Increased preparedness for birth and complications is an essential part of antenatal care and has the potential to increase birth with a skilled attendant. We conducted a systematic review of studies to assess the effect of birth preparedness and complication readiness interventions on increasing birth with a skilled attendant.
PubMed, Embase, CINAHL and grey literature were searched for studies from 2000 to 2012 using a broad range of search terms. Studies were included with diverse designs and intervention strategies that contained an element of birth preparedness and complication readiness. Data extracted included population, setting, study design, outcomes, intervention description, type of intervention strategy and funding sources. Quality of the studies was assessed. The studies varied in BP/CR interventions, design, use of control groups, data collection methods, and outcome measures. We therefore deemed meta-analysis was not appropriate and conducted a narrative synthesis of the findings.
Thirty-three references encompassing 20 different intervention programmes were included, of which one programmatic element was birth preparedness and complication readiness. Implementation strategies were diverse and included facility-, community-, or home-based services. Thirteen studies resulted in an increase in birth with a skilled attendant or facility birth. The majority of authors reported an increase in knowledge on birth preparedness and complication readiness.
Citation: Solnes Miltenburg A, Roggeveen Y, Shields L, van Elteren M, van Roosmalen J, Stekelenburg J, et al. (2015) Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review. PLoS ONE 10(11): e0143382. https://doi.org/10.1371/journal.pone.0143382
Editor: Thomas Niederkrotenthaler, Medical University of Vienna, AUSTRIA
Received: July 3, 2015; Accepted: November 4, 2015; Published: November 23, 2015
Copyright: © 2015 Solnes Miltenburg 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: All relevant data are within the paper and its Supporting Information files.
Funding: ASM received financial support from WHO to participate in the WHO Technical Consultation on health promotion interventions for maternal and newborn health, 15-17 July 2014, Geneva, where the initial results of this systematic review were presented and discussed. YR acknowledges financial support from the Netherlands Society for Tropical Medicine and International Health for writing her PhD thesis of which this study will be part. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: Anayda Portela is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the World Health Organization. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials. The authors have no other interests to disclose.
The presence of a skilled attendant at birth (SBA) is promoted as a key strategy to prevent the leading causes of maternal and neonatal mortality and morbidity [1–3]. Despite a global increase in the number of births attended by SBAs, coverage in sub-Saharan Africa remains low . This is the result of a combination of socio-economic, cultural and health system factors that cause delay in deciding to seek care (phase 1 delay), reaching maternal health care facilities (phase 2 delay) and receiving adequate care (phase 3 delay) . Despite poor functioning health systems in low-and middle income countries [4,6,7] increased preparedness for birth and complications would allow women and their families to anticipate potential delays and ensure timely use of skilled care for birth and arrival at the appropriate facility for complications . Implementation of birth preparedness and complication readiness (BP/CR) interventions that focus on individuals, families and communities are intended to reduce at least the first two delays . It is equally important that health facilities and referral systems are prepared to deliver essential childbirth care and are able to manage complications, which would contribute to reduction of the third delay [9,10].
BP/CR is a process of planning for birth and anticipating actions to take in case of obstetric complications . The concept of BP/CR emerged almost two decades ago and was later included by the World Health Organization (WHO) as an essential part of the antenatal care package [11,12]. According to WHO, BP/CR plans contain the following elements: desired place of birth; preferred birth attendant; location of the closest facility for birth and in case of complications; funds for any expenses; supplies and materials to bring to the facility; an identified labour and birth companion; an identified support person to look after other children at home; identified transport to a facility for birth or in case of complications; and identification of compatible blood donors if needed . Acknowledging that not only women, but also families, communities, health care providers and policy makers need to be birth prepared, JHPIEGO developed a BP/CR matrix which conceptualizes multi-stakeholder preparedness (S1 Fig) [9,10,14].
A recent systematic review of randomized controlled trials (RCTs) showed that BP/CR strategies can reduce maternal and neonatal mortality . However, seven out of the twelve included studies implemented BP/CR through action-learning cycles with women’s groups, a specific intervention and methodology which reported improvements to maternal and newborn health outcomes [16,17]. As the primary objective of BP/CR is to increase care seeking, mortality reduction also depends on accessibility and availability of services being provided. This makes the contributing effect of the BP/CR interventions on mortality less clear. In addition, change in mortality rates over time is difficult to assess and figures are often unreliable . Therefore we set out to systematically review the literature, including qualitative studies, for the effect of BP/CR on increasing SBA .
