices;
Increased diagnosis of maternal morbidity;
Decrease in aggregate case fatality rate from hemorrhage, eclampsia, obstructed labor and genital tract sepsis;
Increased health facility deliveries and caesarean delivery;
Improved quality of care;
Reduction in maternal morbidity and mortality;
Increased provision and quality of EmOC;
Increased facility deliveries;
CBCA helped improve documentation especially cases notes and maternity registers.
Clinical audit approaches in obstetric care are effective in improving quality of clinical care in resource-poor settings and consequently reduce maternal morbidity and mortality. CBCA approaches and reports are limited to health facilities and do not provide a comprehensive overview of all maternal deaths in the community;
There is also some variability in the standard checklists used in clinical audits among studies.
4. Comprehensive interventions targeting health systems strengthening—training of health care workers, infrastructural upgrading and provision of equipment and medical supplies. 1. Ameh et al. 2012 [67]; (level II);
2. Dumont et al. 2013 [68]; (level II);
3. Spitzer et al. 2014 [69]; (level III);
4. Sorensen et al. 2010 [70]; (level III);
5. Richard et al. 2008 [58]; (level II);
6. Sibley et al. 2014 [74]; (level V);
7. Kayongo et al. 2006 [65]; (level II);
8. Kayongo et al. 2006 [66]; (level II);
9. Brazier et al. 2009 [79]; (level II);
10. Santos et al. 2006 [81]; (level II);
11. Findley et al. 2013 [71]; (level II);
12. Mekbib et al. 2003 [72]; (level II);
13. Srofenyoh et al. 2012 [84]; (level III);
14. Agha, 2010 [83]; (level II);
15. Hounton et al. 2008 [76]; (level II);
16. Worku et al. 2014 [75]; (level III);
17. Richard et al. 2008 [58]; (level II);
18. Ediau et al. 2013 [54]; (level II);
19. Warren et al. 2010 [77]; (level II);
20. Galadanci et al. 2011 [78]; (level III);
21. Geerts et al. 2004 [82]; (level III);
22. Doherty et al. 2009 [80]; (level III).
Safety; efficiency; effectiveness; equitability 1. Training of health care workers in basic and comprehensive EmOC;
2. Training in skills for MDR;
3. Training in Advanced Life Support in Obstetrics care (ALSO);
4. Health facility and infrastructure renovations;
5. Strengthening existing referral systems;
6. Supportive supervision;
7. Logistics for supplies, equipment and drugs, record keeping, monitoring and evaluation, MDR.
Availability and improvement in quality of EmOC;
Improved knowledge and confidence in carrying out clinical audits;
Decreased postpartum hemorrhage rates;
Reduction in hospital-based maternal morbidity and mortality;
Significant decrease in neonatal deaths before mother and child discharge;
Improvement in access to quality caesarean deliveries;
Increased use of facility-based maternity care and institutional deliveries;
Increase in fully functional EmOC facilities;
Steady increase in number of complications treated;
Decline in deaths from obstetric complications;
Reduction in the aggregate case fatality rate (CFR).
Health systems capacity strengthening at the facility and community level led to building sustainable human resources and increased coverage for maternal health services, hence improved quality of care and reduction in maternal mortality. Use of competent non-medically qualified persons (NMQP) incur lower remunerations and training costs compared with physicians;
High level of supervision is required for NMQP to offer specialized services;
Training in ALSO had no effect on the management of prolonged labor.
5. Community mobilization and peer-based Interventions 1. Colbourn et al. 2013 [91]; (level II);
2. Mushi et al. 2010 [92]; (level II);
3. Richter et al. 2014 [90]; (level II);
4. Wangalwa et al. 2012 [93]; (level III);
5. Tesfaye et al. 2014 [73]; (level III);
6. Ensor et al. 2014 [95]; (level II);
7. Hounton et al. 2009 [96]; Level II);
8. Ediau et al. 2013 [54] (level II).
timeliness; patient centeredness; equitability; efficiency; safety
1. Community mobilization through women’s groups;
2. Skilled birth attendants;
3. Training health extension workers;
4. Training and deployment of community health development agents;
5. Traditional birth attendants (TBAs);
6. Family and community members meetings on health care;
7. Trained volunteers to provide health care at the community;
8. Village health teams;
9. Peer mentors who women are living with HIV (WLH) to support pregnant WLH.
Community Mobilization: Promotes utilization of obstetric care;
Increase in first and subsequent ANC attendance and postnatal care;
Increase in health facility use and deliveries;
Increase in level of health information about danger signs and risk factors in pregnancy;
Reduction in perinatal mortality rates;
The number of male partners counseled, tested and given results together with their wives at first ANC visit rose.
Peer mentorship:
Higher likelihood to complete both maternal and infant ARV;
Increase adherence to all PMTCT tasks;
Greater likelihood to ask partners to test for HIV;
Less likelihood to report depressed mood;
Deliveries with skilled attendant significantly increased;
Significant increase in attendance of at least four ANC visits, deliveries by skilled birth attendants;
Number of pregnant women attending first ANC visit significantly increased;
The number of pregnant women counseled, tested and given results for HIV during the first ANC attendance significantly rose.
