How can human resources for health interventions ...
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Negero et al. Hum Resour Health (2021) 19:54 https://doi.org/10.1186/s12960-021-00601-3 REVIEW How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review Melese Girmaye Negero 1,2* , David Sibbritt 2 and Angela Dawson 2 Abstract Background: Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the con- tinuum in low- and lower-middle-income countries (LLMICs). Methods: A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions’ impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework. Results: Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, admin- istration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, sup- portive supervision, access to m-Health technology, and modest financial and non-financial incentives for community © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Open Access *Correspondence: [email protected] 1 School of Public Health, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia Full list of author information is available at the end of the article
Transcript of How can human resources for health interventions ...
Negero et al. Hum Resour Health (2021) 19:54 https://doi.org/10.1186/s12960-021-00601-3
REVIEW
How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic reviewMelese Girmaye Negero1,2* , David Sibbritt2 and Angela Dawson2
Abstract
Background: Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the con-tinuum in low- and lower-middle-income countries (LLMICs).
Methods: A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions’ impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework.
Results: Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, admin-istration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, sup-portive supervision, access to m-Health technology, and modest financial and non-financial incentives for community
© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Open Access
*Correspondence: [email protected] School of Public Health, Institute of Health Sciences, Wollega University, Nekemte, EthiopiaFull list of author information is available at the end of the article
Page 2 of 28Negero et al. Hum Resour Health (2021) 19:54
BackgroundApproximately 810 women die from preventable causes related to pregnancy and childbirth daily, and more than 94% of these deaths occur in LLMICs [1]. In the last two decades, deaths from complications during pregnancy, childbirth, and the postnatal period have declined by 38%. However, an average reduction of 3% per year is too slow to achieve the required SDGs target in 2030 [2]. Avoidable maternal and perinatal morbidity and mor-tality are attributed mainly to the poor quality of care received in health facilities [3]. In low-income countries, the 2030 SDGs target of reducing the global maternal mortality ratio to less than 70/100,000 live births and the global neonatal mortality rates to less than 12/1000 live births requires a rapid improvement in the quality of SRMNH care. This involves enhancing the availability, skills, and motivation of healthcare providers [4–6].
The SRMNH care continuum is an integrated and continuous care package with evidence-based interven-tions that are to be delivered over the preconception, pregnancy, birth, and postnatal periods [7]. The recom-mended preconception care (PCC) services include fam-ily planning, abortion care, sexually transmitted diseases prevention and treatment, and health counselling during the pre-pregnancy period [8].
During pregnancy, quality antenatal care (ANC) involves nutritional counselling and multivitamin sup-plements, adequate visits with skilled personnel (eight and above), blood and urine tests, preventive antibiotics, tetanus toxoid injections, and health education on preg-nancy and birth danger signs [9, 10]. Quality intrapartum care (IPC) involves: respectful care, clear and compelling communication between the women and health workers, the option of a companion during labour and childbirth, health facility birth attended by skilled personnel, appro-priate pain relief strategies, mobility in labour where pos-sible, and choice of birth position, the use of uterotonics and delayed cord clamping (after a minute), immediate
kangaroo care and breastfeeding, delayed bathing of the newborn (24 h), and the care of mother and newborn in a health facility for at least 24 h after birth [10, 11]. Qual-ity postnatal care (PNC) includes immediate PNC within 24 h after birth and at least three additional postnatal visits within 42 days after birth for the mother and new-born, home visits in the first week after birth, exclusive breastfeeding, cord care, prophylactic antibiotics for the mother, and health education on maternal and newborn health danger signs [10, 12].
According to the World Health Organization (WHO), the quality of care provided to women and newborns must be safe, effective, timely, efficient, equitable, and people-centred [3, 13]. Safe care is care that minimizes risk and harm to recipients, including avoiding prevent-able injuries and reducing medical errors. Effective care focuses on the provision of services that are based on sci-entific knowledge and evidence-based standards. Timely care avoids harmful delays in giving and receiving care, while efficient care maximizes resource use and avoids wastage. Equitable care does not discriminate based on personal characteristics or socioeconomic status, while people-centred care is care that considers the desire, val-ues, culture, and aspirations of care recipients [3, 13, 14].
