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Background: Reducing maternal mortality ratio (MMR) is a high priority public health issue in developing countries such as Indonesia. The current MMR in Indonesia is 126/100,000 live births. Optimum use of available healthcare facilities for delivery can avert maternal deaths. This study aimed to determine the factors associated with healthcare facility utilization for childbirth in Kuantan Singingi regency, Riau province, Indonesia 2017., Methods: We conducted a community-based cross-sectional study in 15 sub-districts of Kuantan Singingi regency from May-June 2017. We selected 320 mothers from 15 sub-districts who delivered in the last 3 months (February-April 2017). Trained data enumerators collected the relevant data by using a pre-tested semi-structured questionnaire. We used Cox regression analysis to determine the factors associated with delivery at healthcare facilities. Prevalence Ratio (PR) with a 95% confidence interval (CI) for childbirth at healthcare facilities was the key outcome measure., Results: Only 54.4% (174) of the 320 mothers delivered at healthcare facilities. Knowledge about pregnancy danger signs (PR = 1.59, 95%CI:1.15-2.2), attitude towards healthcare services (PR = 0.79, 95%CI:0.33-1.89), and access to health care services (PR = 0.39, 95%CI:0.18-0.84) were the dominant factors of childbirth at healthcare facilities. There was an interaction between attitude and access to healthcare influencing delivery at healthcare facilities., Conclusions: Utilization of healthcare facilities for childbirth was low in Kuantan Singingi regency. Knowledge of pregnancy danger signs was an independent correlate of childbirth at healthcare facilities. Also, the interaction between attitude and access to healthcare showed a significant influence on childbirth at healthcare facilities. We recommend strengthening of existing maternal and child health program with a particular emphasis on complete and quality antenatal care, health education on danger signs of pregnancy and childbirth, and promoting positive attitudes towards healthcare facilities.

Introduction: Every day, approximately 830 women globally die from pregnancy-child birth related complications and all maternal deaths are mainly due to the three phases of delay usually experienced in maternal care which originates from inadequate or lack of birth and emergency preparedness. Despite the benefit of Birth Preparedness and Complications Readiness (BPACR) in the reduction of the three phases of delay and thus reduction of maternal deaths and complications, no study has been conducted in Adjumani district to assess the knowledge and practice of birth preparedness and complication readiness, thus our objective was to assess the knowledge and practice of Birth Preparedness and Complications Readiness (BPACR) among pregnant women attending antenatal clinic at Openzinzi Health Centre (HC) III in Adjumani District., Methods: A descriptive cross sectional study design with a sample of 80 respondents was used for the study. Simple random sampling was used to select the respondents in the study area. A research administered questionnaire was used for data collection., Results: Most of the respondents (27.5%) were in the age group of 26-35 years. The majority 43.75% ended at primary level of education, 50% were unemployed, and the majority 71.25% and 70% knew identifying skilled birth attendants and health facilities respectively as components of BPACR. 76.25% of the respondents mentioned vaginal bleeding and 62.5% over vomiting as danger signs in pregnancy while 12.5% did not know any danger sign in pregnancy. 76.25% identified place for skilled birth, 66.25% identified skilled birth attendant, and only 15% identified blood donor., Conclusion: The practice of BPACR was poor among the pregnant women attending antenatal care at Openzinzi Health Centre III in Adjumani District. The knowledge about BPACR was higher among the educated respondents involved in the study., Competing Interests: The authors declare no competing interests., (© Masudio Florence et al.)

