https://orcid.org/0000-0001-8684-5773
Figures
Abstract
Background
Obstetric emergencies remain a leading cause of maternal morbidity and mortality in sub-Saharan Africa (SSA) despite increased access to facility-based deliveries and emergency obstetric care. Improving outcomes requires not only life-saving clinical interventions but also effective health system strategies. This review mapped published evidence on strategies used to improve outcomes of obstetric emergencies in SSA.
Objective
This scoping review aimed to identify strategies reported in the literature to improve outcomes of obstetric emergencies in SSA.
Methods
The review was reported in accordance with PRISMA-ScR. A comprehensive electronic search of PubMed, CINAHL, SCOPUS, and CORE identified studies published between January 2019 and December 2025. Eligible studies focused on strategies to improve outcomes for pregnant women experiencing obstetric emergencies in sub-Saharan Africa and were published in English. Data were extracted using a standardized data-extraction tool and descriptively mapped through thematic analysis to identify the range and characteristics of strategies reported across studies.
Results
Of the 728 records identified, 64 studies met the inclusion criteria. The identified strategies were organised into four interrelated themes. Three themes described strategies to improve outcomes of obstetric emergencies: (1) life-saving clinical and health system interventions, including pharmacological therapies, monitoring and triage tools, and service-strengthening initiatives; (2) health workforce education, training, and mentorship, which improved provider competence and selected process outcomes but showed variable effects on maternal mortality; and (3) health system organisation, referral mechanisms, and policy implementation, including emergency obstetric care protocols, referral coordination, and service decentralisation. A fourth theme described contextual factors influencing the implementation and effectiveness of these strategies, including infrastructure limitations, resource constraints, workforce shortages, and delays in accessing care.
Conclusion
Improving outcomes of obstetric emergencies in sub-Saharan Africa requires integrated, context-responsive strategies that combine evidence-based clinical interventions with strengthened health systems. This review demonstrates that effective obstetric emergency care depends not only on life-saving clinical management but also on coordinated referral systems, a competent and supported health workforce, functional health system organization, and enabling implementation contexts. Future research should evaluate the effectiveness, scalability, and sustainability of integrated strategies across diverse resource-constrained settings.
Citation: Wachira SW, Wagathu R, Waweru B, Maina R, Ongeso A, Shumba CS, et al. (2026) Strategies to improve outcomes of obstetric emergencies in sub-Saharan Africa: A scoping review. PLoS One 21(9): e0355174. https://doi.org/10.1371/journal.pone.0355174
Editor: Sabita Tuladhar, LMU München: Ludwig-Maximilians-Universitat Munchen, NEPAL
Received: June 23, 2025; Accepted: July 19, 2026; Published: September 1, 2026
Copyright: © 2026 Wachira et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Yes - all data are fully available without restriction; All relevant data are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Obstetric emergencies remain a leading cause of preventable maternal morbidity and mortality globally, with a disproportionate burden borne by countries in sub-Saharan Africa (SSA). SSA accounts for around 70% of global maternal deaths, despite progress in reducing maternal mortality since 2000 [1,2]. This high maternal mortality is driven by delays in the recognition of complications, timely referral, and receipt of appropriate care, factors widely conceptualised within the ‘three delays’ framework and consistently demonstrated in facility-based referral studies [3]. Maternal mortality in SSA is caused by obstetric emergencies, with obstetric haemorrhage, hypertensive disorders of pregnancy, maternal sepsis, obstructed labour, and complications of unsafe abortion accounting for a substantial proportion of maternal deaths [4]. These obstetric emergencies require timely and coordinated responses that extend beyond isolated clinical interventions to include skilled health workers, reliable commodities and blood supply, functional referral pathways, and responsive health system organisation [5–7]. Consequently, strategies to improve outcomes of obstetric emergencies should be understood as multidimensional, encompassing life-saving clinical interventions, workforce capacity-building, effective referral and transport mechanisms, and broader health-system and socio-structural determinants that shape access to timely, quality care.
Maternal mortality remains a major public health challenge, particularly in low- and middle-income countries (LMICs) [8–10], where improvements in obstetric care have not translated into significant reductions in maternal deaths. Despite sustained global efforts, the burden of maternal mortality remains disproportionately high in these settings. The Sustainable Development Goal (SDG) 3, specifically target 3.1, aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [11]. However, achieving this target requires a comprehensive understanding of the factors contributing to maternal mortality and the implementation of effective, context-appropriate interventions.
Effective management of the contributing factors depends on timely recognition and access to quality Emergency Obstetric and Newborn Care (EmONC). However, this remains a challenge in SSA due to shortages of critical health system resources, including emergency and critical care services. In 2017, the World Health Organization (WHO) estimated that approximately 295,000 women died globally due to pregnancy and childbirth-related causes, with nearly two-thirds of these deaths occurring in SSA [12]. More recent estimates indicate that in 2023, Despite being largely preventable, maternal deaths remain disproportionately concentrated in low- and middle-income countries (LMICs), where the maternal mortality ratio is approximately 346 per 100,000 live births compared with 10 per 100,000 live births in high-income countries [11,13]. The lifetime risk of maternal death remains starkly unequal, rising from approximately 1 in 7,933 in high-income countries to nearly 1 in 66 in low-income settings [12]. These disparities highlight the urgent need to strengthen obstetric emergency care in SSA.
