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Background Progress in maternal survival in sub- Saharan Africa has been poor since the Millennium Declaration. Objectives This systematic review aims to investigate the presence and rigour of evidence for effective capacity building for Essential Obstetric and Newborn Care ( EONC) to reduce maternal mortality in rural, sub-Saharan Africa, where maternal mortality ratios are highest globally. Search strategy MEDLINE (1990-January 2014), EMBASE (1990-January 2014), and the Cochrane Library were included in our search. Key developing world issues of The Lancet and the British Journal of Obstetrics and Gynaecology, African Ministry of Health websites, and the WHO reproductive health library were searched by hand. Selection criteria Studies investigating essential obstetric and newborn care packages in basic and comprehensive care facilities, at community and institutional level, in rural sub-Saharan Africa were included. Studies were included if they reported on healthcare worker performance, access to care, community behavioural change, and emergency obstetric and newborn care. Data collection and analysis Data were extracted and all relevant studies independently appraised using structured abstraction and appraisal tools. Main results There is moderate evidence to support the training of healthcare workers of differing cadres in the provision of emergency obstetric and newborn services to reduce institutional maternal mortality and case-fatality rates in rural sub-Saharan Africa. Community schemes that sensitise and enable access to maternal health services result in a modest rise in facility birth and skilled birth attendance in this rural setting. Authors' conclusion Essential Obstetric and Newborn Care has merit as an intervention package to reduce maternal mortality in rural sub-Saharan Africa. [ABSTRACT FROM AUTHOR]