i) Methods and contexts of stakeholders’ engagement.

This theme highlights the different approaches and levels of stakeholder engagement in improving MNH services uptake and delivery. According to the IAP2 Public Participation Spectrum, the level of stakeholders’ engagement in six studies was found to practice ‘Consult’ as stakeholder engagement [14,15,36,38,42,45], five studies practiced ‘Involve’ as stakeholder engagement [28,35,37,41,43], five studies practiced ‘Collaborate’ as stakeholder engagement [24,26,31,39,40], and ten studies practiced ‘Empower’ as stakeholder engagement [12,25,27,29,30,32–34,39,46] in the process of improving the delivery and uptake of maternal and newborn health services (Fig 2).

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Fig 2. Methods, contexts, and outcomes of stakeholders’ engagement in maternal and newborn health services research.

https://doi.org/10.1371/journal.pone.0309888.g002

‘Consult’ as engagement. The ‘Consult’ level of engagement actions as stakeholders’ engagement processes were employed through various approaches in the studies to collect service users’ and other stakeholders’ opinions, feedback, and suggestions in the development, implementation, and evaluation of MNH services. In several studies included in the review, some common techniques used for consultation among multiple stakeholders were conducted using interactive group discussions, consultative meetings, and workshops [14,15,25,38,42,45], community monitoring and dialogue with health authorities [38,42,45]. The consultation also involved interactive sessions on MNH issues with male stakeholders such as husbands, social workers, political activists, religious leaders, and landlords of local communities [14,42]. In the study conducted in Burkina Faso, local traditional leaders, community relay workers, and administrative and religious leaders were consulted and engaged through workshops, group discussions, plenary sessions, application of problem-solving techniques, negotiation, and persuasion and lobbying as a community engagement strategy to improve MNH services [36]. There was also the animation of traditional music concerts for advocacy for safe delivery through wider community influencers’ engagements [36]. The community consultation strategy in this study was inspired by the sense that communities are not ‘empty vessels’ and understanding and building upon local cultural beliefs of MNH care is crucial for effective communication of MNH issues [36]. In Bangladesh, a study reported that stakeholder committees were formed to solicit community opinions and suggestions for improving MNH service provision [38]. The stakeholder committee comprised community members, elected Union Parishad women members, leaders, trained traditional birth attendants (TBA) or village doctors, religious leaders, and leaders from other sectors such as educational institutions and community-based organisations. The stakeholder committee regularly monitored health facility cleanliness, collected client feedback on services, and participated in reviewing maternal death or near-miss cases [38].

‘Involve’ as engagement. The ‘Involve’ as engagement strategies reported in the studies were found to be performed through the involvement of different leaders, beneficiaries, local community health workers, and health committees as intermediaries for gathering community concerns related to MNH services and involved through different actions for enhancing MNH services [28,35,37,41,43]. The involvement actions included capacity building of service users, their male partners/husbands, and community members to raise their voices and support MNH activities [28,35,37,41,43], developing community partnerships around social accountability in MNH through community dialogue [37], and sensitisation workshops among health providers to enhance the capacity to understand users’ voices and promote the practice of social accountability [41]. For example, in rural Tanzania, community members participated in the capacity-building meeting to discuss ways of mobilising the community to establish local transportation services for mothers with obstetric emergencies [37]. As part of community capacity building and engagement, village health workers were locally recruited and mobilised to improve MNH outcomes in rural areas by bridging the gap between communities and formal healthcare systems [37]. Pregnant women in Nepal were involved in the MNH promotion activities through service users-led facilitated peer discussions during ANC visits [28]. Of note, one study from Vietnam engaged male partners/husbands/fathers to promote MNH through role model approaches, where the concept of the "Fathers’ Contest” was designed as a community mobilisation strategy to motivate fathers’ involvement in exclusive breastfeeding and support in MNH service uptake [35]. Farmers and the community organised the contest in the name of "Who loves their wives and children more?". Those fathers demonstrating praiseworthy care for their wives and infants were selected for awards and titles.