Background: Kenya did not meet its maternal mortality ratio (MMR) target under the Millennium Development Goals. The aim of this study was to examine the gaps in knowledge of intrapartum care among obstetric care providers (OCPs) in rural Nandi County, Kenya., Methods: This cross-sectional study in 2015 surveyed 326 nurses, midwives, clinical officers and physicians about their knowledge, attitudes and practices related to normal labor and childbirth, immediate newborn care and management of obstetric complications., Results: Self-reported intrapartum knowledge among OCPs was insufficient according to accepted international standards. The mean total knowledge score for all OCPs based on a validated 30-question inventory was 62% (range 23-90%). Only 14 providers (4%) scored as 'competent' (a score ≥80%). Scores were higher for OCPs who had received pre- and postemployment emergency obstetric care training and those with higher levels of confidence in their skills. Survey respondents identified a lack of knowledge as one of the greatest barriers to high-quality patient care., Conclusions: Increasing training opportunities for OCPs may improve the quality of obstetric care provided to women in Kenya and other high-MMR locations in sub-Saharan Africa and enable progress toward achieving the ambitious Sustainable Development Goals target for maternal survival., (© The Author(s) 2018. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To explore basic and comprehensive emergency obstetric service provision across four districts in rural northern Ghana, and whether women were more likely to deliver at facilities with more skilled care., Methods: Field workers geo-coded all health facilities in East Mamprusi, Sissala East, Kassena Nankana Municipal, and Kassena Nankana West districts, and administered surveys to assess providers and emergency obstetric care available. Data were also prospectively collected on delivery locations of women and neonates who died, or nearly died (near misses), between September 1, 2015 and April 30, 2017., Results: There were 14 physicians for a population of nearly 360 000 women. Six (6%) facilities could provide basic emergency care, and 3 (3%) could provide comprehensive care. Services were distributed unequally, with 6 (67%) of the emergency facilities located in the least populated district. Among the sample of women and neonates who died or nearly died, 175 (39%) delivered at locations unable to provide basic emergency services., Conclusion: Access to emergency obstetric and neonatal care was distributed inequitably across these districts, suggesting the need to revisit geographic placement of facilities relative to population. The study also raised the question of how to ensure facilities are equipped to respond to emergencies., (© 2019 International Federation of Gynecology and Obstetrics.)

Introduction: Several versions of Early Warning Systems (EWS) are used in obstetrics to detect and treat early clinical deterioration to avert morbidity and mortality. EWS can potentially be useful to improve the quality of care and reduce the risk of maternal mortality in resource-limited settings. We conducted a systematic literature review of published obstetric early warning systems, define their predictive accuracy for morbidity and mortality, and their effectiveness in triggering corrective actions and improving health outcomes., Methods: We systematically searched for primary research articles on obstetric EWS published in peer-reviewed journals between January 1997 and March 2018 in Medline, CINAHL, SCOPUS, Science Direct, and Science Citation Index. We also searched reference lists of relevant articles and websites of professional societies. We included studies that assessed the predictive accuracy of EWS to detect clinical deterioration, or/and their effectiveness in improving clinical outcomes in obstetric inpatients. We excluded studies with a paediatric or non-obstetric adult population. Cross-sectional and qualitative studies were also excluded. We performed a narrative synthesis since the outcomes reported were heterogeneous., Results: A total of 381 papers were identified, 17 of which met the inclusion criteria. Eleven of the included studies evaluated the predictive accuracy of EWS for obstetric morbidity and mortality, 5 studies assessed the effectiveness of EWS in improving clinical outcomes, while one study addressed both. Sixteen published EWS versions were reviewed, 14 of which included five basic clinical observations (pulse rate, respiratory rate, temperature, blood pressure, and consciousness level). The obstetric EWS identified had very high median (inter-quartile range) sensitivity-89% (72% to 97%) and specificity-85% (67% to 98%) but low median (inter-quartile range) positive predictive values-41% (25% to 74%) for predicting morbidity or ICU admission. Obstetric EWS had a very high accuracy in predicting death (AUROC >0.80) among critically ill obstetric patients. Obstetric EWS improves the frequency of routine vital sign observation, reduces the interval between the recording of specifically defined abnormal clinical observations and corrective clinical actions, and can potentially reduce the severity of obstetric morbidity., Conclusion: Obstetric EWS are effective in predicting severe morbidity (in general obstetric population) and mortality (in critically ill obstetric patients). EWS can contribute to improved quality of care, prevent progressive obstetric morbidity and improve health outcomes. There is limited evidence of the effectiveness of EWS in reducing maternal death across all settings. Clinical parameters in most obstetric EWS versions are routinely collected in resource-limited settings, therefore implementing EWS may be feasible in such settings., Competing Interests: The authors have declared that no competing interests exist.