Despite increased coverage of antenatal care, skilled birth attendance, and facility-based deliveries, maternal mortality in SSA remains unacceptably high. This apparent paradox highlights persistent gaps in the management of obstetric emergencies, particularly at the health system level. One major gap is the incomplete functionality of EmONC services [14]. Although many facilities are designated as Basic or Comprehensive EmONC (BEmONC/CEmONC) centers, they are often unable to consistently provide the full range of internationally defined signal functions, including administration of uterotonics and anticonvulsants, assisted vaginal delivery, neonatal resuscitation, blood transfusion, and caesarean section. This mismatch between facility designation and actual service readiness results in ‘name-only’ EmONC capacity, weakening referral systems and delaying life-saving interventions.
Health workforce constraints further undermine effective responses to obstetric emergencies. Persistent shortages of skilled midwives, obstetricians, anesthetists, and critical care providers, coupled with high staff turnover, task shifting without adequate supervision, and limited opportunities for continuing professional development, contribute to gaps in clinical competence at the point of care [15,16]. These challenges are strongly associated with delayed recognition and suboptimal management of obstetric emergencies. Additional gaps exist in clinical monitoring and adherence to established care protocols, particularly during labor and the immediate postpartum period. Inconsistent use of standardized labor monitoring tools, inadequate postpartum surveillance, especially within the first 24 hours after birth, and failure to recognize early warning signs contribute to delayed escalation of care and preventable maternal and neonatal deaths.
In response to these challenges, a range of strategies has been proposed and implemented to strengthen obstetric emergency care across different settings. These include expanding access to fully functional EmONC services and strengthening workforce capacity through Continuous Professional Development (CPD). Traditional midwives continue to play a crucial role in maternal and newborn care, particularly in rural and indigenous communities where access to formal health services is limited. Evidence suggests that culturally adapted tools, such as clinical flowcharts co-developed with midwives, can facilitate early recognition of obstetric complications and timely referral [17]. Additionally, CPD programmes, including simulation-based training, have been shown to enhance healthcare providers’ knowledge, skills, confidence, teamwork, and preparedness for managing high-risk obstetric emergencies [18]. Interdisciplinary collaboration has also been identified as a key strategy for improving coordination and continuity of emergency obstetric care [19].
Despite the growing availability of clinical and health-system strategies, evidence on their implementation, adaptation, effectiveness, and sustainability across SSA remains fragmented. Most published studies evaluate isolated interventions within specific facilities or countries, with limited examination of how multiple strategies interact across different levels of the health system or are adapted to diverse resource-constrained contexts. Consequently, there is limited understanding of which combinations of strategies are most effective, under what conditions they work, and how to implement and sustain them at scale to improve outcome of obstetric emergencies.
Although a growing body of literature has examined maternal mortality, emergency obstetric care availability, and individual interventions in SSA, existing reviews tend to focus on single dimensions of care, such as clinical management protocols, workforce training initiatives, or health system readiness in isolation. Few reviews have synthesised evidence across the full continuum of strategies required to improve outcomes in obstetric emergencies, particularly those that integrate life-saving clinical interventions with health workforce capacity, health system organisation, referral mechanisms, and contextual and systemic influences on care delivery. Unlike previous reviews that have focused on individual interventions or specific components of emergency obstetric care, this review adopts a comprehensive health-systems perspective by mapping the full range of strategies reported across the continuum of obstetric emergency management.
Furthermore, much of the existing literature predates recent policy and programmatic shifts and does not explicitly focus on obstetric emergencies as distinct, high-acuity events requiring coordinated responses across levels of care. To address this gap, this scoping review aimed to map and describe the available evidence on strategies used to improve outcomes of obstetric emergencies among pregnant and postpartum women in SSA. Specifically, the review sought to: [1] identify the range of clinical, workforce, referral, health system, and community-based strategies reported in the literature; [2] describe the contexts in which these strategies have been implemented; and [3] identify evidence gaps to inform policy, practice, and future research.
Methods
This scoping review is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [20]. A scoping review approach was selected to map the breadth and nature of available evidence on clinical and health system strategies to improve outcomes in obstetric emergencies, and to identify key concepts, evidence gaps, and implementation contexts across diverse settings.
Eligibility criteria
Eligibility criteria were defined using the Population–Concept–Context (PCC) framework.
Inclusion criteria
Population: Studies involving pregnant or postpartum women experiencing obstetric emergencies, including but not limited to postpartum haemorrhage, hypertensive disorders of pregnancy, sepsis, obstructed labour, and other life-threatening obstetric complications.
Concept: Studies reporting clinical strategies (including but not limited to pharmacological interventions, supportive or critical care management, and use of monitoring tools) and/or health system strategies (including but not limited to workforce training and mentorship, referral and transport systems, service organisation, clinical protocols, or policy-related interventions) aimed at improving maternal outcomes during obstetric emergencies.
Context: Studies conducted in countries classified by the World Health Organization as SSA and published in English between January 2019 and December 2025.
Study design: Empirical studies and relevant evidence-informed conceptual or framework papers describing, evaluating, or informing strategies to improve outcomes of obstetric emergencies in SSA were eligible for inclusion.
Exclusion criteria
Studies were excluded if they:
- i. Did not focus on obstetric emergencies
- ii. Were purely descriptive or epidemiological without reporting an intervention or strategy
- iii. Were conducted outside SSA
- iv. Were published in languages other than English
- v. Were conference abstracts, commentaries, editorials, or review articles
Search strategy
A comprehensive electronic search was conducted in PubMed, CINAHL, Scopus, and CORE to identify studies published from January 2019 to December 2025. Database-specific search strategies combined controlled vocabulary (e.g., MeSH terms) with free-text keywords, using Boolean operators (AND/OR). Core search concepts included obstetric emergencies (e.g., postpartum hemorrhage, hypertensive disorders of pregnancy, obstetric sepsis, obstructed labor), strategies or interventions (e.g., emergency obstetric care, referral systems, workforce training, clinical protocols, critical care), and SSA. The complete search strategies for each database are provided in S1 File.to facilitate reproducibility. In addition to database searches, reference lists of included studies were manually screened to identify further relevant publications. The search included empirical studies and relevant evidence-informed conceptual or framework papers, with no restrictions on study design. The study selection process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and is illustrated in the PRISMA flow diagram (Fig 1).