‘Collaborate’ as engagement. Likewise, the level of engagement denoted as ’Collaborate’ in the papers included in the review embraced the participatory approaches to identify problems, develop solutions, and implement the solutions through the adaptation of different techniques such as participatory workshops, participatory enquiry, community diagnosis/dialogues, co-creation approach, collaborative review meeting, participatory communication (talk shows and radio programs), and collaborations with local volunteers and community-based partners in the implementation of interventions [24,26,31,39,40]. For instance, two studies from Nepal highlighted collaborative efforts as a process for enabling women for MNH through a community health engagement process [24,26]. This involved the engagement of local women as health promoters or facilitators and female community health volunteers to implement the change. These local females played a crucial role in enhancing access and uptake of MNH services by facilitating participatory mother group meetings in the community [24,26].

In Mozambique, the co-creation approach was utilised as a community engagement strategy to involve and collaborate with stakeholders such as male partners, mothers-in-law, community-level decision-makers and other stakeholders for developing education materials, improving transportation services for mothers, and implementing co-created products to enhance health care-seeking behaviours and improving access and uptake of MNH services [31]. In a study from India, service users and their family members collaborated with local service providers to enhance learning, prepare effective birth plans, and practice home-based life-saving skills [25]. In studies from rural Uganda, the participatory inquiry technique was employed to enhance community stakeholder capabilities through mobilisation and support mechanisms[40].

‘Empower’ as engagement. Service users, local health service providers, and community members were empowered and mobilised to enhance MNH service delivery and utilisation. ‘Empower’ level of engagement techniques commonly practised to empower the service users and other stakeholders included community-based participatory approaches such as participatory learning and action cycle, Plan, Do, Study, Act (PDSA) cycle and run charts, Community Action Cycle (CAC), Four ‘D’ Cycle of Appreciative Inquiry (Discovery, Dream, Design, Deliver), co-production, and co-creation approaches [12,25,27,29,30,32–34,39,46]. These participatory approaches identified under this sub-theme were utilised to empower pregnant women and postnatal mothers, women’s groups, local female health promoters/volunteers, health workers, leaders, and other community members by bringing their voices and collaborative efforts in planning and cyclically evaluating MNH actions. For example, in the studies from Tanzania and Kenya, stakeholders strengthened their capacity to facilitate a structured process of problem-solving and testing of change ideas for prioritised quality improvement issues, with the progress systematically monitored by themselves over time using run charts techniques [27,39]. Similar approaches were also used in Uganda and Tanzania, where community volunteers were trained and were one of the key actors within the local health system to improve community-level MNH efforts [46]. Health volunteers were taught to identify MNH issues in their communities and then encouraged to continuously assess the feasibility of improvement of MNH services [46]. Similarly, in a study conducted in Vietnam, local female health promoters used the PDSA cycle to mobilise and empower Maternal and Newborn Health Groups (MNHG) in identifying and prioritising local perinatal health problems, implementing improvement cycles and continuously addressing various issues related to MNH in volunteer groups [32]. The MNHG included community healthcare staff, village health workers, community collaborators, and women’s union representatives.

This stakeholder’s engagement process enhanced their knowledge, skills, and confidence in decision-making by themselves. Similarly, a study from India showed community mobilisation efforts based on the Community Action Cycle (CAC) approach, which were employed to empower communities to actively identify, prioritise, and address MNH problems through collaboration with various community members, including service users, mothers-in-law, male partners/husbands, and community facilitators [25]. Studies from Bangladesh and India showed that local women’s groups were empowered to prioritise MNH issues and collaboratively design and implement strategies to address these identified concerns through participatory learning and action cycles [29,30,33]. Similarly, a study from Nepal highlighted the local stakeholder engagement to strengthen the capacity of health facility management committees, local women’s groups, and Female Community Health Volunteers (FCHVs) to lead discussions on obstacles to institutional delivery and its possible solutions [12]. Likewise, a bottom-up approach to community engagement in Ghana empowered community members to assess MNH service quality on non-technical aspects like staff attitude, punctuality, feedback, information provision, and medication dispensation [34]. Further, the community MNH quality care champions then ensured the implementation of action plans in the health facilities [34].

ii) Outcomes of stakeholders’ engagement.

This theme presents outcomes of stakeholder engagement for improving MNH services in different contexts. The different outcomes resulting from stakeholder engagement were found to be either led by service users or service providers. Those outcomes led by service users were found to be driven by their expectations, needs and preferences for improvements in MNH. This outcome was mostly observed regarding improvements in service users’ experiences, knowledge and attitudes related to MNH. Conversely, the outcomes led by service providers were mostly aligned with the improvements in MNH service delivery and attainments of institutional objectives. Therefore, the wide range of outcomes from stakeholder engagement identified in the included papers were briefly presented under two sub-headings: i) service user-led outcomes and ii) service provider-led outcomes.