The aim of this systematic review is to review the literature of BP/CR interventions and assess its effect on increasing SBA .
As there are several ways to implement and evaluate BP/CR interventions, we formulated the following key research questions to guide our review:
- To what extent does BP/CR result in increasing skilled birth attendance?
- What strategies are used to implement BP/CR?
- What methodologies are used to measure the effectiveness of BP/CR?
Findings in this paper are also included in the WHO recommendations on heath promotion interventions for maternal and newborn health 2015 .
In order to systematically synthesize the body of evidence, we followed the guidelines for systematic reviews of the Cochrane Handbook for Systematic Reviews of Interventions , the PRISMA statement  and the guidelines published by the National Health Service (NHS) Center for Reviews and Dissemination . Details on the specific review methodology can be found in a prior publication (S1 File) . The study protocol was registered at PROSPERO (no: CRD42012003124). Additional methodological considerations not mentioned in the study protocol or which were adjusted during the review process are described below.
Literature search and selection process
We developed a search strategy (S2 File) for three electronic databases: PubMed, Embase and CINAHL. A wide range of search terms was used for high sensitivity as we anticipated that BP/CR terminology had only recently been used in publications. Originally we searched articles published between January 1987 and October 2012. However, this resulted in many irrelevant articles, in which concepts and interventions related to BP/CR were difficult to identify. We therefore excluded studies published before January 2000 and limited our search to the English language. We also manually searched grey literature and reviewed a database that included results of a systematic mapping of research on maternal health in low- and middle-income countries published from 2000 to 2012 [24,25]. The latter was limited to Arabic, English, French, Spanish, Japanese and Portuguese.
Studies were included if they were RCTs, quasi-experimental studies or comparative cohort studies which met the following criteria:
- Study population: pregnant women, women who recently gave birth, husbands of pregnant women or of women who recently gave birth, health care providers, traditional birth attendants (TBAs), all adults in the community (in low- and middle-income countries)
- Interventions: including BP/CR components, which could be facility-based, community-based or home-based implemented both as single intervention or as a package of interventions.
- Comparison: outcome reported must be compared with the outcome in any comparison group,
- Outcomes: birth with SBAs or facility births, maternal and neonatal mortality and morbidity, ANC with a skilled provider and knowledge of danger signs, implementation of BP/CR plan elements such as saving necessary funds, transport arrangements, etc
We excluded interventions that focused on increasing the quality of ANC provision and studies on facility training without the objective of increasing BP/CR. We also excluded descriptive studies on BP/CR, which did not evaluate any BP/CR intervention, but merely described barriers to BP/CR or use of SBAs.
Our search yielded 5552 records, of which 3665 remained after removal of duplicates (Fig 1). All abstracts and titles were searched and screened in duplicate and independently by ASM, YR and MvE. Of the 3665 records, 2991 were found not relevant or published before 2000. Remaining records (n = 674) and additional records identified (n = 12) were compared against JHPIEGO’s BP/CR matrix  to determine whether the study’s conceptualization aligned with the definition of BP/CR used in this review. Two reviewers reviewed the remaining 171 full text records independently for inclusion (ASM, YR, MvE or LS). Reference lists of the included records (n = 21) were hand searched for potentially relevant sources, yielding 9 additional records. Three additional studies were identified after presentation of our preliminary results at the WHO Technical Consultation on health promotion interventions for maternal and newborn health . Disagreements on inclusion of studies were resolved by discussions with third parties (JS, JvR and AP). Included were 33 records covering 20 separate intervention programmes (e.g. some interventions or studies produced multiple articles).
We tailored the NHS Center for Reviews and Dissemination data extraction table to fit our research questions . Data extracted included setting, study design, outcomes, funding sources and intervention description. Data extraction by ASM was checked for accuracy and completeness by YR and LS. If additional data was needed, reports or data files were acquired by contacting authors and / or searching for study reports online.
ASM, YR, MvE and LS independently assessed the quality of the studies. Risk of bias for quantitative studies was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool . The quality of qualitative studies was assessed using the eight criteria developed by Walsh and Downe (2006) .