Background: The institutional maternal mortality ratio (iMMR) in South Africa (SA) is still unacceptably high. A key recommendation from the National Committee on Confidential Enquiries into Maternal Deaths has been to improve the availability and quality of care for women suffering obstetric emergencies., Objectives: To determine whether there was a change in the number of maternal deaths and in the iMMR over time that could be attributed to the training of >80% of healthcare professionals by means of a specifically designed emergency obstetric care (EmOC) training programme., Methods: A before-and-after study was conducted in 12 healthcare districts in SA, with the remaining 40 districts serving as a comparison group. Twelve 'most-in-need' healthcare districts in SA were selected using a composite scoring system. Multiprofessional skills-and-drills workshops were held off-site using the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training programme. Eighty percent or more of healthcare professionals providing maternity care in each district were trained between October 2012 and March 2015. Institutional births and maternal deaths were assessed for the period January 2011 - December 2016 and a before-and-after-training comparison was made. The number of maternal deaths and the iMMR were used as outcome measures., Results: A total of 3 237 healthcare professionals were trained at 346 workshops. In all, 1 248 333 live births and 2 212 maternal deaths were identified and reviewed for cause of death as part of the SA confidential enquiries. During the same period there were 5 961 maternal deaths and 5 439 870 live births in the remaining 40 districts. Significant reductions of 29.3% in the number of maternal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.66 - 0.77) and 17.5% in the number of maternal deaths from direct obstetric causes (RR 0.825, 95% CI 0.73 - 0.93) were recorded. When comparing the percentage change in iMMR for equivalent before-and-after periods, there was a greater reduction in all categories of causes of maternal death in the intervention districts than in the comparison districts., Conclusions: Implementing a skills-and-drills EmOC training package was associated with a significant reduction in maternal deaths.

Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care at birth. While originally the "Three Delays" model was designed to focus on curative services that encompass emergency obstetric care, SMGL expanded its application to primary and secondary prevention of obstetric complications. Prevention of the "first delay" focused on addressing factors influencing the decision to seek delivery care at a health facility. Numerous factors can contribute to the first delay, including a lack of birth planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care, and financial or geographic barriers. SMGL addressed these barriers through community engagement on safe motherhood, public health outreach, community workers who identified pregnant women and encouraged facility delivery, and incentives to deliver in a health facility. SMGL used qualitative and quantitative methods to describe intervention strategies, intervention outcomes, and health impacts. Partner reports, health facility assessments (HFAs), facility and community surveillance, and population-based mortality studies were used to document activities and measure health outcomes in SMGL-supported districts. SMGL's approach led to unprecedented community outreach on safe motherhood issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL districts. In Uganda, the proportion of births that took place in facilities rose from 45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts, facility deliveries increased from 62.6% to 90.2% (44% increase). In both countries, the proportion of women delivering in facilities equipped to provide emergency obstetric and newborn care also increased (from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines in the number of maternal deaths due to not accessing facility care during pregnancy, delivery, and the postpartum period in both countries. This reduction played a significant role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda but not in Zambia. Further work is needed to sustain gains and to eliminate preventable maternal and perinatal deaths., (© Serbanescu et al.)

Introduction: Most maternal that deaths occur in developing countries are considered unfair and can be avoided. In 2008, The WHO proposed a checklist for delivery care, in order to assess whether a simple, low-cost intervention had an impact on maternal and neonatal mortality in low-income countries., Aim: To translate, adapt and validate the content of the WHO Safe Childbirth Checklist (SCC) for its use in Colombia., Methods: The translation of the list was carried out, adaptation was made to our context and validation of content through a panel of experts composed of 17 health workers with experience in maternal and neonatal care and safety. The reliability among the judges was calculated (Rwg) and according to the results, items were modified or added to each section of the list., Results: Modifications were made to the wording of 28 items, none was eliminated, and 19 new items were added. The most important modifications were made to the management guidelines that accompany each item and the items included refer to risks inherent to our environment., Conclusion: The Colombian version of the SCC will be a useful tool to improve maternal and neonatal care and thereby will contribute to reducing maternal and neonatal morbidity and mortality in our country., Competing Interests: Conflict of interest: The authors state that they have no conflict of interest.

