Background
Methods
Results
Characteristics of included studies
Author(s) | Year | Country/ region of study | Preventive intervention implemented | Phase applicable to intervention |
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Bacon | 2003 | sub-Saharan Africa | Improving access to adequate medical care; Health education programs | All three phases |
Banke-Thomas et al. | 2014 | sub-Saharan Africa | Community and Facility based interventions | All three phases |
Fistula carea | 2010 | Guinea (Kissidougou) | Village safe motherhood committees; Financial partnerships; Maternal waiting homes; and Market Towns and Local Resource Mobilisation project | All three phases |
Fistula care (a)a | 2011 | Sierra Leone | Aberdeen’s Women’s Centre: counselling, family planning, and a maternity care unit for pregnancy care, labour and delivery, and postpartum recovery (services to prevent fistulas) | All three phases |
Fistula care (b)a | 2011 | sub-Saharan Africa | Partograph | Phase 3: Receiving adequate care |
Fistula carea | 2013 | Uganda | Partograph | Phase 3: Receiving adequate care |
Gerten et al. | 2009 | Nigeria | Patient educational brochure at a vesicovaginal hospital | Phase 1: Decision to seek care |
Levin and Kabagema | 2011 | sub-Saharan Africa | Partograph | Phase 3: Receiving adequate care |
Markos and Bogale | 2015 | Ethiopia (Bale zone) | Partograph | Phase 3: Receiving adequate care |
Miller et al. | 2005 | sub-Saharan Africa | Fistula prevention centres; Community-based preventions; Maternal waiting homes; and Training course about screening for risk of fistula | All three phases |
Nathan et al. | 2009 | West Africa | Femme pour Femme, community healthcare insurance plan | All three phases |
Ngoma | 2011 | Zambia | EmOC and Safe Motherhood Actions Groups (SMAGs); and Income generating activities (IGA) | All three phases |
Ojanuga | 1991 | Nigeria | Community health education programs; organizing transport for pregnant women in need; and training traditional birth attendants | All three phases |
Ojanuga | 1992 | Nigeria | Health education programs | Phase 1: Decision to seek care |
Seim et al. | 2014 | Niger | Community-mobilization program that arrange transport for women who experience complicated labours | All three phases |
Tahzib | 1989 | Nigeria | Safe motherhood initiatives not specified but aimed at encouraging hospital deliveries, and the improvement of the perception of facilities by women seeking help | All three phases |
Turan et al. | 2007 | Eritrea | Transport of women to healthcare facilities | Phase 2: Accessibility of care |
UNFPA | 2013 | sub-Saharan Africa | Global midwifery program; All-terrain motorbikes (Women and Health Alliance International) | Phase 2: Accessibility of care; Phase 3: Receiving adequate care |
Barriers
Phase one: Decision to seek care
Phase one: Decision to seek care | Phase two: Reaching a facility or preventive intervention | Phase three: Receiving adequate care through a preventive intervention |
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• Lack of awareness about health and preventive interventions ○ Ignorance among the villagers of the dangers associated with unsupervised delivery for women who are at risk ○ Negative experiences of other women at healthcare facilities ○ Illiteracy • Lack of access to preventive interventions • Lack of financial resources serve as a major disincentive to the use of modern health facilities • Reluctance of women to be away from their homes for an undetermined period of time • Language barrier, dependence on translation of a brochure into the reader’s native language | • Preventive strategies regarding birth plans are lagging • Lack of infrastructures such as paved roads, piped water, and electricity. ○ Worsens accessibility during he rainy and harvest seasons • Lack of transport ○ Large distances from the villages to healthcare facilities • Lack of financial resources to pay for transport • Lack of ambulance services and portable oxygen • Limited referral systems i.e. when emergency transport isn’t available | • Perception, healthcare practitioners view women with fistulas as a ‘nuisance’ and ‘embarrassment’ ○ Affects their attitude towards them and in turn the experience of the patient • Limited services and manpower ○ Doctors are preoccupied with high-tech practices, leaving their units overwhelmed with obstetric emergencies ○ Overworked staff ○ Staff shortages and high attrition rates • Lack of skilled healthcare providers ○ High staff turnover at maternity units which results in the loss of valuable skills and training investments ○ Absence of supervisory staff • Lack of financial resources, which leaves the facilities rarely self-sufficient • Lack of reimbursement for village practitioners • Improper/ limited use of the partograph ○ Lack of essential supplies and equipment needed ○ Lack of training |
Phase two: Accessibility of care
Phase three: Receiving adequate care
Facilitators
Phase one: Decision to seek care
Phase one: Decision to seek care | Phase two: Reaching a facility or preventive intervention | Phase three: Receiving adequate care through a preventive intervention |
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• Women with successful treatments acting as ambassadors and advocates for healthcare facilities ○ Women are provided with training on public speaking and interpersonal communication skills • Increased awareness within communities through training ○ About maternal/ child morbidities, and the importance of seeking care • Community involvement ○ Volunteer coordinator provides SMAGs with technical support, and schedule activities and training ○ Increased involvement of men, community leaders, and religious leaders, as they are decision-makers within these communities • Financial support ○ Allowing women to participate in income-generating activities ○ Free healthcare services for pregnant women and children under 5 years old | • Financial support ○ Reimbursement for transport ○ Insurance plan that provides transport costs ○ Community generating money to assist with transport costs • Assistance with transport ○ A politician procured an ambulance, which facilitated the evacuation of labouring women in need ○ All-terrain motorbikes to facilitate transport to healthcare facilities • Volunteers initiate evacuation by phoning a midwife at a facility that has an ambulance available • Volunteers arrange transport to the closest facility • Relocation of midwives in rural areas where the most at-risk women and girls reside • Improved mobile coverage to arrange evacuation | • Mobilisation of recognised experts • Training ○ On the local needs as a means of improving the morale for the provision of preventive care ○ On the improved use of the partograph ○ Of patients so they educate women and their local communities when they return home • Financial support from international foundations and organisations ○ Insurance plan that covers medical costs for pregnant women • Partnerships that provide funds for research, the purchase of essential equipment, and the development of basic infrastructure ○ Donation of supplies and volunteers’ time, which improves adequate staffing, space, equipment, and essential medication • Employment of more midwives • Mobile prenatal clinics serve remote villages |
Phase two: Accessibility of care
Phase three: Receiving adequate care
Discussion
Barriers
Facilitators
Strengths and limitations
Implications for practice and policy
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Future policies and initiatives should focus on increasing awareness of preventive interventions through training programs, and should not only be addressed to women but even more so to men and the leaders of communities.
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Simultaneously, the capability of health facilities to provide EmOC should be strengthened through appropriate and regular training on management of complicated labours, as well as through the provision of basic and essential tools and amenities.
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Lastly, financial support is required both in relation to the provision and payment of services, but also to improve transport and infrastructure, allowing labouring women to arrive sooner at facilities offering preventive care.