Quantitative results were summarised in summary of evidence tables. The studies varied in BP/CR interventions, design, use of control groups, data collection methods, and outcome measures. We therefore deemed meta-analysis was not appropriate and conducted a narrative synthesis of the findings. .
All 20 programmes consisted of interventions wherein BP/CR comprised one element, either as a component (e.g. of ANC education), a sub-intervention (e.g. of a behavioural change strategy) or a primary intervention (e.g. administering a BP/CR package). See tables 1 and 2 for characteristics of included studies. The study designs include one RCT, three cluster RCTs, seven pre and post comparative studies with a control group, one pre and post study without control, seven one group before and after evaluations and one qualitative study. Three quantitative studies also had a qualitative component. Five of the 19 studies with a quantitative component received a moderate and 14 a weak rating. Assessment of four qualitative studies resulted in one moderate and three weak ratings (S1 Table).
The studies were conducted in sub-Saharan Africa (n = 7), South East Asia (n = 12) and Central America (n = 1). The Maternal Neonatal Health (MNH) programme supported by the Johns Hopkins University Centre for Communication Programs (JHU/CCP) in Guatemala, Nepal, Indonesia and Burkina Faso and the Skilled Care Initiative of Family Care International in Burkina Faso, Kenya and Tanzania were multi-country programmes.
Results of studies are presented in Tables 3 and 4. We distinguished between BP/CR programs that aim to increase SBA for all births and those promoting SBA in case of complications. The latter took place in contexts with extremely low SBA and where the majority of births take place at home; consequently BP/CR messages are different and focused on care seeking for complications and the intervention also contributed to ensure safe birth practices at home.
Effect on birth with a skilled attendant
Across multi-country programmes, i.e. Skilled Care Initiative and the MNH programme, results varied. The Skilled Care Initiative found increases in SBA in Burkina Faso and Tanzania, but not in Kenya [30,36,39]. Exposure to BP/CR interventions in Tanzania correlated with increased likelihood of seeking skilled care during childbirth. Of respondents exposed to ANC counselling on BP/CR 74% sought skilled care versus 64% of those unexposed (p<0.05) .
The MNH programme resulted in an increase in facility births or birth with SBAs in Burkina Faso and Guatemala [42,43]. No improvements were found in Nepal and Indonesia [40,41]. In Burkina Faso improvements were mainly due to an increase in births assisted by auxiliary midwives from baseline to endline (15.6% to 41.7%, p<0.05), which was higher for the exposed group. All authors of the MNH programmes reported an increase in knowledge of BP/CR and increase in BP/CR actions, however, this did not necessarily increase seeking skilled care .
In Tanzania, an intervention package, comprising training of Safe Motherhood Promotors and education on the importance of a birth preparedness plan through home visits, showed an increase of 51.4% in SBA post-intervention compared to 34.1% at baseline (P<0.05) . Turan et al. (2011) trained community members (women and men) as Maternal Health Volunteers to lead participatory education sessions (including BP/CR) using visual aids. Facility births in the intervention group increased (3.2% to 46.8%, (OR 26.2, 95% CI 11.4–60.3), while the facility births in the control group increased from 4% to 15%. In India, a birth preparedness intervention geared towards families and communities resulted in an increase in births at primary care facilities (p<0.001) and government hospitals (p<0.001) .
Of the six studies of interventions aiming to increase access to care for complications, three resulted in increased facility births [54,59,55]. Hossain et al (2006) implemented a multi-stakeholder intervention consisting of facility-based interventions (facility upgrades and improvements in quality of care) and community interventions addressing birth planning and community mobilization to ensure timely recognition and referral of obstetric emergencies. The intervention site received all interventions, the comparison site only a facility upgrade and the control site received none. The intervention area showed an 8.1% increase in facility births (p<0.01 95% CI 7.2–9.0); however, both the control and comparison area had a higher pre-intervention facility birth rate. Darmstadt et al (2010) found a significant increase of facility births in the intervention area (from 12.1% at baseline to 20.2% at endline) compared to the control area (increase from 12.5% at baseline to 16.5% at endline—P<0,05).
Most authors reported a statistically significant improvement in knowledge on BP/CR (Table 4). Mullany et al (2007) showed that couple counselling significantly improved knowledge compared to individual counselling and they suggested that immediate conversations between spouses might enhance knowledge retention . Knowledge acquired was not always consistently related to the intervention as was shown by Sood et al (2004), who found that knowledge of danger signs was higher in the control group .