According to the WHO, human resources for health are "all people engaged in actions whose primary intent is to enhance health". This includes a range of profession-als from clinical to managers, technicians, and research-ers [15, 16]. Well-trained, competent, and motivated HRH is crucial to delivering SRMNH care quality across the continuum from PCC to PNC. Therefore, improving health worker performance is key to achieving the SDGs maternal and neonatal health targets [13]. Low-income countries are experiencing a chronic shortage of health-care providers; many are not geographically distributed according to health service needs and are perform-ing below required standards [6, 17–19]. A systematic review by Lassi et al. conducted in 2016 concluded that
health workers (CHWs) improved the quality of care continuum. Skills-based, regular, short, focused, onsite, and clini-cal simulation, and/or mobile phone-assisted in-service training of skilled personnel were more productive than knowledge-based, irregular, and donor-funded training. Facility-based maternal and perinatal death reviews, coupled with training and certification of skilled personnel, positively affected SRMNH care quality across the continuum. Pre-conception care, an essential component of the SRMNH care continuum, lacks studies and services in LLMICs.
Conclusions: We recommend maternal and perinatal death audits in all health facilities; respectful, woman-centered care as a critical criterion of RBF initiatives; local administration of health worker allowances and incentives; and integration of CHWs into the healthcare system. There is an urgent need to include preconception care in the SRMNH care continuum and studies in LLMICs.
Keywords: Human resources for health intervention, Skilled personnel, Lay personnel, Quality of care, Sexual, Reproductive, Maternal, And newborn health, The continuum of care, Deductive qualitative content analysis, Low- and lower-middle-income countries
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improving the management, capacity, and motivation of existing HRH is vital to improving maternal healthcare quality [6].
A synthesis by Munabi-Babigumira et al. (2017) found that pre-service and in-service training, adequate staff-ing, supervision, incentives, leadership and management support, adequate equipment and supplies, and team-work and collaboration improved the ability of skilled personnel to deliver quality IPC and PNC services [20]. Althabe et al. (2008) demonstrated that interactive work-shops and reminders, educational outreach visits, audit and feedback, mass-media and patient-mediated inter-ventions, financial incentives, and/or organizational and regulatory interventions had a moderately positive effect on healthcare provider performance and the quality of ANC, IPC, PNC, and neonatal care services in low- and middle-income countries [21]. Sibley et al. (2009) found that training in advice on ANC, IPC, and PNC; manage-ment of normal delivery; advice on breastfeeding; and timely detection and referral of women with obstetric complications by traditional birth attendants (TBAs) had a positive effect on the increment of timely referrals and reduction of maternal, perinatal and neonatal mortalities, and stillbirth rates [22]. However, there are no reviews examining HRH interventions’ contribution to lay and/or skilled personnel’s performance to improve SRMNH care quality across the continuum in LLMICs. The review by Lassi et al. focused on skilled personnel only and lacked an examination of HRH interventions contribut-ing to SRMNH care quality across the continuum [6]. We, therefore, undertook an updated and comprehen-sive review to examine HRH interventions and SRMNH outcomes.
MethodsA deductive qualitative content analysis of HRH inter-ventions and their effects on SRMNH care quality along the continuum was undertaken using an a priori con-ceptual framework to help direct and define the study and deliver practical insights for health policy and prac-tice decision-making [23, 24]. We used the WHO-HRH Action Framework [25, 26] to define HRH interventions (Fig. 1). The framework identifies six action fields (Man-agement, Leadership, Partnership, Finance, Education, and Policy) [25, 26]. The Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidance was followed in this review [27], which is regis-tered in the International Prospective Register of System-atic Reviews [28].
Search protocolIn consultation with two public health research librar-ians from the University of Technology Sydney (UTS), a
Population, Interventions, Comparators, Outcomes, and Study design (PICOS) design, was applied to develop the review question: in LLMICs, how can HRH interventions contribute to SRMNH care quality across the continuum?
Included studies were those that described: (a) an HRH management, leadership, partnership, finance, education, and/or policy intervention (see definitions at Additional file 1: Table S1.); (b) one or more HRH interventions’ effect on two or more consecutive quality SRMNH care packages across the continuum (a study reporting HRH interventions delivered in conjunction with one or more non-continuous SRMNH care packages was excluded since it was not a continuum); (c) the role of skilled and/or lay personnel (see definitions at Additional file 1: Table S2.); and (d) primary research studies in English (other languages were excluded due to resource con-straints) conducted in LLMICs (see inclusion criteria at Additional file 1: Table S3.). Studies that did not include any of the six HRH interventions were excluded. We defined a quality SRMNH care package as one that con-tained a safe, effective, timely, efficient, equitable, and people-centred package of interventions that comprised PCC, ANC, IPC, and/or PNC (maternal and/or newborn) services as described by the WHO [8, 13]. As noted in the protocol for this review, the main outcome of the review is quality of care (defined according to WHO as care that is safe, effective, timely, efficient, equitable, and people-centered). Additional outcomes included were maternal and/or neonatal health outcomes directly related to the quality of care. These involve maternal and/or neonatal morbidity or mortality and uptake of the recommended and life-saving interventions facilitated by health workers (such as early initiation of breastfeeding, delayed bathing of newborns, and cord care) [28].
