How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

Agarwal et al. (2019) [54]

X

X

X

X

X

X

Ayalew et al. (2017) [41]

X

X

X

X

X

X

X

X

Balakrishnan et al. (2016) [55]

X

X

X

X

X

X

X

Basinga et al. (2011) [44]

X

X

X

X

X

X

X

Binyaruka et al. (2015) [46]

X

X

X

X

X

X

Bonfrer et al. (2014) [40]

X

X

X

X

X

Duysburgh et al. (2016) [61]

X

X

X

X

X

X

Edwards et al. (2011) [50]

X

X

X

X

X

X

X

Engineer et al. (2016) [39]

X

X

X

X

X

X

Ghosh et al. (2019) [56]

X

X

X

X

X

Gomez et al. (2018) [52]

X

X

X

X

X

X

Kambala et al. (2017) [42]

X

X

X

X

X

X

X

Larson et al. (2019) [47]

X

X

X

X

Magge et al. (2017) [45]

X

X

X

X

X

X

X

Maru et al. (2017) [43]

X

X

X

X

X

X

X

McDougal et al. (2017) [57]

X

X

X

X

X

X

X

X

Mwaniki et al. (2014) [58]

X

X

X

X

X

X

Okawa et al. (2019) [53]

X

X

X

X

X

X

X

Okuga et al. (2015) [48]

X

X

X

X

X

X

X

X

X

Pirkle et al. (2013) [62]

X

X

X

X

X

X

X

Rahman et al. (2011) [51]

X

X

X

X

X

X

Satti et al. (2012) [59]

X

X

X

X

X

X

X

Waiswa et al. (2015) [49]

X

X

X

X

X

X

X

X

Zeng et al. (2018) [60]

X

X

X

X

X

X

Total number of Xs

15

19

16

16

9

18

2

21

24

18

Agarwal et al. (2019) [54]

India

Training and deployment of lay personnel to provide: health education, linkage of women to healthcare facilities, and home-based ANC and PNC services

06 years

Accredited Social Health Activists (ASHAs)

Primary care (Community based)

Indian Human Development Survey (IHDS)-II (2011–2012 data): secondary data analysis

Exposure to ASHA agents: significantly associated with ANC 1 and SPAB use across the continuum; no significant impact on ≥ 4 ANC or PNC use between exposed and non-exposed women; 12% increase in women receiving at least some of the services; 8.8% decrease in women receiving no services; it is not significantly associated with completion of all services along the continuum

Moderate

Ayalew et al. (2017) [41]

Ethiopia

Standards-Based Management and Recognition (SBM-R) approach (multi-faceted interventions): BEmONC training; supportive supervision; audit and site mentoring; sector-wide leadership; quality improvement team in each facility; mobilizing financial resources; and community involvement

03 years

Doctors, health officers, midwives, and nurses

Primary healthcare (8 Health centres) and 3 secondary care Hospitals

A post-only intervention versus comparison facilities design: observations of service delivery using structured checklists to measure provider performance in ANC, uncomplicated labour and delivery care, and immediate PNC

A significant difference of 22 pp for each newborn and mother PNC skill area; significant positive impact on maternal and newborn health providers' performance during labour and delivery and immediate PNC services, but not during ANC services

High

Balakrishnan et al. (2016) [55]

India

Mobile technology—a health system strengthening multi-stakeholder cooperation (mHealth platform): community-based frontline health workers training on mHealth platform and provision of maternal and child healthcare; supportive supervision; and mobilizing financial resources

02 years

ASHAs, Anganwadi workers, auxiliary nurse-midwives, and lady health supervisors

Primary care (community based)

A quasi-experimental study with pre- and post-implementation evaluation at intervention, and control areas: coverage of quality indicators of maternal–child healthcare continuum compared with control area and the previous year

Implementation blocks had higher coverage of all the 07 quality indicators as compared to the control and the previous year—intervention area vs previous year vs control: registration within the 1st trimester (15% vs 10% vs 10%), complete ≥ 3 ANC visits (56% vs 51% vs 48%), at least 1TT vaccine (79% vs 74% vs 80%), ≥ 90 Iron and Folic Acid Tablets (62% vs 50% vs 49%), health facility birth (84% vs 59% vs 67%), breastfeeding within 1 h of birth (98% vs 73% vs 73%), at least 1 PNC home visit (28% vs 18% vs 10%); there was equity of services across castes for all indicators—scheduled castes/tribes vs other castes: registration within the 1st trimester (15% vs 15%), complete ≥ 3 ANC contacts (55% vs 56%), at least 1 TT vaccine (77% vs 79%), ≥ 90 Iron and Folic Acid Tablets (60% vs 62%), health facility birth (78% vs 87%), breastfeeding within 1 h of birth (95% vs 95%), at least 1 PNC home visit (29% vs 28%); timely capture of data compared to paper-based reporting: average time lag of 72 days (≈ 2.5 months) is overcome by instant data capture with the mHealth platform

High

Basinga et al. (2011) [44]

Rwanda

Quarterly performance-based payment for healthcare providers, directly observed supervision, leadership, and hospital team advisory group

18–23 months

Doctors and mid-level cadres

Primary care (Primary health centres)