ANC attendance was not evaluated in all BP/CR studies. Study results varied from a significant increase in ANC attendance [36,39,42,47,48,54,43], earlier booking dates [46,48] to not any effect [40,45]. Different outcome measures and cut-off points for frequency or timing of ANC visits were used.
Of the five studies reporting on neonatal mortality, Kumar et al (2012) report significantly lower neonatal mortality in the BP intervention group  and Hodgins et al (2009) showed fewer neonatal deaths over time . No significant difference was found in other studies.
Strategies to implement BP/CR
After reviewing the studies on strategies used for BP/CR implementation, we grouped strategies into five categories. Some interventions used multiple strategies: education through home visits by volunteers or community health workers [43,46,49–52,54,56,59,61], BP/CR messages integrated into ANC education at facility level [41,42,45,43], visual aids with BP/CR messages such as booklets or flipcharts [36,39–43,47,49,50,55,59], participatory community mobilization activities including drama, songs and dance [30,36,39–41,43,46,48,49,55,59] and media campaigns (e.g. radio spots, jingles or television dramas). The majority of studies were published between 2004 and 2012 suggesting increased interest in BP/CR and using the label of BP/CR after introduction by JHPIEGO.
Methodologies to measure effectiveness
Definitions of BP/CR varied from identifying a place of birth and preferred SBA, to preparing funds for complications, to arranging for (emergency) transport and knowledge of danger signs. Focus was either solely on the mother, or on both the mother and newborn. Across studies, household surveys were most frequently employed to evaluate programme effectiveness. Although interventions targeted different study populations (women, husbands and mothers in law), authors almost exclusively evaluated women’s behaviour as primary outcome [62–68]. The study population was heterogeneous across studies, ranging from pregnant women who gave birth during the study period [45,52] to women who had ‘recently’ given birth. A number of multi-country programmes had outcome measures at family or health worker level. Some authors measured facility birth as an indicator for SBA. Methods to assess if women were birth prepared and complication ready differed greatly across studies, due to varying scales and index criteria used.
Heterogeneity of study designs and BP/CR interventions, and lack of high quality evidence prevents making a pooled analysis. Although BP/CR interventions can increase knowledge of danger signs and preparations for birth and complications, this did not always correspond to an increased use in SBA at birth. Where an increase in SBA or facility birth was reported, BP/CR interventions were primarily part of a package of multiple interventions and involved multiple stakeholders, making it difficult to attribute the effect to the BP/CR component alone.
Interventions where BP/CR was a primary component can be better assessed in terms of causality, but what these results mean in a complex reality is unclear [45,46,69]. Many variables influence both programme interventions and outcomes such as female education and policy changes [48,70]. Active involvement of policy makers in BP/CR interventions facilitated implementation at the national level in some countries [30,40–43]. We will analyse this further in a separate publication . Increased use of SBA in BP/CR programmes within a package of interventions could be due to facility or infrastructure improvements, community-based behavioural change interventions, other factors, or due to interactions between all .
Although the JHPIEGO BP/CR matrix includes preparedness of facilities and health providers, BP/CR studies rarely focus on the supply side of skilled care . Ensuring that services are equipped to meet the increased demand likely to be generated by BP/CR interventions is crucial. Advising community members to prepare for facility birth, while health services or health providers are not birth prepared or complication ready, or while local health systems are not ready for an increased caseload, can lead to an increase of in-facility complications or maltreatment. Consequently, negative in-facility experiences can increase delay in care seeking  and should be avoided as much as possible. Also, negatively contributing factors at ANC need to be addressed for proper BP/CR counselling such as insufficient human resources and time constraints [69,71,72].
Although most studies report increased knowledge of BP/CR, not all clarify whether this resulted in plans or actions. Knowledge alone does not equate to an increase in care-seeking behaviour, especially for maternity care services, often due to financial, structural, geographical or cultural factors [73,74]. Studies that focussed on ‘knowledge on danger signs’ and ‘preparing transport and funds in the event of an emergency’ predominantly aimed to increase access to Emergency Obstetric Care (EmOC) in case of complications. However, most births start uncomplicated and risk identification is unreliable . Delays in reaching skilled care are partially caused by delayed recognition of signs and symptoms of labour onset [76,77]. We argue that BP/CR programmes should follow Safe Motherhood programmes in their shift towards the promotion of skilled care for all births and include education on the signs of uncomplicated labour to ensure timely preparations .