Search strategySix bibliographic databases (PubMed, Web of Sci-ence/Core Collection, SCOPUS, CINAHL, EMBASE/OVID, and Cochrane Library/trials) were systematically searched in consultation with two public health research librarians from the UTS (Additional file 1: Table S4.). The search engine: HRH Global Resource Centre was searched for grey literature. Quantitative, qualitative, and mixed-method studies published between 01 January 2000 and 31 December 2019 were retrieved. This period was chosen to evaluate progress over time in SRMNH care quality along the continuum in relation to HRH interventions since the end of the Alma Ata Health for All Declaration in 2000, the Millennium Development Goals (MDGs) era, and in the first 5 years of implemen-tation of the SDGs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guideline was used to outline the review process [29]. A
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total of 2157 studies were identified, including 1923 from six bibliographic databases and 234 from the HRH Global Resource Centre (Fig. 2), with 477 duplicates being iden-tified and removed using the endnote de-duplication guidelines [30].
Two reviewers (MG and AD) independently used the Covidence online production tool for the title and abstract screening, full-text screening, data abstrac-tion, and quality assessment. Differences in decisions regarding the final papers for review and quality assess-ment were resolved through a review by the third author (DS), and a consensus was reached. A total of 1437 and 219 articles were excluded during the title and abstract screening and full-text eligibility assessment, respec-tively, because they did not meet the inclusion criteria.
Quality appraisalTwo reviewers (MG and AD) independently appraised the methodological quality of 25 studies that met the inclusion criteria to describe their methodological qual-ity and ensure that there was enough methodological
detail to ensure rigour to be included for the review. The Cochrane methods were applied to appraise the qual-ity of randomized controlled trials (RCTs) (Additional file 1: Table S5) [31]. Each RCT was evaluated for internal validity and quality of reporting. Quality of quasi-exper-imental, prospective (pre/post), post-only and com-parison, and post-only studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal checklist for quasi-experimental studies (non-randomized experi-mental studies) (Additional file 1: Table S6) [32]. Stud-ies collecting qualitative or mixed data were appraised using the United Kingdom’s National Health Service Critical Appraisal Skills Programme (CASP) qualitative checklist (Additional file 1: Table S7) [33]. We included intervention studies with a methodologically low risk of bias or moderate to high quality for the review. One pre/post-test study was excluded during the quality appraisal because it has a low-quality score (3 out of 9). Using the quasi-experimental studies’ quality appraisal tool, a study with "yes" responses for the 9 signalling questions of less than 4 was considered low quality [34].
Fig. 1 HRH action framework, WHO [25]
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Data abstraction and synthesisData from the 24 studies were systematically extracted into tables using templates based on the Cochrane meth-ods to integrate qualitative and implementation evidence within intervention effectiveness reviews [35].
A deductive qualitative content analysis of the extracted text related to each implemented HRH intervention from each included study was undertaken through coding texts according to emergent descriptions and labelling and structured along with the four categories of SRMNH care continuum [36, 37]. Tables and concept maps were used to plot patterns and relationships across these categories, and robustness was assessed through critical reflection and discussion between the three authors.
ResultsTwenty-four intervention studies were included in this review and are summarized in Table 1. According to the World Bank Country and Lending Groups’ Classifica-tion 2019–2020 [38], 11 studies were from low-income
countries [39–49], 11 were from lower-middle-income countries [50–60], and two were conducted in both low-income and lower-middle-income countries [61, 62] (Table 2).
The included studies described interventions that had been implemented in a range of settings: primary care (n = 13) [39, 40, 44, 47–49, 54–57, 59–61, 63], secondary care hospitals (n = 1) [52], primary care, and secondary care hospitals (n = 8) [41–43, 45, 46, 50, 53, 58], primary care, and secondary and tertiary care hospitals (n = 1) [51], and referral hospitals (n = 1) [62].