Prospective impact evaluation between P4P facilities (intervention) and traditional input-based funding facilities (controls); baseline and end-line surveys at facilities and households; difference-in-differences analysis (DiD) where p-value was the cluster-adjusted t-test

Greatest effect on indicators that had the highest payment rates and needed the least effort from the service provider: an increase of 0·157 standard deviations (p = 0·02) in ANC quality (against Rwandan prenatal clinical care practice guidelines), 7.2% increase in Tetanus vaccine injections during ANC (p = 0·057), no improvements in ≥ 4 ANC coverage (p = 0·825), 23% increase in facility birth in the intervention group (p = 0·017)

High

Binyaruka et al. (2015) [46]

Tanzania

Biannual P4P for health workers and district and regional health managers targeting eight specific MCH care services, leadership

13 months

Skilled personnel

Primary healthcare (health centres, faith-based and parastatal dispensaries, and public dispensaries) and secondary care hospitals

A Controlled Before and After household and facility survey study: DiD analysis (effect-β)

A 0.05 (β: 0.05; p = 0.03) increase in the patient satisfaction score for non-targeted services, a 5.0% reduction in out-of-pocket payment for birth (β: − 5.0; p = 0.023). No evidence of effect of P4P on patient experience of care for targeted services: at least 2 doses of intermittent preventive malaria treatment (IPT) during ANC (p = 0.001), HIV treatment during ANC (p = 0.893), health facility birth (p = 0.001), polio vaccine at birth (p = 0.093), PNC (p = 0.823), postnatal family planning (p = 0.844), ANC contents (p = 0.118), interpersonal care satisfaction during birth (p = 0.505), staff kindness during birth (p = 0.088), waiting time (p = 0.636), consultation time (p = 0.650)

High

Bonfrer, Poel and Doorslaer (2014) [40]

Burundi

Performance-based financing (PBF); quarterly quality assessment by local regulatory authorities

01–04 years

Doctor, nurse, and midwife

Primary healthcare facilities

Burundi Demographic and Health Survey-BDHS (2010–2011) data; the difference-in-differences analysis; provinces with PBF vs. without PBF

No significant effect on first-trimester ANC, ≥ 1 ANC visit or BP measurement during pregnancy; significant impact with 10 pp increase (p < 0.001) on ≥ 1 anti-tetanus vaccination during ANC and with 5 pp increase on SPAB for women where PBF was in place from the start of pregnancy; no significant effect on neonatal mortality; no impact on equitable care: higher probability of BP measurement during pregnancy among non-poor; a significant increase in SPAB (p < 0.028) among the non-poor, and no effect on SPAB among the poor

High

Duysburgh et al. (2016) [61]

Rural Burkina Faso, Ghana, and Tanzania

A computer-assisted clinical decision support system (eCDSS) and performance-based incentives: performance productivity; job satisfaction; financial and non-financial incentives; incentive policies; local research stakeholder cooperation (eCDSS maintenance)

02 years

Medical officer, assistant medical officer, clinical officer, assistant clinical officer, nurse/midwife and auxiliary nurse/midwife

Rural primary healthcare facilities

An intervention study: 06 intervention and 06 non-intervention PHC facilities in each country; assessment of quality of care in each facility by health facility surveys, direct observation of antenatal and childbirth care, patient satisfaction exit interviews, and reviews of patient records and maternal and child health registers; pre- vs. post-intervention and intervention vs. non-intervention health facilities' quality assessment