The strength of this review lies in its broad literature base, including published and unpublished studies (e.g. reports from NGOs). Although we limited our initial search to English language, the systematic mapping of maternal health research did not have this limitation. It is likely that we included all relevant studies by crosschecking our search results with this broad database and by being open for inclusion of additional articles at the WHO Technical Consultation . Facility birth in many studies was used as an indicator for birth with SBAs, this must be interpreted with caution as many facilities may lack the availability or presence of SBAs . Similarly only four studies presented their definition of an SBA and it is unclear if in the other studies a SBA was defined according to our definition. Despite wide spread promotion of BP/CR through the JHPIEGO and WHO publications, definitions and indicators of BP/CR varied greatly across studies, therefore comparing studies was challenging which also prevented the possibility of conducting a meta-analysis.
Although BP/CR in theory is compelling as a strategy to increase birth with a SBA, robust evidence of the effect of BP/CR in itself on increasing birth with a skilled attendant remains limited. This review does suggest that BP/CR interventions in combination with other interventions have the potential to increase use of SBAs and to increase timely use of facility care for birth and obstetric and newborn complications. We argue that BP/CR interventions seem as strong as the weakest link in the continuum of maternal care pathway.
Clarification of definitions of BP/CR is needed to guide future programme implementation and evaluation. Expert meetings and internationally-agreed upon definitions and indicators for BP/CR could help. However as specific actions and messages required to prepare for birth and complications are highly context specific, it seems undesirable to aim for uniformity. Creating a flexible BP/CR definition that allows local adaptation is a step forward. Collaboration between target groups is a crucial step, and requires further study. An excellent way to locally define and implement BP/CR programmes would be to develop and study local BP/CR pathways collaboratively with target groups from community to policy level. The JHPIEGO matrix is a helpful tool to start this process. Study of this process and outcomes, should include mixed methods by transdisciplinary research teams .
S1 Fig. Birth Preparedness and Complication Readiness Matrix.
We thank Rene Otten for sharing his expertise on medical information systems and reviews. We would like to thank the participants of the WHO Technical Consultation on Health Promotion Interventions for Maternal and Newborn Health that took place between 15–17 of July 2014 at WHO headquarters in Geneva, for discussing the preliminary outcomes of this review and their valuable inputs. Helen Smith of the University of Manchester also contributed to the extraction and analysis of the data.
Conceived and designed the experiments: ASM YR MvE LS JS JvR. Performed the experiments: ASM YR MvE LS. Analyzed the data: ASM YR MvE LS JS JvR AP. Contributed reagents/materials/analysis tools: ASM YR MvE LS JS JvR AP. Wrote the paper: ASM YR MvE LS JS JvR AP.
- 1. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066–74. pmid:16581405
- 2. Nyamtema AS, Urassa DP, van Roosmalen J. Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change. BMC Pregnancy Childbirth. 2011;11(1):30.
- 3. WHO, ICM, FIGO: Making Pregnancy Safer: the Critical Role of the Skilled Attendant. WHO; 2004. Available: http://whqlibdoc.who.int/publications/2004/9241591692.pdf.
- 4. Requejo J, Bryce J, Victora C, Team TC to 2015 writing. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. Lancet 2014; 1–229.`
- 5. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Science & Medicine 1994;38: 1091–110.
- 6. Graham WJ. Now or never: the case for measuring maternal mortality. Lancet 2002;359: 701–4. pmid:11879885
- 7. Goodburn E, Campbell O. Reducing maternal mortality in the developing world: sector-wide approaches may be the key. BMJ 2001;322: 917–20. pmid:11302911
- 8. JHPIEGO. Monitoring Birth Preparedness and Complications Readiness; Tools and Indicators for Maternal and Newborn Health. Baltimore: JHPIEGO 2004: 1–44.
- 9. Stanton CK. Methodological issues in the measurement of birth preparedness in support of safe motherhood. Evaluation Review 2004;28: 179–200 pmid:15130180
- 10. JHPIEGO/Maternal and Neonatal Health (MNH) Program. Birth Preparedness and Complication Readiness: A Matrix of Shared Responsibility. Baltimore, MD; 2001.