Community mobilization interventions to reduce maternal mortality improved equitable access maternal health services and thus and reduce maternal mortality. Also, peer mentors interventions by WLH for pregnant WLH led significant overall benefits compared to standard care. Community mobilization interventions cannot substitute for a formal health system but serves as a veritable platform to bridge inequities in maternal health care access and utilization.
6. Home visits and counseling by health care workers. 1. le Roux et al. 2013 [100]; (level II);
2. Lewycka et al. 2013 [101]; (level II);
3. Magoma et al. 2013 [94]; (level II);
4. Rotheram-Borus et al. 2014 [89]; (level II);
5. Jennings et al. 2010 [102]; (level II);
Patient centeredness; Equitability 1. Home visit by community health workers (CHWs);
2. Home visit by peer groups;
3. Use of women’s groups and volunteer peer counselor for health education;
4. Birth plans counseling and health education;
5. Job aids counseling by nurses and midwives;
6. counseling by lay nurse aides.
Improved adherence to condom use among pregnant WLH;
Increased uptake of skilled delivery and post-delivery care;
Improvement in birth preparedness among women;
Danger sign recognition by pregnant women;
Skilled deliveries and newborn care;
Enhanced maternal and child outcomes;
Mothers in the intervention group were more likely to use condoms consistently.
Home visits and counseling by community health workers can help reduce maternal mortality in resource-limited settings with limited access to facility-based maternal health care. Home visit interventions most often require antenatal visits to initiate contacts with the pregnant women;
High intervention coverage may be required in order to achieve significant reductions in maternal mortality;
Methods on conducts of home visit intervention may vary widely across countries and regions and as such may affect the external validity of the findings in this review.
7. Emergency transportation, communication and referrals for obstetric care. 1. Mucunguzi et al. 2014 [103]; (level II);
2. Schoon, 2013 [104]; (level II);
3. Tayler-Smith et al. 2013 [105]; (level III);
4. Fournier et al. 2009 [106]; (level III);
Equitability; timeliness; safety 1. Transportation and communication intervention;
2. Inter-facility transportation program;
3. Patient transfer system to emergency obstetric care facilities;
4. Maternity referral system for emergency obstetric health services;
5. Voucher scheme plus round trip transportation.
Increase in hospital deliveries;
Reduction in the average hospital stillbirths;
Increased access to emergency obstetric care and caesarean sections;
Increased institutional deliveries;
Reduced risk of death form an obstetric emergency;
Decrease in maternal mortality rates;
Reliable communication and transport services increased access to and utilization of maternal health services, particularly in caesarean section deliveries;
Effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality.
Emergency transport can play an important role in reducing maternal mortality and morbidity;
Effective communication systems, transport services and prompt referrals to appropriate facilities will increase access to and utilization of maternal health services, particularly caesarean delivery services and result in a reduction of maternal mortality.
Emergency transportation of pregnant women to maternal health care facilities and subsequent referral often have reliance on mobile phones;
Referral to emergency obstetric care in most rural settings is beset with challenges such as difficult topographical landscape, limited number of vehicles, and the spread of maternal health care facilities.
8. Prevention of mother-to-child transmission (PMTCT) of HIV 1. Byamugisha et al. 2011 [109]; (level II);
2. Delvaux et al. 2008 [112]; (level II);
3. Pirkle et al. 2014 [110]; (level V);
4. Ediau et al. 2013 [54]; (level II).
1. Training of health care workers on strategies to enhance the PMTCT;
2. Equipping of health facilities with medical supplies used in PMTCT;
3. Community mobilization to encourage male partners’ acceptance of HIV testing through joint attendance to clinics with women.
Increase in the number of pregnant women attending first ANC visit;
Number of male partners counseled, tested and given results for HIV together with their wives at first ANC visit also rose significantly;
Significant rise in the number of pregnant women delivering in the health facilities.
PMTCT services involving capacity training of health care workers on PMTCT provision, availability of medical supplies used in PMTCT and community mobilization to encourage male partners’ acceptance of HIV testing improves maternal health indicators in SSA. This review considered only the non-drug components of PMTCT. Therefore, it is difficult to isolate the specific effects of the non-drug components, from the cascade of PMTCT services.
9. Task shifting interventions 1. Gessessew et al. 2011 [123]; (level III);
2. Jennings et al. 2011 [122]; (level III).
effectiveness; equitability
1. Antenatal counseling by lay nurse aids;
2. Performance of emergency caesarean sections by non-physician clinicians (NPCs).
Improved maternal knowledge on prenatal care, birth preparedness and recognition of danger signs among women being counseled;
Reduced hospital-based maternal and fetal deaths arising from obstetric complications;
Postoperative outcomes achieved under the care of non-medically qualified persons were similar to those attained by physicians.
Task shifting interventions may improve cost effective access to and availability of maternal health care services without compromising the essential maternal health service delivery or patient outcomes. Task shifting interventions often employ competent non-medically qualified persons who incur lower remunerations and training costs compared with physicians, however, high level of supervision is required for them to deliver the expected impact services.