Background: Reducing Maternal Mortality Rate (MMR) is considered by the international community as one of the eight Millennium Development Goals. Based on previous studies, Skilled Assistant at Birth (SAB), General Fertility Rate (GFR) and Gross Domestic Product (GDP) have been identified as the most significant predictors of MMR in South Sudan. This paper aims for the first time to develop profile limits for the MMR in terms of significant predictors SAB, GFR, and GDP. The paper provides the optimal values of SAB and GFR for a given MMR level., Methods: Logarithmic multi- regression model is used to model MMR in terms of SAB, GFR and GDP. Data from 1986 to 2015 collected from Juba Teaching Hospital was used to develop the model for predicting MMR. Optimization procedures are deployed to attain the optimal level of SAB and GFR for a given MMR level. MATLAB was used to conduct the optimization procedures. The optimized values were then used to develop lower and upper profile limits for yearly MMR, SAB and GFR., Results: The statistical analysis shows that increasing SAB by 1.22% per year would decrease MMR by 1.4% (95% CI (0.4-5%)) decreasing GFR by 1.22% per year would decrease MMR by 1.8% (95% CI (0.5-6.26%)). The results also indicate that to achieve the UN recommended MMR levels of minimum 70 and maximum 140 by 2030, the government should simultaneously reduce GFR from the current value of 175 to 97 and 75, increase SAB from the current value of 19 to 50 and 76., Conclusions: This study for the first time has deployed optimization procedures to develop lower and upper yearly profile limits for maternal mortality rate targeting the UN recommended lower and upper MMR levels by 2030. The MMR profile limits have been accompanied by the profile limits for optimal yearly values of SAB and GFR levels. Having the optimal level of predictors that significantly influence the maternal mortality rate can effectively aid the government and international organizations to make informed evidence-based decisions on resources allocation and intervention plans to reduce the risk of maternal death.

Background:  The poor emphasis on the role of husbands in birth preparedness and complication readiness (BPCR) is a major factor that should be addressed in tackling maternal mortality., Aim:  To assess the level of husbands' participation in BPCR and associated factors., Setting:  Wolaita Sodo town, Southern Ethiopia., Methods:  A community based cross-sectional study was conducted among 608 husbands of pregnant women and nursing mothers. Multivariate logistic regression model was used for the analysis., Results:  Forty-five per cent of husbands studied had poor participation in BPCR. Out of the total husbands studied, 40% (235) did not identify transportation, 49% (291) did not accompany their wives to antenatal care (ANC) clinic, 59% (350) did not identify skilled birth attendant, 26% (155) did not identify health facility for delivery and 30% (179) did not save money for emergency. Only 42% (250) of husbands had awareness of emergency conditions, while 75% (444) did not make postpartum plan. Husbands who knew the place of birth of the baby [adjusted odds ratio (AOR) = 7.23; 95% confidence interval (CI): 2.98-17.54] and those who discussed with their wives about birth preparedness (AOR = 2.03; 95% CI: 1.37-3.02) were significantly more likely to participate in BPCR compared to those who did not., Conclusion:  Participation of husbands in BPCR was poor in the study area. The level of participation in relation to selection of service provider and health facility, financial and transportation planning for delivery and identifying blood donor needs attention to achieve better husband participation in BPCR.

We investigated perceptions of the causes of maternal mortality by women attending referral hospitals in Nigeria. Focus group discussions were conducted with various categories of women. Our results showed that women were aware of the medical causes of mortality, although a few listed divine reasons. Delays in reaching hospitals or after women arrive in hospitals featured prominently as lead causes mentioned by women. Listening to women as end-users is an important approach to identify points of remediation in the provision of maternal health care. This should be taken into cognizance when policymakers or international agencies plan the prevention of maternal deaths in developing countries.