No significant difference in quality scores of ANC and delivery care to pre-intervention time or non-intervention facilities’ scores. Total ANC observation quality scores (pre- vs post-intervention: 0.83 vs 0.87, p = 0.06; intervention vs non-intervention facilities at end line: 0.87 vs 0.86, p = 0.33); total ANC satisfaction survey quality scores (pre- vs post-intervention: 0.42 vs 0.71, p = 0.09; intervention vs non-intervention facilities at end line: 0.71 vs 0.55, p = 0.73); total ANC patient record review quality scores (pre- vs post-intervention: 0.75 vs 0.82, p = 0.03; intervention vs non-intervention facilities at end line: 0.82 vs 0.71, p = 0.03); total childbirth observation quality scores (pre- vs post-intervention: 0.65 vs 0.75, p = 0.01; intervention vs non-intervention facilities at end line: 0.75 vs 0.68, p = 0.11); total childbirth satisfaction survey quality scores: (pre- vs post-intervention: 0.70 vs 0.84, p = 0.71; intervention vs non-intervention facilities at end line: 0.84 vs 0.83, p = 0.90); total BEmONC signal functions scores (pre- vs post-intervention: 0.75 vs 0.72, p = 0.09; intervention vs non-intervention facilities at end line: 0.72 vs 0.68, p = 0.97); history taking on vaginal bleeding—ANC observation scores (pre- vs post-intervention: 0.22 vs 0.32, p = 0.17; intervention vs non-intervention facilities at end line: 0.32 vs 0.19, p = 0.02); counselling on vaginal bleeding—ANC observation scores (pre- vs post-intervention: 0.49 vs 0.43, p = 0.65; intervention vs non-intervention facilities at end line: 0.43 vs 0.42, p = 0.80); history taking on vaginal bleeding—childbirth observation scores (pre- vs post-intervention: 0.32 vs 0.32, p = 0.20; intervention vs non-intervention facilities at end line: 0.32 vs 0.31, p = 0.54); administer oxytocin after childbirth—childbirth observation scores (pre- vs post-intervention: 0.92 vs 0.96, p = 0.70; intervention vs non-intervention facilities at end line: 0.96 vs 0.91, p = 0.72); monitoring uterine retraction after childbirth—childbirth observation scores (pre- vs post-intervention: 0.41 vs 0.60, p = 0.02; intervention vs non-intervention facilities at end line: 0.60 vs 0.56, p = 0.17); assessing vaginal bleeding after childbirth—childbirth observation scores (pre- vs post-intervention: 0.60 vs 0.78, p = 0.10; intervention vs non-intervention facilities at end line: 0.78 vs 0.72, p = 0.38); ANC satisfaction scores—counselling on vaginal bleeding (pre- vs post-intervention: 0.44 vs 0.47, p = 0.91; intervention vs non-intervention facilities at end line: 0.47 vs 0.17, p = 0.79); women who received oxytocin (%)—childbirth record review (pre- vs post-intervention: 89 vs 89, p = 0.96; intervention vs non-intervention facilities at end line: 89 vs 96, p < 0.01); checking BP—ANC observation scores (pre- vs post-intervention: 0.98 vs 0.97, p = 0.96; intervention vs non-intervention facilities at end line: 0.97 vs 0.93, p = 0.77); lab proteinuria examination—ANC observation scores (pre- vs post-intervention: 0.32 vs 0.47, p = 0.03; intervention vs non-intervention facilities at end line: 0.47 vs 0.22, p < 0.01); counselling on hypertensive disorders danger signs—ANC observation scores (pre- vs post-intervention: 0.45 vs 0.43, p = 0.68; intervention vs non-intervention facilities at end line: 0.43 vs 0.37, p = 0.57); monitoring BP—childbirth observation scores (pre- vs post-intervention: 0.53 vs 0.68, p = 0.04; intervention vs non-intervention facilities at end line: 0.68 vs 0.62, p = 0.30); counselling on hypertensive disorder danger signs—ANC satisfaction scores (pre- vs post-intervention: 0.02 vs 0.42, p = 0.17; intervention vs non-intervention facilities at end line: 0.42 vs 0.19, p = 0.90); lab proteinuria exam—ANC record review (pre- vs post-intervention: 0.51 vs 0.69, p = 0.11; intervention vs non-intervention facilities at end line: 0.69 vs 0.29, p = 0.01); partograph correctly used—childbirth observation (pre- vs post-intervention: 0.58 vs 0.75, p = 0.03; intervention vs non-intervention facilities at end line: 0.75 vs 0.60, p = 0.15); deliveries with correctly completed partograph (%)—record review (pre- vs post-intervention: 42 vs 70, p < 0.01; intervention vs non-intervention facilities at end line: 70 vs 48, p < 0.01)

High

Edwards and Sahab (2011) [50]

Rural Bangladesh

Skills-based training; collaboration and teamwork at all levels; community involvement; monthly supportive supervision; leadership

06 years

Village health volunteers, community health workers, community health assistants, and community skilled personnel

Primary care (healthcare centres and community based), and General hospital (Comprehensive essential obstetric and newborn care)

Country case study: Lutheran Aid to Medicine in Bangladesh (LAMB) Integrated Rural Maternal and Child Healthcare' Home-to-Hospital, Continuum-of-Care' approach

LAMB areas vs. national sample: care received by women (≥ 1 ANC: 81% vs. 52%; SPAB: 32.2% vs. 18%; caesarean section rate: 4.8% vs. 2.7%; and PNC: 85% vs. 22%); a higher proportion of poor women (in wealth quintile-1) received ANC, SPAB, caesarean section, and PNC; the gap in service use between the poorest and the richest women is much smaller

Moderate

Engineer et al. (2016) [39]

Afghanistan

Quarterly Pay-for-Performance (P4P) for health workers; mobilizing financial resources

23–25 months

Skilled personnel

Primary healthcare facilities

A cluster-randomized trial: end line household survey and quality assessment in health facilities in P4P and comparison areas

The P4P had no significant impact on increasing coverage or equity (by wealth index) of targeted MCH services at population level (P4P vs comparison): modern contraception (10.7% vs 11.2%; p = 0.90); ANC (56.2% vs 55.6%; p = 0.94); SPAB (33.9% vs 28.5%, p = 0.17); PNC (31.2% vs 30.3%, p = 0.98); equity in SPAB /concentration index (0.1758 vs 0.1000; p = 0.3);

Quality of care (P4P vs comparison): Overall Client Satisfaction and Perceived Quality of Care Index (76.5% vs 75.1%; p = 0.2); Health Worker Satisfaction Index (63.8% vs 63.4%; p = 0.9); Health Worker Motivation Index (72.7% vs 72%; p = 0.4); quality of care/ history taking and physical examinations index (76.4% vs 72.3%; p = 0.01); quality of care/client counselling index (35.3% vs 29.3%; p = 0.01); quality of care/time spent with client index (14.5% vs 8.6%; p = 0.05)