Study selection
Following the database search, titles and abstracts of retrieved studies were downloaded and exported into EndNote for reference management. Deduplication was conducted by PG. Before commencing study selection, all reviewers participated in an online calibration meeting to review the screening tool, discuss the Population–Concept–Context (PCC)-based eligibility criteria, and ensure a shared understanding of the inclusion and exclusion criteria prior to screening. The review team was then organised into four pairs of independent reviewers ([SW, BW], [RW, CA], [RM, DM], and [LK, AO]) to screen titles and abstracts against the predefined inclusion and exclusion criteria. Studies deemed potentially eligible were advanced to full-text screening. Any discrepancies arising during either stage of screening were resolved through discussion and consensus between reviewers. Where consensus could not be reached, eligibility decisions were resolved through consultation with a third independent reviewer (BM). Only studies meeting the inclusion and exclusion criteria were included in the final review.
Data extraction and quality assessment
The review team utilized the PCC Framework to validate the data extraction design and approach [20,21]. A standardised data extraction tool was used, and characteristics of interest were extracted. Two [2] independent reviewers ([SW, BW], [RW, CA], [RM, DM], [LK, AO]) conducted data extraction from the eligible studies included in the final review. The reviewers jointly harmonized the extracted data through mutual consensus, with the third reviewer (BM) providing their opinion to inform the final decision. The extracted data included the study objective or aim, author(s), year of publication, country, study design, study population or sample, intervention or strategy, implementation context, and reported maternal or obstetric outcomes.
Quality assessment
Consistent with established scoping review methodology, a formal methodological quality assessment (critical appraisal) of the included studies was not undertaken. The primary purpose of this review was to map the breadth and characteristics of the available evidence rather than to evaluate the methodological quality of individual studies. In line with the Joanna Briggs Institute guidance and the PRISMA-ScR reporting framework, no studies were excluded for methodological quality. During study selection, eight reviewers (SW, BW, RW, CA, RM, DM, LK, and AO) independently screened titles, abstracts, and full-text articles against the predefined eligibility criteria to minimise selection bias. Any disagreements regarding study eligibility were resolved through discussion until consensus was reached.
Strategy for mapping the evidence
Extracted data were descriptively mapped to identify the range, characteristics, and implementation contexts of strategies reported across the included studies. An inductive thematic analysis was undertaken to organize the mapped evidence into conceptually related categories representing the major types of strategies identified [22]. The mapping process involved iterative review and refinement of the extracted data by two reviewers (PG and SW), who collaboratively grouped similar strategies into overarching themes through discussion and consensus. The mapped evidence is presented using descriptive tables, figures, and narrative summaries that address the review question and objectives.
Results
The comprehensive search identified 728 records from PubMed, CINAHL, Scopus, CORE, and manual reference list screening. After removal of 256 duplicate records, 472 unique records underwent title and abstract screening. Of these, 400 records were excluded for not meeting the eligibility criteria, and 72 full-text articles were assessed for eligibility. Eight full-text articles were excluded because they did not align with the review objective or did not report a strategy, intervention, or mechanism aimed at improving outcomes of obstetric emergencies. Consequently, 64 studies met the eligibility criteria and were included in this scoping review (Fig 1).
Characteristics of the included studies
A total of 64 studies published between 2019 and 2025 met the eligibility criteria and were included in this scoping review. The studies represented a broad range of methodological designs, including qualitative, cross-sectional, cohort, randomized controlled, mixed-methods, implementation, observational, and retrospective studies. The studies were conducted across multiple countries in SSA and encompassed diverse healthcare settings, including primary healthcare facilities, district hospitals, referral hospitals, tertiary hospitals, and community settings.
The included studies examined strategies targeting a range of obstetric emergencies, most commonly postpartum hemorrhage, hypertensive disorders of pregnancy, maternal sepsis, obstructed labor, and pregnancy-related critical illness. Reported strategies included life-saving clinical interventions, health workforce education and mentorship, referral and transport systems, health system strengthening initiatives, implementation of clinical protocols, quality improvement interventions, and policy or governance approaches. Most studies reported process outcomes, such as provider competence, referral performance, timeliness of care, implementation outcomes, and service readiness, whereas comparatively fewer studies evaluated maternal mortality, severe maternal outcomes, or maternal near-miss as primary endpoints. The characteristics of the included studies are presented in Table 1.
The included studies were published between 2019 and 2025 and demonstrated a relatively consistent distribution across the review period. Although the number of publications varied slightly by year, evidence on strategies to improve outcomes of obstetric emergencies was available throughout the study period, indicating continued research activity in this area. The distribution of studies by year of publication is presented in Table 2.
The included studies were conducted across several countries in SSA, although their geographical distribution was uneven (Fig 2). Ethiopia contributed the largest number of studies, followed by Nigeria, South Africa, Tanzania, Uganda, and Kenya. Collectively, these countries accounted for most of the available evidence, while relatively few studies were identified from other countries within the region. This distribution highlights the concentration of published evidence in a limited number of countries and indicates important geographical gaps in the literature.
Multi-country studies were counted once for each country represented; one pan-SSA conceptual study was classified as “Multi-country/SSA.”.