- 11. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 2001;357:1565–70. pmid:11377643
- 12. Di Mario S, Basevi V, Gori G, Spettoli D. What is the effectiveness of antenatal care? (Supplement). Copenhagen: WHO Regional Office for Europe Health Evidence Network. 2005.
- 13. World Health Organization. Birth and emergency preparedness in antenatal care. Intergrated management of pregnancy and childbirth (IMPAC). WHO; 2006.
- 14. Portela A, Santarelli C. Empowerment of women, men, families and communities: true partners for improving maternal and newborn health. British Medical Bulletin 2003;67: 59–72. pmid:14711754
- 15. Soubeiga D, Gauvin L, Hatem M a, Johri M. Birth Preparedness and Complication Readiness (BPCR) interventions to reduce maternal and neonatal mortality in developing countries: systematic review and meta-analysis. BMC Pregnancy and Childbirth 2014;14:129 pmid:24708719
- 16. Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. 2013;381(9879):1736–46.
- 17. World Health Organization. WHO recommendation on community mobilization through facilitated participatory learning and action cycles with women’s groups for maternal and newborn health. WHO;2014.
- 18. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375(9726):1609–23. pmid:20382417
- 19. Solnes Miltenburg A, Roggeveen Y, van Elteren M, Shields L, Bunders J, van Roosmalen J, et al. A protocol for a systematic review of birth preparedness and complication readiness programs. Systematic Reviews. 2013;2(1):11.
- 20. World Health Organization. WHO recommendations on health promotion interventions for maternal and newborn health 2015. WHO;2015.
- 21. Higgins JPT, Green S (Eds): Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration; 2011
- 22. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA group: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009;62:1006–1012 pmid:19631508
- 23. Center for reviews and dissemination: Systematic Reviews—CRD guidance for undertaking reviews in healthcare. York: CRD; 2009.
- 24. The mapping “Health system and community-based interventions for improving maternal health and for reducing maternal health inequalities in low- and middle-income countries: a two-stage mixed-methods research synthesis” was conducted under the European Union “Multilateral Association for Studying Health inequalities and enhancing north-south and south-south COoperaTion” (MASCOT) project and the MH-SAR project (Maternal Health South Africa-Rwanda funded by the Netherlands Organization for Scientific Research. The WHO provided technical and financial support during the mapping for reviewers to identify articles addressing health promotion interventions for maternal health, including birth preparedness and complications readiness.
- 25. The final database for the MASCOT/MH/SAR mapping including the protocol is available at http://eppi.ioe.ac.uk/webdatabases4/Intro.aspx?ID=11.
- 26. WHO Technical Consultation on health promotion interventions for maternal and newborn health, 15–17 July 2014, Geneva, Switzerland.
- 27. Effective Public Health Practice Project. Quality Assessment Tool For Quantitative Studies. Hamilton, ON; 1998.
- 28. Walsh D, Downe S: Appraising the quality of qualitative research. Midwifery 2006;22: 108–119. pmid:16243416
- 29. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N, Roen K, Duffy S: Guidance on the Conduct of Narrative Synthesis in Systematic Reviews: A Product from the ESRC Methods Programme. Lancaster: Institute for Health Research, Lancaster University; 2006
- 30. Brazier E, Andrzejewski C, Perkins ME, Themmen EM, Knight RJ, Bassane B. Improving poor women’s access to maternity care: Findings from a primary care intervention in Burkina Faso. Social science & medicine 2009;69: 682–90.
- 31. Hounton S, Chapman G, Menten J, De Brouwere V, Ensor T, Sombié I, et al. Accessibility and utilisation of delivery care within a Skilled Care Initiative in rural Burkina Faso. Tropical medicine & international health. 2008;13: 44–52.
- 32. Graham WJ, Conombo SG, Zombré DS, Meda N, Byass P, De Brouwere V. Undertaking a complex evaluation of safe motherhood in rural Burkina Faso. Tropical Medicine & International Health. 2008;13: 1–5.
- 33. Hounton S, Sombié I, Meda N, Bassane B, Byass P, Stanton C, et al. Methods for evaluating effectiveness and cost-effectiveness of a Skilled Care Initiative in rural Burkina Faso. Tropical Medicine & International Health. 2008;13: 14–24.