Selection: LR

Performance: LR

Attrition: LR

Detection: LR

Reporting: LR

Ghosh R. et al. (2019) [56]

India

Multi-faceted onsite nurse mentoring and simulation (diagnosis and management of intrapartum asphyxia and PPH): skills demonstrations, didactic sessions, high-fidelity simulation, bedside mentoring, and team training during actual patient care were the mentoring activities; weekly nurse-mentoring, PRONTO International's simulation, team training; NGO collaboration

20 months

Auxiliary Nurses and general nurse-midwives

BEmONC facilities at Primary care

A quasi-experimental (b/n facilities) and a longitudinal (within facilities) comparison studies over time

Between-facility comparisons across phases: diagnosis was higher in final week of intervention (intrapartum asphyxia: 4.2–5.6%, PPH: 2.5–5.4%) relative to the 1^st week (intrapartum asphyxia: 0.7–3.3%, PPH: 1.2– 2.1%); within-facility comparisons: intrapartum asphyxia Dx among all live births increased from 2.5% in week-1 to 4.8% in week-5, after which it reduced to 4% through week-7, PPH Dx increased from week-1 through 5 (from 1.6% to 4.4%) after which it decreased through week-7 (3.1%); facility performance index—on a scale of 100 from baseline (1st 3 wks.) to end line (≥ 4 wks.): median intrapartum care score (IQR) = [21 (8–29)—58 (42–67)], median newborn care score (IQR) = [42 (35–50) 71 (58–79)]; diagnosis per additional week of mentoring, adjusted incidence rate ratios (IRR, 95% CI): asphyxia (Wks. 1–5: 1.21(1.13, 1.29), p < 0.001; wks. 5–7: 0.91(0.82, 1.01), p = 0.073; PPH (Wks. 1–5: 1.17 (1.05, 1.31), p = 0.006; wks. 5–7: 0.86 (0.77, 0.97), p = 0.017; management per additional week of mentoring (IRR, 95%CI): asphyxia [(radiant warmer: 1.05 (1.01, 1.09), p = 0.005; drying-stimulation: 1.05 (1.02, 1.08), p = 0.003; suctioning: 1.03 (0.99, 1.06), p = 0.127; positive pressure ventilation (PPV):1.09 (1.02, 1.15), p = 0.007] and PPH [IV fluids: 1.01 (0.97, 1.04), p = 0.688; uterotonics: 0.99 (0.95, 1.03), p = 0.700]

High

Gomez et al. (2018) [52]

Ghana

On-site, low-dose, high-frequency training in BEmONC of registered or certified skilled personnel: two 4-day low-dose sessions, high-frequency practice sessions using anatomic models and mentoring with SMS reminder messages and quizzes; clinical simulation; follow-up mentorship and appraisal (mobile or onsite); mobilizing financial resources

18 months

Midwives

40 secondary care public and missionary hospitals

A cluster-randomized trial: prospective intrapartum stillbirths and 24-h newborn mortality for 12 months. Baseline mortality rates were collected retrospectively 6 months pre-intervention

36% reduction (ARR: 0.64; 95% CI: 0.53–0.77; p < 0.001) in 1st 1–6 months of implementation and 52% reduction (ARR: 0.48; 95% CI: 0.36–0.63; p < 0.001) in second 7–12 months of implementation in intrapartum stillbirth rates as compared to pre-intervention period, respectively; 59% reduction (ARR: 0.41; 95% CI: 0.32–0.51; p < 0.001) in 1st 1–6 months and 70% reduction (ARR: 0.30; p < 0.001) in 2nd 7–12 months in 24-h newborn mortality rates as compared to pre-intervention period, respectively

Selection: SC

Performance: LR

Attrition: LR

Detection: LR

Reporting: LR

Kambala et al. (2017) [42]

Rural Malawi

RBF for Maternal and Newborn Health initiative: quarterly performance-based financing (supply-side financial incentive upon attainment of a pre-defined set of indicators, 70% for staff bonuses and 30% for health facility’s operational activities, health management teams were rewarded with financial incentives based on the overall performance of a district as a measure of the adequacy of supervision) and financial incentives to women for delivering in a health facility (demand-side incentive, conditional cash transfers to mothers for giving birth in a health facility); health workers advisory group; mobilizing financial resources; refresher in-service training on antenatal management, obstetric care, and quality assurance; RBF policy

03 years

Healthcare managers, skilled personnel

33 primary and secondary EmOC facilities (Basic and comprehensive)

Mixed method prospective sequential controlled pre- and post-test study over intervention vs. control facilities: client exit interviews, in-depth interviews and FGDs with women and In-depth interviews with health service providers; difference-in-differences analysis (DiD)