Background: China is one of the few Countdown countries to have achieved Millennium Development Goal 5 (75% reduction in maternal mortality ratio between 1990 and 2015). We aimed to examine the health systems and contextual factors that might have contributed to the substantial decline in maternal mortality between 1997 and 2014. We chose to focus on western China because poverty, ethnic diversity, and geographical access represent particular challenges to ensuring universal access to maternal care in the region., Methods: In this systematic assessment, we used data from national census reports, National Statistical Yearbooks, the National Maternal and Child Health Routine Reporting System, the China National Health Accounts report, and National Health Statistical Yearbooks to describe changes in policies, health financing, health workforce, health infrastructure, coverage of maternal care, and maternal mortality by region between 1997 and 2014. We used a multivariate linear regression model to examine which contextual and health systems factors contributed to the regional variation in maternal mortality ratio in the same period. Using data from a cross-sectional survey in 2011, we also examined equity in access to maternity care in 42 poor counties in western China., Findings: Maternal mortality declined by 8·9% per year between 1997 and 2014 (geometric mean ratio for each year 0·91, 95% CI 0·91-0·92). After adjusting for GDP per capita, length of highways, female illiteracy, the number of licensed doctors per 1000 population, and the proportion of ethnic minorities, the maternal mortality ratio was 118% higher in the western region (2·18, 1·44-3·28) and 41% higher in the central region (1·41, 0·99-2·01) than in the eastern region. In the rural western region, the proportion of births in health facilities rose from 41·9% in 1997 to 98·4% in 2014. Underpinning such progress was the Government's strong commitment to long-term strategies to ensure access to delivery care in health facilities-eg, professionalisation of maternity care in large hospitals, effective referral systems for women medically or socially at high risk, and financial subsidies for antenatal and delivery care. However, in the poor western counties, substantial disparity by education level of the mother existed in access to health facility births (44% of illiterate women vs 100% of those with college or higher education), antenatal care (17% vs 69%) had at least four visits), and caesarean section (8% vs 44%)., Interpretation: Despite remarkable progress in maternal survival in China, substantial disparities remain, especially for the poor, less educated, and ethnic minority groups in remote areas in western China. Whether China's highly medicalised model of maternity care will be an answer for these populations is uncertain. A strategy modelled after China's immunisation programme, whereby care is provided close to the women's homes, might need to be explored, with township hospitals taking a more prominent role., Funding: Government of Canada, UNICEF, and the Bill & Melinda Gates Foundation., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.)

The process of labour and delivery remains an unnecessary and preventable cause of death of women and babies around the world. Although the rates of maternal and perinatal death are declining, there are large disparities between rich and poor countries, and sub-Saharan Africa has not seen the scale of decline as seen elsewhere. In many areas, maternity services remain sparse and under-equipped, with insufficient and poorly trained staff. Priorities for reducing the mortality burden are provision of safe caesarean section, prevention of sepsis and appropriate care of women in labour in line with the current best practices, appropriately and affordably delivered. A concern is that large-scale recourse to caesarean delivery has its own dangers and may present new dominant causes for maternal mortality. An area of current neglect is newborn care. However, innovative training methods and appropriate technologies offer opportunities for affordable and effective newborn resuscitation and follow-up management in low-income settings., (Copyright © 2016. Published by Elsevier Ltd.)

Objectives: In Zambia, only 56% of rural women deliver in a health facility, and improving facility delivery rates is a priority of the Zambian government. 'Mama kit' incentives - small packages of childcare items provided to mothers conditional on delivering their baby in a facility - may encourage facility delivery. This study measured the impact and cost-effectiveness of a US$4 mama kit on rural facility delivery rates in Zambia., Methods: A clustered randomised controlled trial was used to measure the impact of mama kits on facility delivery rates in thirty rural health facilities in Serenje and Chadiza districts. Facility-level antenatal care and delivery registers were used to measure the percentage of women attending antenatal care who delivered at a study facility during the intervention period. Results from the trial were then used to model the cost-effectiveness of mama kits at-scale in terms of cost per death averted., Results: The mama kits intervention resulted in a statistically significant increase in facility delivery rates. The multivariate logistic regression found that the mama kits intervention increased the odds of delivering at a facility by 63% (P-value < 0.01, 95% CI: 29%, 106%), or an increase of 9.9 percentage points, yielding a cost-effectiveness of US$5183 per death averted., Conclusions: This evaluation confirms that low-cost mama kits can be a cost-effective intervention to increase facility delivery rates in rural Zambia. Mama kits alone are unlikely to completely solve safe delivery challenges but should be embedded in larger maternal and child health programmes., (© 2016 John Wiley & Sons Ltd.)