1. i) Service user-led outcomes. Several studies in the review reported the wider engagement of service users and other community stakeholders empowered service users and community members and enhanced their MNH knowledge and behaviour [12,14,15,24,25,28,32–35,39,40,42–44]. Two studies from India showed that community engagement meetings involving pregnant women, household decision-makers, community stakeholders, and health workers improved women’s approaches towards receiving support from their families, facilitating easier access to antenatal care, arrangements for transport, permission for emergency care, and identification of a health facility for delivery [29,43]. Studies from Nepal highlighted the FCHV-led participatory intervention with rural women’s groups’ engagements improved antenatal care check-ups, institutional delivery, trained birth attendance, and hygienic care [12,24,26,28]. As part of participatory engagement, the community developed some innovative strategies to support mothers, such as community-generated funds for maternal or infant care, stretcher schemes, production and distribution of clean delivery kits, home visits by group members to newly pregnant mothers, and awareness raising with a locally made film to create a forum for discussion [26]. The increased engagement of Health Development Army (HDA) leaders in southern Ethiopia also led to improved utilisation of MNH services [15]. Study findings from Ghana suggested that bottom-up community engagement in MNH could be a novel strategy to enhance trust and confidence, particularly in a low-resource context [34]. Male involvement in the MNH was recognised as a "new strategy for old problems," where fathers’ involvement in supporting antenatal care had a positive impact on the overall uptake of MNH services and newborn care, including the early initiation of breastfeeding and reduced the use of pre-lacteal feeding [35,39].

Moreover, the participatory engagement of local women groups in MNH interventions in Bangladesh, India, Nepal, and Vietnam reported a considerable reduction in neonatal and maternal mortality [26,29,30,32,33]. The local women’s group mobilisation led to a considerable decrease in neonatal mortality by up to 38%, along with positive changes in home delivery practices, essential newborn care, and feeding practices [30,32,33]. Community-level volunteers such as the Accredited Social Health Activists (ASHA) programme in India and FCHVs in Nepal helped identify MNH-related health problems, prioritise the problems, and develop and implement strategies to address them at grassroots levels [26,29]. It was found to contribute to improving neonatal survival and reducing maternal mortality [26,29]. Likewise, community mobilisation facilitated timely access to emergency obstetric care and improved neonatal survival, transportation services, and facility-based deliveries [25]. In rural Tanzania, community-led initiatives helped establish a community transportation system for mothers with obstetric emergencies, which was developed due to local community stakeholder engagement efforts [37].

1. ii) Service provider-led outcomes. Several studies in the review reported that the engagement of multiple stakeholders at different levels and contexts was found to have a positive influence on improving the quality and delivery of MNH services. In Kenya, collaborative engagements of local MNH service providers supported and mentioned by the facilitation team helped to address performance gaps through rigorous examination, root cause identification, and the development and implementation of change ideas [27]. The initiative highlighted the successful improvement of healthcare quality in small rural facilities in low-income settings without additional external resources. It also highlighted the applicability of quality improvement principles to enhance access and adherence to standards at care points [27]. Similarly, a study from Uganda showed that the engagement of stakeholders using the community Dialogue Model involved community beneficiaries, particularly women; engaging with diverse stakeholders in a participatory advisory process enabled the participants to bring their voices to design the social accountability initiatives in improving MNH [41]. The initiative addresses the essential elements of voice, accountability and responsiveness in the context of community involvement [41]. Two studies from Nepal highlighted that strengthening health facility management committees and mobilising FCHVs successfully reduced institutional barriers to maternal care [12,24]. The engagement of local female health promoters enhanced the capacity of FCHVs to organise mothers’ group meetings, engage wider community stakeholders, and strengthen the local health systems [24]. Similarly, the study conducted in southern Mozambique reported that the MNH promotion had greater acceptance through service users and community engagement strategy [31]. The engagement of household decision-makers and community leaders helped to build local support for maternal health and adapt messages to local needs [31]. In Burkina Faso, various consultation techniques for engaging stakeholders were utilised to reach a consensus and achieve community support for improving and utilising MNH services [36].