End-term vs baseline cohorts (DiD adjusted): mean effect estimate of women’s perceptions on interpersonal relations (ANC: − 0.2, p = 0.56; L&D: − 0.1, p = 0.70; PNC: − 0.3, p = 0.45); mean effect estimate of women’s perceptions on quality of amenities (ANC: − 0.2, p = 0.54; L&D: − 0.3, p = 0.45; PNC: − 0.49, p = 0.14); mean effect estimate of women’s perceptions on technical care (ANC: − 0.2; p = 0.39; L&D: − 0.1, p = 0.85; PNC: − 0.31, p = 0.38). No significant effect on women’s perceptions of technical care, quality of amenities, and interpersonal relations for any of the three sets of services observed (ANC, L&D, and PNC); increased the proportion of women reporting to have received medications/treatment during childbirth. Qualitative interviews: most women reported improved health service provision as a result of the intervention; drugs, equipment, and supplies were readily available due to the RBF4MNH; instances of neglect, disrespect, and verbal abuse during the process of care; increased workload resulting from an increased number of women seeking services at RBF4MNH facilities

Moderate

Larson et al. (2019) [47]

Rural Tanzania

In-service training; mentoring; supportive supervision; peer outreach

04 years

Mid-level cadres

Primary care (community-based and primary care clinics)

A cluster-randomized study: baseline (2012) and end line (2016) household surveys in control and intervention catchments; difference-in-differences analysis (DiD)

Total study population-DiD: improved quality of ANC/contents of ANC [Adjusted (A) RR: 1.64; 95% CI: 1.00–2.71]; perceived quality of ANC (ARR: 1.14; 95% CI: 0.88–1.47); perceived obstetric care quality at intervention facility (ARR: 1.13; 95% CI: 0.79–1.62); reduced payment for obstetric care at intervention facility (ARR: − 3.76; 95% CI: − 7.02 to − 0.49). Previous home births-DiD: improved quality of ANC/contents of ANC (ARR: 2.31; 95% CI: 1.44–3.71); improved perceived quality of ANC (ARR: 1.57; 95% CI: 1.07–2.31); perceived obstetric care quality at intervention facility (ARR: 1.12; 95% CI: 0.78–1.59); reduced payment for obstetric care at intervention facility (ARR: − 2.24; 95% CI -4.76—0.28)

Selection: LR

Performance: SC

Attrition: LR

Detection: LR

Reporting: LR

(Magge et al. (2017) [45]

Rwanda

Monthly onsite, regular clinical mentorship and training on evidence-based life-saving maternal and newborn care; learning collaborative to build healthcare workers’ leadership in data utilization for continuous quality improvement (QI); mobilizing financial resources; procurement and distribution of essential equipment and supplies

18 months

Nurses, community health supervisors, data officers, and health facility and district leadership

Primary care (Community-based and health centres), and secondary care hospitals

A retrospective case study using the quantitative method: pre–post intervention evaluation

Pre- vs post-intervention: ≥ 4 ANC (23% vs 38%); 1st trimester ANC (23% vs 34%); pregnant women with premature rupture of membrane (PROM) treated with antibiotics (24% vs. 38%); pregnant women with preterm labour treated with corticosteroids (26% vs 75%); SPAB (87% vs. 95%); time to C-section in minutes [median, (IQR): 99 (50–195) vs. 72 (59–77)]; immediate skin-to-skin care after delivery (19% vs. 87%); newborns checked for danger signs within 24 h of birth (47% vs. 98%)

Moderate

Maru et al. 2017) [43]

Rural, remote Nepal

Accountable public–private partnership through integrating community health workers into facility-based care: CHWs conduct surveillance of conditions in the community, triage, referral, and care coordination with healthcare facilities; government’s performance-based accountable payment

18 months

Community health workers

Primary healthcare (Community-based, village clinics/health posts) and secondary care district hospitals

A prospective pre–post pilot study: a household-level census survey to compare population-level maternal, newborn, and child healthcare indicators to the baseline

Pre- vs post-intervention: ≥ 4 ANC [(Increased by 6.4 pp); coverage increased (83% vs 90%)]; health facility birth [(increased by 11.8 pp; p < 0.001); coverage increased (81% vs 93%)]; postnatal contraception [(rate increased by 27.5 pp; p < 0.001); coverage increased (19% vs 47%)]; infant mortality rate (18.3/1000 vs 12.5/1000); 95% received ultrasound examination by month 8 or 9 of pregnancy

Moderate

McDougal et al. (2017) [57]

India

Training, mobilizing, monitoring, and empowering government Frontline workers (FLWs) and community outreach (home-based) interventions: job aids and tools; mobile service training course for FLWs to expand and refresh their knowledge of life-saving RMNCH behaviours; community involvement; mobilizing financial resources; local policy

02 years

ASHAs, auxiliary nurse midwives, and Anganwadi (Social Service) workers

Primary care (community-based and primary healthcare facilities)

A two-armed quasi-experimental study (intervention vs. control areas); house to house survey of women aged 15–49 with a 0–5-month-old child at baseline and follow-up; difference-in-differences (DiD) analyses