The 64 included studies employed diverse methodological approaches, reflecting the breadth of research on strategies to improve outcomes of obstetric emergencies in SSA (Table 3). Cross-sectional studies constituted the largest proportion of the evidence base, followed by qualitative and cohort/observational studies. Quasi-experimental, intervention, pilot, and before-and-after studies were fewer in number, while randomized controlled trials, economic evaluations, implementation studies, interrupted time-series studies, and conceptual/framework papers were limited. Overall, the methodological profile indicates that the available evidence is largely descriptive, observational and implementation-oriented, with relatively few experimental studies evaluating intervention effectiveness.
Thematic analysis
The included studies reported a wide range of strategies aimed at improving outcomes of obstetric emergencies in SSA. To facilitate synthesis and presentation, the identified strategies were organised into three broad domains: life-saving clinical and health-system interventions, health workforce education, training and mentorship, and health system organisation, referral mechanisms and policy implementation. Across all three domains, implementation was influenced by several contextual health-system and socio-environmental factors. An overview of the identified strategies is presented in Table 4.
Theme 1: Life-saving interventions
The mapped evidence identified life-saving clinical and health-system interventions as the most frequently reported strategies for improving outcomes of obstetric emergencies in SSA. These interventions aimed to prevent maternal deterioration, reduce severe maternal morbidity, and improve survival through timely recognition, evidence-based clinical management, strengthened service delivery, and early escalation of care. As summarised in Table 5, the interventions were grouped into three interrelated categories: (i) clinical therapies, (ii) health-system strengthening interventions, and (iii) monitoring and triage approaches. [27,36,37,46,52].
Clinical therapies.
Clinical therapies primarily targeted the prevention and management of postpartum hemorrhage, hypertensive disorders of pregnancy, maternal sepsis, obstructed labor, and other life-threatening obstetric complications. Frequently reported interventions included non-pneumatic anti-shock garments (NASG), magnesium sulphate for severe pre-eclampsia and eclampsia, uterotonics, blood transfusion, emergency peripartum hysterectomy, and other evidence-based emergency obstetric treatments. Collectively, these interventions improved physiological stabilisation, reduced progression to severe complications, and supported timely management when implemented according to clinical guidelines by adequately trained healthcare providers.
Despite these benefits, several studies continued to report maternal morbidity and mortality, particularly where delays in diagnosis, limited availability of blood products, shortages of essential medicines, inadequate post-intervention monitoring, or delayed escalation of care constrained effective implementation. These findings suggest that the effectiveness of clinical therapies depends not only on the intervention itself but also on the capacity of the health system to deliver timely, high-quality care.
Systems-strengthening interventions.
Health-system strengthening interventions focused on improving the organisation, accessibility, and responsiveness of emergency obstetric care services. Commonly reported strategies included establishment of obstetric high-dependency units (HDUs), decentralisation of Comprehensive Emergency Obstetric and Newborn Care (CEmONC), strengthening referral coordination through initiatives such as the Mobile Obstetric Referral System (MORES), maternal near-miss and clinical review (NMCR) processes, rural ambulance services, and bundled emergency care packages for postpartum hemorrhage.[36,42,45,59,73–75].
These interventions generally enhanced referral efficiency, service readiness, continuity of care, and access to timely emergency obstetric services. While several studies reported improvements in severe maternal outcomes and health-system performance, others documented persistent ICU mortality, delays in referral, and resource limitations, indicating that health-system strengthening alone may be insufficient without concurrent improvements in workforce capacity and infrastructure.
Monitoring and triage tools.
Monitoring and triage approaches supported the early recognition of maternal deterioration and informed timely clinical decision-making during obstetric emergencies. Frequently reported approaches included obstetric early warning systems, shock index thresholds, lung ultrasound, maternal near-miss surveillance, ICU admission criteria, and assessments of Emergency Obstetric and Newborn Care (EmONC) signal functions.[77,80,86,87]. Although these approaches improved risk identification and prioritisation of care, their effectiveness depended on the availability of skilled personnel, functional referral systems, and adequate critical care capacity to enable timely escalation and definitive management.
Overall, the mapped evidence indicates that life-saving clinical and health-system interventions improve the recognition and management of obstetric emergencies and strengthen the delivery of emergency obstetric care. However, their effectiveness was consistently influenced by workforce capacity, referral efficiency, availability of essential resources, and broader health-system readiness, underscoring the importance of implementing these strategies as integrated components of emergency obstetric care rather than as isolated interventions.(Table 4).
Theme 2: Health workforce education, training, and mentorship
Health workforce education, training, and mentorship emerged as key strategies for strengthening the management of obstetric emergencies across SSA. The mapped evidence demonstrated that capacity-building initiatives targeted healthcare providers’ knowledge, clinical competence, confidence, teamwork, and preparedness to recognise and manage life-threatening obstetric complications [33,37,39,40,46,47,57,63,88–90]As summarised in Table 6, these interventions included skills-and-drills training, competency-based Emergency Obstetric and Newborn Care (EmONC) education, pre-service and in-service training, continuing professional development (CPD), clinical mentorship, supportive supervision, and simulation- and digital learning approaches
Workforce education and competency development.
Across the included studies, education and competency-based training consistently improved providers’ knowledge, technical skills, confidence, and adherence to evidence-based clinical guidelines for managing obstetric emergencies [33,37,39,40,46,47,57,63,88–90]. Training interventions targeted healthcare providers’ knowledge, skills, and confidence in managing obstetric emergencies and included skills-and-drills courses, mentorship programs, pre-service and in-service training, continuous professional development (CPD), and emerging digital and simulation-based approaches (Table 6). Skills-and-drills training, simulation-based education, structured EmONC courses, and competency-focused learning enhanced providers’ ability to recognise obstetric complications, make timely clinical decisions, and work effectively within multidisciplinary teams. Several studies also reported improvements in selected process indicators, including availability of EmONC signal functions, provider preparedness, and service readiness following implementation of these educational interventions [81,83].