Objective: To clarify the problems related to maternal deaths in Japan, including the diseases themselves, causes, treatments and the hospital or regional systems., Design: Descriptive study., Setting: Maternal death registration system established by the Japan Association of Obstetricians and Gynecologists (JAOG)., Participants: Women who died during pregnancy or within a year after delivery, from 2010 to 2014, throughout Japan (N=213)., Main Outcome Measures: The preventability and problems in each maternal death., Results: Maternal deaths were frequently caused by obstetric haemorrhage (23%), brain disease (16%), amniotic fluid embolism (12%), cardiovascular disease (8%) and pulmonary disease (8%). The Committee considered that it was impossible to prevent death in 51% of the cases, whereas they considered prevention in 26%, 15% and 7% of the cases to be slightly, moderately and highly possible, respectively. It was difficult to prevent maternal deaths due to amniotic fluid embolism and brain disease. In contrast, half of the deaths due to obstetric haemorrhage were considered preventable, because the peak duration between the initial symptoms and initial cardiopulmonary arrest was 1-3 h., Conclusions: A range of measures, including individual education and the construction of good relationships among regional hospitals, should be established in the near future, to improve primary care for patients with maternal haemorrhage and to save the lives of mothers in Japan., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

An estimated 289,000 maternal deaths, 2.6 million stillbirths and 2.4 million newborn deaths occur globally each year, with the majority occurring around the time of childbirth. The medical and surgical interventions to prevent this loss of life are known, and most maternal and newborn deaths are in principle preventable. There is a need to build the capacity of health-care providers to recognize and manage complications during pregnancy, childbirth and the post-partum period. Skills-and-drills competency-based training in skilled birth attendance, emergency obstetric care and early newborn care (EmONC) is an approach that is successful in improving knowledge and skills. There is emerging evidence of this resulting in improved availability and quality of care. To evaluate the effectiveness of EmONC training, operational research using an adapted Kirkpatrick framework and a theory of change approach is needed. The Making It Happen programme is an example of this., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Task shifting-moving tasks to healthcare workers with a shorter training-for emergency obstetric care (EmOC) can potentially improve access to lifesaving interventions and thereby contribute to reducing maternal and neonatal morbidity and mortality. The present paper reviews studies on task shifting for the provision of EmOC. Most studies were performed in Sub-Saharan Africa and South Asia and focused primarily on task shifting for the performance of cesarean deliveries. Cesarean delivery rates increased following EmOC training without significant increase in adverse outcomes. The paper discusses the advantages and disadvantages of task shifting in EmOC and the role of this approach in improving maternal and newborn health in the short and long term., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Global strategies to reduce maternal mortality include the ambitious goal of achieving universal access to antenatal care by 2015. This target is unlikely to be achieved, especially in developing countries where antenatal coverage is often less than 50 per cent. Although much is known about the types of women who do not engage with antenatal services, there is limited information about their reasons for non-attendance. By summarising a variety of findings from qualitative studies, this article seeks to identify relevant issues. It highlights some of the problems of applying a standardised model of antenatal care in countries where resources are limited and belief systems are at odds with westernised understandings of pregnancy and childbirth.

Background: Although there is a general agreement on the importance of antenatal care to improve the maternal and perinatal health, little is known about its importance to improve health facility delivery in developing countries. The objective of this study was to assess the association of antenatal care with birth in health facility., Methods: A systematic review with meta-analysis of Mantel-Haenszel odds ratios was conducted by including seventeen small scale studies that compared antenatal care and health facility delivery between 2003 and 2013. Additionally, national survey data of African countries which included antenatal care, health facility delivery and maternal mortality in their report were included. Data were accessed via a computer based search from MEDLINE, African Journals Online, HINARI and Google Scholar databases., Results: The regression analysis of antenatal care with health facility delivery revealed a positive correlation. The pooled analysis also demonstrated that woman attending antenatal care had more than 7 times increased chance of delivering in a health facility. The comparative descriptive analysis, however, demonstrated a big gap between the proportion of antenatal care and health facility delivery by the same individuals (27%-95% vs 4%-45%). Antenatal care and health facility delivery had negative correlation with maternal mortality., Conclusion: The present regression and meta-analysis has identified the relative advantage of having antenatal care to give birth in health facilities. However, the majority of women who had antenatal care did not show up to a health facility for delivery. Therefore, future research needs to give emphasis to identifying barriers to health facility delivery despite having antenatal care follow up.