- 34. Newlands D, Yugbare-Belemsaga D, Ternent L, Hounton S, Chapman G. Assessing the costs and cost-effectiveness of a skilled care initiative in rural Burkina Faso. Tropical Medicine & International Health. 2008;13: 61–7.
- 35. Graham W, Themmen E, Bassane B, Meda N, De Brouwere V. Evaluating skilled care at delivery in Burkina Faso: principles and practice. Tropical Medicine & International Health. 2008;13: 6–13.
- 36. Family Care International. Care-Seeking During Pregnancy, Delivery and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya. FCI;2003.
- 37. Moore M, Copeland R, Chege I, Pido D, Griffiths M. A behavior Change Approach to investigating Factors Influencing Women’s Use of Skilled Care in Homa Bay District, Kenya. Washington, D.C.; 2002.
- 38. Family Care International. Care-Seeking During Pregnancy, Delivery and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya. FCI;2003.
- 39. Family Care international. Testing Approaches for Increasing Skilled Care During Childbirth: Key Findings from Igunga District, Tanzania. FCI;2007.
- 40. Sood S, Urvashi C, Mishra P, Neupane S. Measuring the effects of behavioral change intervention in Nepal with population based survey results. JHPIEGO;2004.
- 41. Sood S, Urvashi C, Palmer A, Molyneux I. Measuring the effects of the SIAGA behavior change campaign in Indonesia with population-based survey results. JHPIEGO;2004.
- 42. Fonseca-Becker F, Schenck-Yglesias C. Measuring the effects of behavioral change and service delivery interventions in Guatemala with population based survey results. JHPIEGO;2004.
- 43. Moran AC, Sangli G, Dineen R, Rawlins B, Yaméogo M, Baya B. Birth-Preparedness for Maternal Health : Findings from Koupéla District, Burkina Faso. J Health Popul Nutr 2006;24(4):489–97. pmid:17591346
- 44. Baya B, Sangli G, Maiga A. Measuring the effects of behavior change interventions in Burkina Faso with populatin-based survey results. JHPIEGO;2004.
- 45. Mullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health education research 2007;22:166–76. pmid:16855015
- 46. Mushi D, Mpembeni R, Jahn A. Effectiveness of community based safe motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC Pregnancy and Childbirth. 2010;10: 14 pmid:20359341
- 47. McPherson R a, Khadka N, Moore JM, Sharma M. Are birth-preparedness programmes effective? Results from a field trial in Siraha district, Nepal. Journal of health, population, and nutrition 2006;24: 479–88. pmid:17591345
- 48. Turan J, Tesfagiorghis M, Polan M. Evaluation of a community intervention for promotion of safe motherhood in eritrea. Journal of Midwifery & Women’s Health. 2011;56: 8–17.
- 49. Skinner J, Rathavy T. Design and evaluation of a community participatory, birth preparedness project in Cambodia. Midwifery. 2009;25: 738–43. pmid:18384920
- 50. Hodgins S, McPherson R, Suvedi BK, Shrestha RB, Silwal RC, Ban B, et al. Testing a scalable community-based approach to improve maternal and neonatal health in rural Nepal. Journal of perinatology: official journal of the California Perinatal Association. Nature Publishing Group; 2010;30:388–95.
- 51. Sinha D. Empowering Communities to Make Pregnancy Safer: an intervention in rural Andhra Pradesh. Health and population innivation fellowship programme working paper, No 5. New Delhi: Population Council. 2008
- 52. Kumar V, Kumar A, Das V, Srivastava NM, Baqui AH, Santosham M, et al. Community-driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India. IJOG 2012;117: 48–55.
- 53. Kumar V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S, et al. Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet. 2008;372: 1151–62. pmid:18926277
- 54. Darmstadt GL, Choi Y, Arifeen SE, Bari S, Rahman SM, Mannan I, et al. Evaluation of a cluster-randomized controlled trial of a package of community-based maternal and newborn interventions in Mirzapur, Bangladesh. PloS One 2010;5:e9696. pmid:20352087
- 55. Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reproductive health 2010;7:30. pmid:21054870
- 56. Ahluwalia IB, Schmid T, Kouletio M, Kanenda O. An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. IJOG 2003;82: 231–40.
- 57. Kaharuza F. Tia Mimba, Weka Pesa: Birth Preparedness in Rural Tanzania. 2001.