Moreover, two studies from Tanzania showed the wider stakeholders’ engagement in the contributions to MNH services’ quality improvement [39,42]. Collaborative learning sessions, mentoring, and coaching enhanced health workers’ knowledge and skills in quality improvement topics, boosting motivation and capacity to implement quality improvement (QI) using PDSA cycles and run charts [39]. The regular community dialogues discovered concerns about healthcare staff attitudes, lack of privacy during delivery, denial of trusted companions’ access, insufficient facilities for post-delivery care, and a lack of food [27]. Likewise, in another study, the facilitator-based initiative postpartum care quality improvement initiative was achieved by employing diverse stakeholder engagement strategies that fostered an empowering and collaborative work approach [42]. The participatory approach strengthened providers’ leadership skills and enabled them to optimise utilising the limited local resources to produce quality MNH services [27].

iii) Facilitators and barriers to stakeholders’ engagement.

Though not all the papers included in the review have documented barriers and facilitators from their formal evaluation of the stakeholder engagements process, a wide range of barriers and facilitators were recognised. The facilitators for the stakeholder engagement included decentralised health governance structures, which enhanced the decision-making process for the management of local stakeholders’ involvement of local leaders and their aspiration to demonstrate leadership and public accountability in the community to create a favourable environment for accelerating the stakeholder engagement process at the grassroots level [12,14,15,31,32,37,40]. Proactive engagement from the technical team in negotiating with local leaders showed a unique and impactful approach to quality improvement, jointly with wider stakeholders’ engagement [42]. In addition, the local non-governmental organisations (NGOs) with extensive experience in selected communities played effective roles in bringing stakeholders together, establishing collaboration and helping foster relationships of trust and credibility with local community members [24,26,45]. Mobilisation of formal and informal social structures enabled continuing stakeholder engagements in MNH [37]. Institutional leadership support was crucial in facilitating implementation efforts at institution-based initiatives [12,27,42]. Reaching service users through community resource persons and regular structured dialogues with communities enhanced both engagement and service utilisation [27].

In countries that have already established community volunteer systems, such as FCHVs in Nepal [12,24,28], Accredited Social Health Activists in India [43], Village Health Workers in Vietnam [32], Health Development Army in Ethiopia, Lady Health Workers in Pakistan [14], Community Health Workers in Democratic Republic of the Congo [41], Community relay workers in Burkina Faso [36], and similar types of volunteers in other countries contributed towards facilitating the stakeholder engagements in MNH improvement process in different ways. However, supervision was crucial to motivate community health volunteers and retain their participatory process in MNH initiatives. The demand-driven comprehensive community partnership approach with a better understanding of the social structure of the local context, the political and cultural logic of power and the ownership of the stakeholder engagement process were instrumental for the meaningful engagement of diverse stakeholders in MNH improvement [36,38]. The use of participatory learning action cycles by local volunteers enabled their responsiveness to work actively on context specific MNH issues [25,27,32,34,39,46]. Effective stakeholder engagements were also contingent on the participants’ identity and selection process of community representatives, which could serve as a platform for already-known groups or individuals to exert their influence.

On the contrary, the lack of a sense of personal/group responsibility and ownership towards initiatives among stakeholders, poor trust between the community and local health workers, unmet demand of financial accountability, ambiguity in the communities’ role, expectations, and obligations, inadequate understanding of policy processes and institutions (policy literacy), and inadequate local people’s commitment towards initiatives were noted as impeding factors for stakeholders’ engagement process [14,24,31,40]. Despite the priority for engagement of marginalised groups in certain studies, the effective engagement of such groups was hindered due to a lack of support from local political leaders, poor financial support and inadequate capacity-building systems [12,30]. The low representation from certain groups, particularly underrepresented or decision-maker groups, hinders the participants from openly engaging and sharing their views during meetings [31]. Male partners/husbands (i.e. fathers) exhibited less engagement in MNH activities, which was attributed not only to socio-cultural circumstances but also to constraining the availability of their appropriate time to participate, given their long hours of work shifts dedicated to familial support outside the home [31,35]. The stakeholders’ participation challenges were especially from rural and poor socio-economic backgrounds due to inadequate incentives, absenteeism, workload, and distance from the community for the stakeholder engagement activities [15,30]. Similarly, an unclear organisational structure, lack of clarity about team mobilisation, and inadequate resources to cover the workloads also hampered stakeholder engagement [42]. In some studies, gendered barriers included women feeling restricted in unions, joining groups, and actively engaging in service improvement actions despite their willingness [13,27,31,32].