The mean number of services/behaviours used along the RMNH continuum of care (CoC) was significantly higher in intervention areas as compared to control areas at follow-up (0.94 vs. 0.51 health services/behaviours; p < 0.0001); overall RMNH CoC coverage in intervention areas increased by 0.41 (Coefficient: 0.41; 95% CI 0.24–0.59; p < 0.001) health services/behaviours as compared to the control areas: DiD: ≥ 4 ANC (p = 0.23); SPAB (p = 0.98); nothing applied to the cord (p = 0.01); skin-to-skin care (p = 0.03); first bath delayed by ≥ 2 days (p = 0.26); breastfed child within 1 h of birth (p = 0.39); PNC visit for mother or baby within 48 h (p = 0.69); postpartum contraception (p < 0.01); child exclusively breastfed (p = 0.47); gender equity interaction analysis showed diminished intervention effects on ANC, SPAB and exclusive breastfeeding for women married as minors

High

Mwaniki et al. (2014) [58]

Rural Kenya

Quality improvement ‘collaborative’ health worker advising: regular meeting of a group of health workers from different health facilities that work on the same set of quality indicators to examine performance gaps in service delivery, the causes of these gaps, and solutions to address them; employee relations; leadership; community involvement

20 months

Healthcare managers, skilled personnel, community health workers, and traditional birth attendants

Primary care (3 health centres and 17 dispensaries), and 1 government-run secondary care hospital

A pre- and post-implementation evaluation: data were collected and entered into routine govt. registers daily by the teams and were then used to evaluate 20 indicators of care quality improvement activities monthly

ANC visits in the first trimester (< 16 weeks G.A) increased significantly (8% to 24%; p = 0.002), and those making ≥ 4 ANC visits significantly increased (37% to 64%; p < 0.001); ANC visits per month with standardized care substantially increased (< 40% to 80–100%; p < 0.001) within 03 to 06 months; SPAB significantly increased per month from (33% to 52%; p = 0.012); pregnant women actively referred from the community (by community representatives) to health facilities for ANC, and birth care significantly increased (13 per month to 81 per month; p < 0.001)

Moderate

Okawa et al. (2019) [53]

Rural Ghana

Orientation of supervisors and healthcare providers in the continuum of care (CoC); distribution of CoC cards to women, home visits to provide PNC within 48 h for those who missed the first 24 h visit; mobilizing financial resources; monthly supervision and monitoring; capacity building to lead sector-wide collaboration

12 months

Doctor, midwife, nurse, community health officer, and community health nurse, and health assistant

Primary healthcare (community-based, private clinics, health centres) and secondary care district hospital

A cluster randomized controlled trial: baseline and follow-up survey to measure adequate contacts (≥ 4 ANC, SPAB, and three timely contacts within 6 weeks postnatal) and quality care (six components during ANC, 3 during peripartum care (PPC), and 14 during postnatal); difference-in-differences analysis (DiD)

The interventions improved contacts with healthcare providers and quality of care during PNC, not in ANC or IPC, regular contacts with healthcare providers did not guarantee quality of care: 12.6% of women in the intervention group received all 6 items during ANC (4.9% baseline), 33.6% received all 3 items during PPC (23.8% baseline) and 41.5% of women and their newborns received all 14 items during PNC (11.5% baseline); adjusted DiD estimators: no significant changes across the three phases: ANC (p = 0.61), PPC (p = 0.69) and PNC (p = 0.35); the percentage of adequate contacts with high-quality care in the intervention group in the follow-up survey and the adjusted DiD estimators (with baseline adequate contacts for ANC, PPC and PNC of 4.9%, 20.2% and 1.3%, respectively) were 12.6% and 2.2 (p = 0.61) at ANC, 31.5% and 1.9 (p = 0.73) at PPC and 33.7% and 12.3 (p = 0.13) at PNC in the intention-to-treat design (real world-effectiveness of the intervention), whereas 13.0% and 2.8 (p = 0.54) at ANC, 34.2% and 2.7 (p = 0.66) at PPC and 38.1% and 18.1 (p = 0.02) at PNC in the per-protocol design (ideal world-designated by possession of continuum-of-care card); in intention-to-treat design, 76.9% of women in the intervention group in the follow-up survey had adequate contacts during ANC; however, only 12.6% had quality-adjusted adequate contacts; 82.0% SPAB, while only 31.5% had SPAB with high-quality care; during PNC, 62.2% of women and their newborns had adequate contacts, however, only 33.7% had quality-adjusted adequate PNC contacts

Selection: LR

Performance: LR

Attrition: LR

Detection: LR

Reporting: LR

Okuga et al. (2015) [48]

Uganda

Recruitment, training, immediate deployment and incentivization of CHWs; skilled personnel’s in-service training and provision of essential equipment and supplies: selected by the community; 07 days training on identifying pregnant women, and make two pregnancy home visits and three postnatal home visits in the first week after birth; financial and non-financial incentives (t-shirt, briefcase and certificate, and transport allowance); directly observed supervision visits by nurses/midwives and group supervision meetings monthly then quarterly; mobilizing financial resources

02 years

Community health workers and skilled personnel

Primary care (community-based and primary healthcare facilities)

A community-based cluster-randomized control trial: in-depth interviews (IDIs) and focus group discussions (FGDs) involving facility-based health workers, members of the District Health Team, village leaders, mothers with children less than 6 months of age, and CHWs both from urban and rural areas