Mentorship and continuing professional development.
Clinical mentorship and continuing professional development complemented formal training by reinforcing knowledge and supporting the translation of skills into routine clinical practice. Mentorship programmes, supportive supervision, structured feedback, and CPD initiatives strengthened adherence to clinical protocols and promoted continuous professional learning, although important competency gaps persisted in several settings [58,72]. One study reported that nearly 80% of providers had not met CPD requirements despite implementation of mentorship programmes, highlighting the need for sustained investment in workforce development [72].
Digital learning and innovative educational approaches.
Emerging digital and technology-assisted educational strategies were also identified. Smartphone applications, app-based videos, simulation-supported curricula, and digital learning resources improved educators’ capacity, students’ knowledge, and providers’ engagement while demonstrating potential to expand access to emergency obstetric education in resource-constrained settings [73,74]. However, shortages of trained faculty, educational resources, and infrastructure continued to limit implementation and scalability of these approaches.
Although education, training, and mentorship interventions consistently strengthened provider competence and improved several process outcomes, their effects on maternal mortality were less consistent. Some studies demonstrated improvements in service readiness and availability of EmONC signal functions without corresponding reductions in maternal or neonatal mortality, while others reported persistent gaps in provider knowledge, preparedness, and timely recognition of obstetric emergencies [58,72,83,85]. Overall, the mapped evidence suggests that workforce strengthening is an essential component of improving obstetric emergency care but is most effective when implemented alongside broader health-system strengthening strategies.
Theme 3: Health system organisation, referral mechanisms, and policy implementation
Health system organisation, referral mechanisms, and policy implementation constituted a major domain of strategies identified to improve outcomes of obstetric emergencies in SSA. The mapped evidence demonstrated that these strategies focused on strengthening the organisation, governance, accessibility, and responsiveness of emergency obstetric care across different levels of the health system As summarised in Table 7, interventions included strengthening Emergency Obstetric and Newborn Care (EmONC) services, decentralising comprehensive emergency obstetric care, improving referral and transport systems, implementing clinical policies and protocols, and institutionalising quality improvement and maternal surveillance mechanisms.
Health system organisation and service delivery.
Several studies reported strategies aimed at strengthening the organisation and delivery of emergency obstetric care through expansion of Comprehensive Emergency Obstetric and Newborn Care (CEmONC) services, decentralisation of specialist care, establishment of functional referral networks, and improvements in facility readiness [24,34,38,48,56,61].
Referral mechanisms and emergency transport systems.
Strengthening referral pathways and emergency transport systems was consistently identified as a strategy for improving timely access to definitive obstetric care [53,56,76,80–82]. Reported interventions included structured referral coordination systems, rural ambulance services, the Mobile Obstetric Referral System (MORES), referral communication platforms, and standardised referral protocols. Collectively, these approaches improved communication between facilities, reduced referral delays, enhanced continuity of care, and facilitated more timely management of women experiencing obstetric emergencies. Nevertheless, persistent delays related to transport, geographical accessibility, and coordination continued to affect referral efficiency in several settings [81,82,86,87].
Policy implementation, governance, and quality improvement.
Policy implementation and governance strategies focused on strengthening the quality and accountability of emergency obstetric care through implementation of national clinical guidelines, Emergency Obstetric and Newborn Care policies, maternal and perinatal death surveillance and response (MPDSR), WHO maternal near-miss and clinical review (NMCR) processes, clinical audit, and quality improvement initiatives [30,53,56,57,62,77]. These strategies supported standardisation of clinical practice, improved monitoring of maternal outcomes, strengthened accountability, and facilitated identification of avoidable factors contributing to maternal morbidity and mortality. Several studies reported improvements in access to emergency obstetric services and selected maternal outcomes following implementation of these system-level reforms, although effectiveness varied according to local health-system capacity and implementation fidelity.
Overall, the mapped evidence indicates that strengthening health system organisation, referral mechanisms, and policy implementation enhances the accessibility, coordination, and quality of emergency obstetric care. However, the effectiveness of these strategies depended on adequate infrastructure, functional referral systems, sufficient human resources, leadership, governance, and sustained implementation across all levels of the health system [24,34,38,48,56,61].
Additional findings: Contextual factors influencing the implementation of strategies
Although not identified as strategies within the scope of this review, the included studies consistently reported contextual factors that influenced the implementation and effectiveness of interventions aimed at improving outcomes of obstetric emergencies. These factors were identified across all thematic areas and affected the delivery, uptake, sustainability, and impact of clinical, workforce, and health-system strategies.[23,25,26,30,35,41,49–51,53,58,62,64–67]. As summarised in Table 8, the contextual factors clustered into four interrelated domains: health-system capacity, workforce constraints, resource availability, and delays in accessing and receiving care.
Health-system capacity.
Health-system limitations were the most frequently reported contextual factors influencing implementation of obstetric emergency strategies. Studies described inadequate health infrastructure, limited critical care capacity, fragmented referral systems, weak governance, and deficiencies in health information systems that constrained timely and effective emergency obstetric care [24,26,27,33,36,42,50–52,54,59]. These limitations reduced service readiness and restricted the ability of health facilities to consistently deliver evidence-based emergency obstetric interventions despite the availability of recommended clinical and health-system strategies..
Workforce constraints.