- 58. Ahluwalia IB, Robinson D, Vallely L, Gieseker KE, Kabakama A. Sustainability of community-capacity to promote safer motherhood in northwestern Tanzania: what remains? Global health promotion. 2010;17: 39–49. pmid:20357351
- 59. Hossain J, Ross SR. The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh. IJOG 2006;92: 320–8.
- 60. Barbey A, Faisel AJ, Myeya J, Stavrou V,Stewart J,Zimicki S. Dinajpur SafeMother Initiative Final Evaluation Report. 2001.
- 61. Baqui A. Impact of an integrated nutrition and health programme on neonatal mortality in rural northern India. Bulletin of the World Health Organization 2008;86: 796–804. pmid:18949217
- 62. Urassa DP, Pembe AB, Mganga F. Birth preparedness and complication readiness among women in Mpwapwa district, Tanzania. Tanzania Journal of Health Research 2012;14:1–7.
- 63. Kabakyenga JK, Östergren P-O, Turyakira E, Pettersson KO. Knowledge of obstetric danger signs and birth preparedness practices among women in rural Uganda. Reproductive Health 2011;8: 33. pmid:22087791
- 64. Kakaire O, Kaye DK, Osinde MO. Male involvement in birth preparedness and complication readiness for emergency obstetric referrals in rural Uganda. Reproductive health 2011;8: 12. pmid:21548976
- 65. Ekabua JE, Ekabua KJ, Odusolu P, Agan TU, Iklaki CU, Etokidem AJ. Awareness of birth preparedness and complication readiness in southeastern Nigeria. ISRN obstetrics and gynecology 2011;2011: 560641. pmid:21808742
- 66. Hiluf M, Fantahun M. Birth Preparedness and Complication readiness among women in Adigrat Town, north Ethiopia. Ethiop. J. Health Dev 2007;22: 14–20.
- 67. Hailu M, Gebremariam A, Alemseged F, Deribe K. Birth preparedness and complication readiness among pregnant women in Southern Ethiopia. PloS One 2011;6:e21432. pmid:21731747
- 68. Mukhopadhyay DK, Mukhopadhyay S, Bhattacharjee S, Nayak S, Biswas AK, Biswas AB. Status of birth preparedness and complication readiness in Uttar Dinajpur District, West Bengal. Indian Journal of public health 2013;57: 147–54 pmid:24125929
- 69. Magoma M, Requejo J, Campbell O, Cousens S, Merialdi M, Filippi V. The effectiveness of birth plans in increasing use of skilled care at delivery and postnatal care in rural Tanzania: a cluster randomised trial. Trop Med Int Health. 2013;18(4):435–43. pmid:23383733
- 70. Solnes Miltenburg A, Roggeveen Y, van Roosmalen J, Smith H. Ready steady go! What matters in getting women birth prepared and complication ready. Forthcoming.
- 71. Magoma M, Requejo J, Merialdi M, Campbell OMR, Cousens S, Filippi V. How much time is available for antenatal care consultations? Assessment of the quality of care in rural Tanzania. BMC Pregnancy Childbirth. 2011;11(1):64.
- 72. Church-Balin C. Behavioral change interventions for safe motherhood, common problems,unique soluions. The MNH program experience. Crump S, editor. Baltimore; 2004.
- 73. Glanz K, Rimmer BK, Viswanath . Health behavior and health education. Theory, Research, and Practice. 4th ed. Glanz K, Rimmer BK, Viswanath , editors. San Francisco: Jossey-Bass; 2008.
- 74. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP GA. Facilitators and barriers to facility- based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reproductive health. 2014;11.
- 75. Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatric and perinatal epidemiology 2001;15: 1–42. pmid:11243499
- 76. Magoma M, Requejo J, Campbell OMR, Cousens S, Filippi V. High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention. BMC pregnancy and childbirth. 2010;10: 13 pmid:20302625
- 77. Adegoke a a, Van den Broek N. Skilled birth attendance-lessons learnt. BJOG. 2009;116: 33–40. pmid:19740170
- 78. Edmonds JK, Paul M, Sibley L. Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: an empirical study. Midwifery. 2012;28: 554–60 pmid:22884893
- 79. UNDP/UNFPA/WHO/World Bank Special Programme of Research D and RT in HR (HRP). Social science methods for research on sexual and reproductive health. Collumbien M, Busza J, Cleland J, Campbell OMR, editors. 2012.