CHWs highly appreciated in the community and seen as important contributors to maternal and newborn health at a grassroots level; more women attending ANC during the first trimester; husbands/partners save money, provide women with money for emergencies, transport, and babies’ needs; women attend to their health needs during pregnancy; women recognize danger signs; more births at health facilities; women experience a caring attitude from health workers; women with CHW referral slips are seen faster at hospital or health unit; women put only salty water on the baby’s umbilical cord rather than animal dung and herbs; bathing is delayed instead of immediately practiced; more women taking their newborn babies to health facilities for PNC and immunization; immediate breastfeeding at birth and continuous breastfeeding; more women giving colostrum

Moderate

Pirkle et al. (2013) [62]

Mali and Senegal

Maternal death review (auditing maternal deaths in the facility), workshops on obstetrical best experiences, and periodic visits by international experts: a 6-day workshop to train and certify health professional leaders in EmOC best practice, audit techniques, and sexual and reproductive rights; a multidisciplinary audit committee established in each facility to undertake a monthly audit according to the WHO guidelines; staff trained in best practice obstetric care; educational outreach sessions every three months and re-certification; international observatories; leadership; supportive supervision; mobilizing financial resources

02 years

Doctors, midwives, and nurses

Referral hospitals (Comprehensive EmOC centres)

A cluster-randomized controlled trial: one pre-intervention year and two intervention years to measure obstetric care quality in the post-intervention year. A criterion-based clinical audit (CBCA) to measure patient history, clinical examination, laboratory examination, birth care, and PNC; reviewing patient charts; t-test analysis

Women treated at intervention hospitals have, on average, 5 pp greater CBCA scores than those treated at control hospitals (β: 0.052; 95% CI: 0.003–0.102; p = 0.04): intervention vs control hospitals: initial interview CBCA scores (82.3% vs 81.1%); first clinical exam CBCA scores (86.4% vs 80.5%; p < 0.05); laboratory exams CBCA scores (33.3% vs 31.7%); birth care CBCA scores (63.3% vs 62.8%); postnatal monitoring CBCA scores (56.2% vs 46.1%; p < 0.05); significantly more women received good quality care (> 70% criteria attainment): (44.1% vs 29.7%; p < 0.001); significantly greater CBCA scores in women treated (68.2 vs 64.5; p < 0.05)

Selection: LR

Performance: LR

Attrition: LR

Detection: LR

Reporting: LR

Rahman et al. (2011) [51]

Bangladesh

Community involvement in bi-monthly pregnancy surveillance, home-based care through CHWs; health facility-based training on management of normal and complicated deliveries and newborn complications for doctors and midwives, standard guidelines development and implementation for management of maternal and newborn complications; mobilizing financial resources

02 years

Doctors, midwives, and CHWs

Primary care (community-based, healthcare centre), secondary care district hospital, and tertiary care hospitals

Pre- and post-intervention community-based survey at intervention and comparison areas; difference-in-differences analysis

Intervention area: perinatal mortality decreased by odds of 36% as compared to pre-intervention period (AOR: 0.64; 95% CI 0.52–0.78); significant reduction in perinatal mortality in intervention area as compared to the comparison area (p = 0.018); post-intervention area: early pregnancy (GA: 12–14 weeks) ANC home visit: 94.3%, late pregnancy (GA: 32–34 weeks) ANC home visit: 77%; post- vs pre-intervention area: health facility ANC visits (ANC 3 + : 78% vs 38%, ANC 2: 12% vs 43%, ANC 1: 6% vs 15%), health facility birth (72% vs 55%; p < 0.001), cesarean section rates (16% vs 8%; p < 0.001), < 1 day timing of first newborn bath (4% vs 30%; p < 0.001), colostrum as first newborn food (96% vs 83%; p < 0.001); < 30 min timing of first breast feeding (81% vs 61%; p < 0.001), preterm births (before 37-week gestation) significantly decreased (12.3% vs 16.8%; p < 0.001); intervention vs comparison areas: still birth rate (23/1000 births vs 31/1000 births), early neonatal deaths (17/1000 live births vs 27/ 1000 live births); perinatal mortality rate (3.2% vs 5.6%)

High

Satti et al. (2012) [59]

Rural mountainous Lesotho

Training and performance-based incentives: 3 months training of 100 women, mostly TBAs, to identify pregnant women and accompany them to a health centre for ANC, birth care, and PNC services (clinic-affiliated maternal health workers); deployment of a nurse-midwife to the health centre to provide ANC and birth care and supervise the maternal health workers; public–private sectors partnership

02 years

Traditional birth attendants (TBAs), nurse-midwife

Primary care (community-based and primary healthcare centre)

Before and after secondary data analysis of ANC and delivery registers

The average number of ANC 1 visit increased from 20 to 31 per month; 520 women tested for HIV during the ANC 1 visit, where 94% were with unknown status compared to 18 new PMTCT clients registered in the year preceding the program; VDRL (syphilis) testing for 644 women (86% of ANC 1 visit); haemoglobin testing for 637 women (85% of ANC 1 visit); 218 mothers (122 in year 2) admitted to maternal waiting houses (55% of health facility birth); 178 health facility birth in the 1st year of the program and 216 in the 2nd year, compared to 46 in the year preceding the program; 49 women with complications successfully transferred to the district hospital; no maternal deaths among the women in the program