Workforce-related challenges included shortages of skilled healthcare providers, inadequate supervision, high staff turnover, uneven distribution of trained personnel, and limited opportunities for continuing professional development [31,54,59,63,65–67,84]. These factors affected providers’ ability to maintain competency, recognise maternal deterioration promptly, adhere to evidence-based protocols, and sustain improvements achieved through education, mentorship, and health workforce strengthening initiatives.
Resource availability.
Resource constraints were reported throughout the evidence base and included shortages of essential medicines, blood products, equipment, transport, and financial resources required to support emergency obstetric care [35,39,49,57,62,82]. Limited availability of these resources frequently reduced the effectiveness of otherwise evidence-based clinical and health-system interventions, highlighting the importance of adequate health-system investment for successful implementation.
Delays across the continuum of care.
Several studies also highlighted persistent delays in recognising obstetric complications, deciding to seek care, reaching appropriate health facilities, and receiving definitive treatment after arrival [24,27,50,59,75,93]. These delays reflected broader geographical, organisational, socioeconomic, and health-system challenges that continued to undermine the timely delivery of emergency obstetric care despite implementation of evidence-based strategies.
Collectively, these findings indicate that contextual factors influence the implementation and effectiveness of strategies across all domains of obstetric emergency care. Although these factors were not the primary focus of this review, they consistently shaped how interventions were delivered, adopted, and sustained, emphasising the importance of considering local health-system context when implementing strategies to improve maternal outcomes in SSA
Discussion
This scoping review mapped strategies reported to improve outcomes of obstetric emergencies in SSA and demonstrated that effective emergency obstetric care requires coordinated interventions across clinical, workforce, and health-system domains. Rather than identifying a single intervention sufficient to improve maternal outcomes, the mapped evidence showed that successful management of obstetric emergencies depends on the integration of evidence-based clinical care, competent and supported health workers, functional referral systems, responsive service organisation, and enabling implementation contexts. This finding aligns with global maternal health guidance emphasizing that reductions in maternal morbidity and mortality require not only increased service coverage, but also improvements in quality of care, health-system readiness, timely referral, and emergency response capacity [15].
Life-saving interventions
This review identified life-saving clinical and health-system interventions as the cornerstone of strategies reported to improve outcomes of obstetric emergencies in SSA. Across the included studies, interventions aimed at strengthening emergency obstetric care contributed to earlier recognition of maternal deterioration, improved adherence to evidence-based clinical management, enhanced service readiness, and better coordination of emergency care [28,30,32,37,43,45,46,55,60,61,69,70,76–78,82,88]. Collectively, these findings demonstrate that improving maternal outcomes depends not only on timely clinical management but also on the capacity of health systems to deliver life-saving interventions rapidly and consistently.
These findings are consistent with the World Health Organization’s recommendations on Emergency Obstetric and Newborn Care (EmONC) and Essential Emergency and Critical Care (EECC), which emphasise that high-quality emergency obstetric care requires coordinated clinical management supported by functional referral pathways, appropriate monitoring, and health-system readiness rather than isolated therapeutic interventions [93,94]. Similarly, recent global evidence indicates that improvements in maternal survival are achieved when evidence-based clinical interventions are implemented within health systems that ensure timely access to comprehensive emergency obstetric services, adequate infrastructure, and multidisciplinary care [95,96].
A significant contribution of this review is the demonstration that clinical interventions alone are insufficient to achieve sustained improvements in maternal outcomes. Across the mapped evidence, interventions were most successful when accompanied by health-system strengthening measures such as improved referral pathways, enhanced critical care capacity, standardised monitoring systems, and quality improvement initiatives [37,43,45,46,55,60,61,69,70,76–78,82,88]. Conversely, where these enabling systems were weak, improvements in clinical processes did not consistently translate into reductions in maternal mortality or severe maternal outcomes. This finding reinforces the growing consensus that effective obstetric emergency care requires coordinated implementation of both clinical and health-system interventions rather than isolated therapeutic approaches.
These findings highlight the importance of implementing life-saving clinical interventions as part of integrated emergency obstetric care systems rather than as isolated clinical practices. Strengthening referral pathways, ensuring uninterrupted availability of essential medicines and blood products, expanding critical care capacity, and embedding continuous quality improvement within maternity services are likely to maximise the effectiveness and sustainability of evidence-based interventions aimed at reducing maternal morbidity and mortality in SSA.
Health workforce education, training, and mentorship
This review identified health workforce education, training, and mentorship as fundamental strategies for strengthening the management of obstetric emergencies across SSA. The mapped evidence demonstrated that competency-based education, simulation training, clinical mentorship, continuing professional development (CPD), and digital learning approaches consistently improved healthcare providers’ knowledge, technical competence, confidence, teamwork, and adherence to evidence-based clinical protocols [34,38,40,41,47,48,58,64,72–74,83,85,89,90]. These findings highlight the central role of a competent and well-supported health workforce in improving the quality and responsiveness of emergency obstetric care.
Health workforce training and mentorship initiatives were widely implemented to strengthen provider competence in recognising and managing obstetric emergencies, particularly among midwives and other frontline cadres. Consistent with existing systematic reviews, training interventions were associated with improvements in provider knowledge, skills, and adherence to clinical protocols [16,97]. Simulation-based education, in particular, has demonstrated value in improving clinical decision-making and team performance in obstetric emergencies, especially in settings with limited exposure to high-acuity cases [16,19]. Continuing professional development (CPD) approaches were also highlighted as important mechanisms for sustaining competence over time. Recent evidence indicates that CPD programmes for midwives can support improved management of obstetric complications, although their effectiveness varies depending on implementation quality and system support [18]. Despite these gains, this review found that training interventions demonstrated variable effects on maternal mortality, reflecting a well-documented challenge in translating individual-level capacity building into sustained clinical outcomes [98]. Training benefits were frequently undermined by workforce shortages, high workload, limited supervision, and a lack of essential resources. These findings support the view that workforce development strategies are most effective when embedded within broader organisational reforms that promote supportive supervision, adequate staffing, and enabling work environments.