Background: Several demographic and health surveys in Africa have shown the high prevalence of home delivery, but little is known how strongly skilled person unattended deliveries are associated with maternal and perinatal mortality. The aim of this review was to assess the gross correlation of maternal mortality ratios (MMR) and perinatal mortality rates (PMR) with the proportion of skilled health personnel attended deliveries., Methods: In this study, a systematic review was conducted after a computer based literature search was run in the electronic databases from 1990 through September 2013. Bivariate linear regression analyses were done for the proportion of skilled person attended deliveries in relation with MMR, stillbirth and neonatal mortality rates using national survey data of 41 African countries., Results: African countries with relatively small population sizes and with middle to high income were found to have above 90% skilled person attended deliveries. Several African countries with a high proportion of skilled person attended deliveries (60%-100%) were able to reduce the MMR to the range of 56-370/100,000 live births. Several Sub Saharan African (SSA) countries were far from their northern counterparts. The regression analyses demonstrated a negative correlation of the proportion of skilled health personnel attended deliveries with the MMR, stillbirth rate and neonatal mortality rate., Conclusion: According to the national data of the included African countries, skilled delivery attendance was associated with significant reduction of maternal, fetal and neonatal mortality. SSA countries need to benchmark the experience of the North African countries to reduce the high maternal and perinatal deaths.

Background: Timor-Leste is a young developing country in Asia. Most of its infrastructure was destroyed after a long armed conflict for independence. Despite recent expansion of health facilities and investment in healthcare, maternal mortality remains high with most mothers still giving birth at home. This study investigated factors affecting the non-utilisation of health service for childbirth in the aftermath of the independence conflict., Methods: The Timor-Leste Demographic and Health Survey 2009-2010 was the latest two-stage national survey, which used validated questionnaires to obtain information from 26 clusters derived from 13 districts of the country. Factors influencing non-utilisation of health facility for childbirth were investigated using univariate and multivariable logistic regression analyses, accounting for the cluster sampling and sample weight of the survey., Results: Of the total 5986 participants included in the study, 4472 (74.8%) did not deliver their last child at a health facility. Lack of education for the mother (adjusted odds ratio (OR): 2.04; 95% confidence interval (CI) 1.56 to 2.66) and her partner (OR: 1.45; 95% CI 1.14 to 1.84), low household wealth status (OR: 5.20; 95% CI 3.93 to 6.90), and rural residence (OR: 2.83; 95% CI 2.22 to 3.66), were associated with increased likelihood of non-utilisation of health facility for childbirth. Working mothers (OR: 1.55; 95% CI 1.32 to 1.81), who had high parity (OR: 1.78; 95% CI 1.36 to 2.32) and did not attend antenatal care service (OR: 4.68; 95% CI 2.65 to 8.28) were also vulnerable for not delivering at a health facility. Conversely, the prevalence of non-utilisation of health facility for childbirth reduced with increasing number of service components received during antenatal care visits (OR: 0.72; 95% CI 0.64 to 0.80)., Conclusions: Only a quarter of Timorese women delivered at a health facility. In order to reduce maternal mortality, future interventions should target disadvantaged mothers from poor families, those residing in rural areas, have higher parity but no education, and who seldom attend antenatal care service, by improving their utilisation of health facility for childbirth.

Background: One of the effective strategies for reducing the number of maternal deaths is delivery by a skilled birth attendant. Low utilization of skilled birth attendants has been attributed to delay in seeking care, delay in reaching a health facility and delay in receiving adequate care. Health workers could play a role in helping women prepare for birth and anticipate complications, in order to reduce delays. There is little evidence to support these birth preparedness and complication readiness (BP/CR) programs; however, BP/CR programs are frequently implemented. The objective of this review is to assess the effect of BP/CR programs on increasing skilled birth attendance in low-resource settings., Methods: Due to the complexity of BP/CR programs and the need to understand why certain programs are more effective than others, we will combine both quantitative and qualitative studies in this systematic review. Search terms were selected with the assistance of a health information specialist. Three reviewers will independently select and assess studies for quality. Data will be extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Discussion between the reviewers will resolve disagreements. If disagreements remain, a third party will be consulted. Data analysis will be carried out in accordance with the BP/CR matrix, developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). Study data will be grouped and analyzed by quality and study design and regrouped according to type of intervention strategy., Discussion: This review will provide: 1) an insight into existing BP/CR programs, 2) recommendations on effective elements of the different approaches, 3) proposals for concrete action plans for health professionals in the field of reproductive health in resource-poor settings and 4) an overview of existing knowledge gaps requiring further research., Trial Registration: PROSPERO registration no.: CRD42012003124.