Moderate

Waiswa et al. (2015) [49]

Rural Uganda

Training CHWs for 5 days on the identification of pregnant women in their community, and undertaking two home visits during pregnancy and three visits after birth at or as close to days 1, 3, and 7 reinforced by directly observed supervision; 6 days in-service training for SABs in 20 public and private health facilities on goal-oriented ANC, managing maternal complications, infection prevention, managing normal labour and partograph use, neonatal resuscitation, care of the sick newborn, and extra care for small babies using kangaroo mother care; community involvement; non-financial incentives (t-shirt, briefcase, certificate); travel refund; mobilizing financial resources

02 years

Community health workers and skilled personnel

Primary care (community-based and primary healthcare facilities)

A cluster-randomized controlled trial: community-based baseline and end-line surveys; t-test analysis (p) for comparison between intervention and control end lines

The interventions provided improved maternal and essential newborn care practices to poorer families—intervention vs control clusters: ≥ 4 ANC visits (47% vs 43.6%; p = 0.165); mothers with knowledge of two or more pregnancy-related danger signs (32.7% vs 38%; p = 0.126); mothers received ≥ 1 home visit during pregnancy (68.2% vs 7.3%; p < 0.001); SPAB (79.6% vs 78.9%; p = 0.826); use of TBAs dropped by (5.7% vs 0%); women visited by a CHW in the first week after birth (62.8% vs 5.8%; p < 0.001); newborn put to the breast within 1 h of birth (72.6% vs 66%; p = 0.0116); newborn given colostrum (93.4% vs 91.2%; p = 0.086); baby exclusively breastfed in first month of life (81.8% vs 75.9%; p = 0.042); newborn placed skin-to-skin with mother within 1 h of birth (80.7% vs 74.2%; p = 0.071); newborn wrapped immediately after birth (99.6% vs 99.8%; p = 0.562); first bath delayed ≥ 24 h after birth (49.6% vs 35.5%; p < 0.001); cord cut with clean instrument (88.1% vs 84.4%; p = 0.074); nothing applied to umbilical cord after cutting (63.9% vs 53.1%; p = 0.002); LBW babies given kangaroo mother care (22.4% vs 9.3%; p = 0.089)

Selection: LR

Performance: LR

Attrition: LR

Detection: LR

Reporting: LR

Zeng et al. (2018) [60]

Rural Zambia

Results-based and input-based financing; mobilizing financial resources: with the RBF, health facilities were provided with incentives tied to performance on pre-agreed MCH care indicators. Sixty percent of the incentive payment was used for staff bonuses, and 40% was used for operational activities. In IBF, health facilities received funding only for operational activities that were not tied to performance

27 months

Skilled personnel

Primary healthcare facilities

A triple-matched cluster-randomized trial: before and after trial household and facility surveys; difference in Differences (DiD) analysis

RBF districts-DiD: coverages were improved by 19.5% for injectable contraceptives (p < 0.05), − 1.5% ANC, 3% IPT in pregnancy (p < 0.05), 12.8% SPAB (p < 0.01), 8.2% PNC (p < 0.05) and 6.1% to 20.4% infant vaccinations as compared to controls; IBF districts-DiD: coverages were improved by − 2.3% for injectable contraceptives, 0% ANC, 0.7% IPT in pregnancy, 17.5% SPAB (p < 0.01), 13.2% PNC (p < 0.01) and 0.3% to 5.6% infant vaccinations as compared to controls; RBF districts-DiD: coverages were improved by 21.8% for injectable contraceptives (p < 0.05), − 1.5% ANC, 2.3% IPT in pregnancy, − 4.9% SPAB, − 5.1% PNC and − 1% to 18.6% infant vaccinations as compared to IBF districts; RBF districts: quality of care index-DiD: improved by 9.7% for injectable contraceptives, 2.9% for ANC, 3.1% for SPAB, 2.3% for PNC and 3.8% for infant vaccinations as compared to the controls; IBF districts: quality of care index-DiD: improved by 4.8% for injectable contraceptives, 2.8% for ANC, 2.4% for SPAB, 3% for PNC and 0.6% for infant vaccinations as compared to the controls; RBF districts: quality of care index-DiD: improved by 4.9% for injectable contraceptives, 0% for ANC, 0.7% for SPAB, − 0.8% for PNC and 3.2% for infant vaccinations as compared to IBF districts; pregnant women and children < 5 years in RBF districts gained 604 and 14,574 QALYs, respectively, while pregnant women and children < 5 years in IBF districts gained 302 and 8,274 QALYs, respectively, as compared to the controls; pregnant women and children < 5 years in RBF districts gained 302 and 6,300 QALYs, respectively, as compared to the IBF districts; incremental cost–effectiveness ratios of US$ 809 and 413 per QALY gained for RBF and IBF districts, respectively, as compared to controls. Incremental cost-effectiveness ratio of US$ 1324 per QALY gained for RBF districts as compared to the IBF districts

Selection: LR

Performance: LR

Attrition: LR

Detection: LR

Reporting: LR