Health System organization, Referral Mechanisms and Policy Implementation
This review identified health system organisation, referral mechanisms, and policy implementation as essential strategies for improving outcomes of obstetric emergencies in SSA. The mapped evidence demonstrated that strengthening Emergency Obstetric and Newborn Care (EmONC) services, decentralising comprehensive emergency obstetric care, improving referral coordination, strengthening emergency transport systems, implementing evidence-based clinical protocols, and institutionalising quality improvement and maternal surveillance mechanisms enhanced access to timely emergency obstetric care and improved service delivery across diverse healthcare settings [25,30,35,39,49,53,56,57,62,80,81,86,87].
These findings highlight the importance of well-organised and responsive health systems in supporting effective management of obstetric emergencies.The organization of emergency obstetric care and the functionality of referral mechanisms emerged as critical determinants of timely access to life-saving interventions. Studies of emergency obstetric care policies and referral systems consistently identified gaps between policy intent and effective implementation, particularly in peripheral and rural facilities [23,95]. Although facility-based deliveries have increased across many settings, this expansion has not consistently translated into improved outcomes where facilities lack basic or comprehensive emergency obstetric readiness.
Strengthening referral coordination, decentralising comprehensive emergency obstetric and newborn care services, and implementing clear standard operating procedures were associated with improved service utilisation and, in some contexts, reductions in maternal mortality. These findings are consistent with evidence demonstrating that geographic proximity to functional emergency care and efficient referral pathways are essential for survival during obstetric emergencies [51,95]. However, persistent barriers related to transport availability, communication breakdowns, and inter-facility coordination continue to contribute to avoidable delays and adverse outcomes. Weak accountability and monitoring mechanisms further limit the effectiveness of emergency obstetric care policies, reinforcing the importance of linking policy implementation with robust measurement and learning systems [96].
Additional findings: Contextual factors influencing the implementation of strategies
An important finding of this review was the consistent influence of contextual factors on the implementation and effectiveness of strategies to improve outcomes in obstetric emergencies across SSA. Across the included studies, health-system limitations, workforce shortages, inadequate infrastructure, stock-outs of essential medicines and blood products, limited critical care capacity, and weaknesses in referral systems frequently constrained the implementation and sustainability of life-saving clinical, workforce, and health-system interventions [24,26,27,31,33,36,42,50–52,54,59,61,63,65–67,71,75,84,93]. These findings demonstrate that the effectiveness of evidence-based interventions is strongly shaped by the health-system context in which they are implemented.
The contextual factors identified in this review align with the broader maternal health literature, which recognizes health-system readiness as a critical determinant of maternal survival in low-resource settings [99]. Persistent shortages of skilled health workers, inadequate infrastructure, limited access to emergency transport and critical care services, and interruptions in the availability of essential medicines and blood products continue to undermine the delivery of timely, high-quality emergency obstetric care, despite increasing coverage of facility-based births and emergency obstetric services.
The findings also reinforce the continued relevance of the Three Delays Model as a framework for understanding persistent maternal morbidity and mortality [100]. Similar to previous studies conducted in SSA and other low-resource settings, this review found that delays in recognising complications, reaching appropriate health facilities, and receiving definitive treatment were frequently driven by transport challenges, inefficient referral pathways, limited facility readiness, and organisational constraints [99,101]. These interconnected delays often reduced the effectiveness of otherwise evidence-based clinical and health-system interventions.
The findings highlight that sustainable improvements in obstetric emergency care require implementation strategies responsive to local health-system contexts. Investments in clinical interventions, workforce development, and health-system reforms should therefore be paired with strengthened governance, referral coordination, infrastructure, supply chains, health information systems, and continuous quality improvement to ensure that evidence-based strategies can be implemented effectively and sustained over time.
Strengths and limitations
This review has several limitations. First, the search was restricted to studies published in English between January 2019 and December 2025; consequently, relevant studies published in other languages or outside this time frame may not have been captured. Second, although a comprehensive search was conducted across multiple electronic databases and supplemented by manual reference list screening, unpublished studies, grey literature not indexed in the selected databases, and ongoing implementation initiatives may have been missed. Third, the included studies were methodologically heterogeneous, encompassing qualitative, quantitative, mixed-methods, implementation, and conceptual studies conducted across diverse healthcare settings. This heterogeneity precluded formal comparison of intervention effectiveness or quantitative synthesis and is consistent with the exploratory nature of a scoping review. Fourth, although methodological quality appraisal was undertaken to support interpretation of the evidence, quality assessments were not used to exclude studies, in keeping with established scoping review methodology. Consequently, the review maps the breadth of available evidence rather than the effectiveness of specific interventions.
Despite these limitations, this review has several important strengths. It provides a comprehensive and up-to-date synthesis of evidence published between 2019 and 2025, maps the full spectrum of strategies used to improve outcomes of obstetric emergencies across SSA, and integrates clinical, workforce, health-system, and implementation perspectives within a single review. By identifying both evidence gaps and contextual factors influencing implementation, the review offers a broad evidence base to inform future research, policy, and implementation of integrated strategies to strengthen emergency obstetric care in resource-constrained settings.
Conclusion and recommendations
Conclusion
This scoping review mapped the range of strategies reported to improve outcomes of obstetric emergencies in SSA and demonstrated that effective emergency obstetric care depends on integrated, context-responsive approaches rather than isolated interventions. The evidence indicates that improvements in maternal outcomes require coordinated implementation of life-saving clinical interventions, a competent and well-supported health workforce, functional referral systems, responsive health service organisation, and effective policy implementation within adequately resourced health systems. The review further highlights that contextual factors—including workforce shortages, infrastructure limitations, resource constraints, and delays in accessing and receiving care—strongly influence the implementation and effectiveness of these strategies.
The findings emphasize the importance of strengthening health systems alongside evidence-based clinical care to achieve sustainable reductions in maternal morbidity and mortality. Policymakers, programme implementers, and healthcare leaders should prioritise integrated strategies that combine clinical excellence with workforce development, strengthened referral systems, quality improvement, and robust governance to improve emergency obstetric care across diverse settings in SSA.
Implications for policy, practice, and research
Implications for policy.
The findings of this review suggest that policies aimed at reducing maternal morbidity and mortality should move beyond isolated clinical interventions towards integrated health-system strengthening. Policymakers should prioritize investments that simultaneously strengthen Emergency Obstetric and Newborn Care (EmONC) services, referral and transport systems, health workforce capacity, critical care services, supply chains for essential medicines and blood products, and maternal surveillance systems. National maternal health policies should also emphasize effective implementation, monitoring, and continuous quality improvement to ensure that evidence-based interventions are translated into routine practice across all levels of the health system.
Implications for practice.
For healthcare providers and health service managers, the review highlights the importance of delivering evidence-based obstetric emergency care within well-functioning systems of care. Clinical interventions should be supported by regular competency-based education, simulation training, structured mentorship, continuing professional development, multidisciplinary teamwork, standardised clinical protocols, and effective referral coordination. Healthcare facilities should also strengthen early recognition of maternal deterioration, improve communication across referral networks, and institutionalise routine audit and maternal death surveillance processes to promote learning and accountability.
Implications for research.
The review identified important evidence gaps that warrant further investigation. Future research should evaluate integrated packages of clinical, workforce, and health-system interventions rather than individual strategies in isolation. Greater emphasis should be placed on implementation research that examines how interventions are adapted, implemented, scaled, and sustained across diverse resource-constrained settings. There is also a need for more rigorous prospective and experimental studies evaluating long-term maternal and neonatal outcomes, implementation fidelity, cost-effectiveness, and health-system impacts. Furthermore, research from underrepresented countries within SSA is needed to improve the geographical representativeness of the evidence base and to inform context-specific policy and practice.
Recommendations
Based on the mapped evidence, the following recommendations are proposed to strengthen the prevention and management of obstetric emergencies and improve maternal outcomes in SSA.
- 1. Strengthen integrated emergency obstetric care
Health systems should prioritize implementing integrated emergency obstetric care that combines evidence-based clinical interventions with functional referral systems, timely access to Comprehensive Emergency Obstetric and Newborn Care (CEmONC), critical care services, and effective monitoring and triage. Investments should focus on ensuring uninterrupted availability of essential medicines, blood products, equipment, and appropriately staffed emergency obstetric services to optimize timely management of life-threatening complications.
- 2. Invest in sustainable health workforce development
Governments, professional regulatory bodies, and training institutions should institutionalize competency-based pre-service and in-service education, structured continuing professional development (CPD), simulation-based training, clinical mentorship, and supportive supervision for healthcare providers involved in emergency obstetric care. These initiatives should be embedded within comprehensive workforce strategies that address staffing shortages, retention, equitable deployment, workload management, and career development to ensure sustained improvements in quality of care.
- 3. Strengthen health system organisation, referral systems, and governance
Health system leaders should strengthen the organisation and governance of emergency obstetric care by improving referral coordination, expanding equitable access to functional EmONC and CEmONC services, decentralizing emergency obstetric care where appropriate, implementing evidence-based clinical guidelines and standard operating procedures, and institutionalizing maternal and perinatal death surveillance and response (MPDSR) together with continuous quality improvement initiatives. Effective implementation should be supported by strong leadership, accountability mechanisms, routine monitoring, and use of health information for decision-making.
- 4. Address implementation context and health-system constraints
Implementation of obstetric emergency strategies should explicitly address contextual factors that influence their effectiveness. Policymakers and program implementers should prioritize investments in health infrastructure, emergency transport, supply chain management, digital health systems, communication networks, and financing mechanisms that improve service readiness and reduce delays across the continuum of care. Tailoring implementation strategies to local health-system contexts will enhance adoption, sustainability, and long-term impact.
- 5. Prioritize implementation research and evaluation
Future research should move beyond evaluating individual interventions towards implementation research examining integrated packages of clinical, workforce, and health-system strategies. Well-designed prospective, mixed-methods, and implementation studies are needed to evaluate effectiveness, implementation fidelity, scalability, sustainability, cost-effectiveness, and long-term maternal and neonatal outcomes across diverse settings in SSA. Attention should be given to underrepresented countries and health-system contexts to strengthen the regional evidence base and support context-specific policy and practice.
Supporting information
S1 File. Search strategies used for the electronic databases.
https://doi.org/10.1371/journal.pone.0355174.s001
(DOCX)
S1 Checklist. PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0355174.s002
(DOCX)
Acknowledgments
We thank the Dean of the Aga Khan University School of Nursing and Midwifery, East Africa, for providing protected time to support manuscript writing. We also thank the Aga Khan University Faculty of Health Sciences and Library staff for assisting with access to institutional databases during the electronic search.
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