The interventions involved different cadres of health personnel [16]. Twelve studies included skilled per-sonnel (doctors, nurses, nurse-midwives, midwives, auxiliary nurses, auxiliary midwives, auxiliary nurse midwives, and/or health officers) [39–41, 44, 46, 47, 52, 53, 56, 60–62], three focused on lay personnel (CHWs and/or TBAs) [43, 50, 54]. Five studies included skilled and lay personnel [48, 49, 51, 57, 59], one involved skilled personnel, lay personnel, and lady health
Records identified through database searching
(n = 1923)CINAHL: 167; Cochrane-trials: 171; EMBASE:
200; PubMed: 606; SCOPUS: 276; Web of Science: 503
Screen
ing
Includ
edIden
�fica�o
n Additional records identifiedthrough other sources
(n= 234)HRH Global Resource center
Records after duplicates removed (n= 1680)
Titles and abstracts screened (n= 1680)
Records excluded (n= 1437)
Full-text articles assessed for eligibility (n= 243)
Full-text articles excluded, with reasons
(n= 219)
Studies included in the final review (n= 24)
Eligibility
Fig. 2 Overview of the literature review process, PRISMA 2009 [29]
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supervisors [55]. One study focused on skilled person-nel, and healthcare managers [42], one involved skilled personnel, community health supervisors, data officers, and healthcare managers [45], and one study focused on skilled personnel, lay personnel, and healthcare managers [58].
All studies included in the review were intervention studies with 22 collecting quantitative data, one collect-ing qualitative data, and one collecting mixed data.
Fifteen studies had policy-related interventions [39, 40, 42–44, 46, 48, 49, 52, 54, 57–61], 19 had finance-related interventions [39–46, 48, 49, 51–53, 55, 57, 59–62], 16 had education-related interventions [41, 42, 45, 47–57, 59, 62], 16 had partnership-related interventions [41–45, 48–51, 55–59, 61, 62], 9 had leadership-related interven-tions [41, 44–46, 48, 50, 53, 58, 62], and 18 had manage-ment-related interventions [40, 41, 43, 44, 47–50, 52–59, 61, 62]. Of the 10 studies that had been conducted dur-ing the MDGs era, eight featured finance, partnership, and management-related, seven policy-related, and six education-related HRH interventions [40, 44, 46, 48–51, 58, 59, 62], while of 14 studies conducted during the five
years SDGs era (2016–2020), 11 papers studied educa-tion and finance-related, ten management related, eight policy and partnership related, and three leadership-related HRH interventions[39, 41–43, 45, 47, 52–57, 60, 61]. The HRH interventions that involved education and finance positively affected SRMNH care quality along the continuum. Of the studies conducted during the MDGs era, five investigated HRH interventions implemented to provide SRMNH care quality across ≥ 3 components of the SRMNH care continuum [46, 48–51]. In the studies conducted during the 5 years of the SDGs era, ten fea-tured HRH interventions implemented to provide quality SRMNH care across ≥ 3 components of the SRMNH care continuum [39, 41–43, 45, 53–55, 57, 60]. HRH interven-tions that had an effect on SRMNH care quality across the continuum are outlined as follows.
PCC, ANC, IPC, and PNC continuumTwo cluster-randomized trials involving skilled person-nel were identified [39, 60]. Engineer et al. [39] described the effect of payment for performance (P4P) on the quality of maternal and child health (MCH) services in
Table 1 Summary of studies about effects of HRH interventions on SRMNH care quality across the continuum in LLMICs, 2020
References HRH interventions The SRMNH care continuum
Policy Finance Education Partnership Leadership Management PCC ANC IPC PNC
Agarwal et al. (2019) [54] X X X X X X
Ayalew et al. (2017) [41] X X X X X X X X
Balakrishnan et al. (2016) [55] X X X X X X X
Basinga et al. (2011) [44] X X X X X X X
Binyaruka et al. (2015) [46] X X X X X X
Bonfrer et al. (2014) [40] X X X X X
Duysburgh et al. (2016) [61] X X X X X X
Edwards et al. (2011) [50] X X X X X X X
Engineer et al. (2016) [39] X X X X X X
Ghosh et al. (2019) [56] X X X X X
Gomez et al. (2018) [52] X X X X X X
Kambala et al. (2017) [42] X X X X X X X
Larson et al. (2019) [47] X X X X
Magge et al. (2017) [45] X X X X X X X
Maru et al. (2017) [43] X X X X X X X
McDougal et al. (2017) [57] X X X X X X X X
Mwaniki et al. (2014) [58] X X X X X X
Okawa et al. (2019) [53] X X X X X X X
Okuga et al. (2015) [48] X X X X X X X X X
Pirkle et al. (2013) [62] X X X X X X X
Rahman et al. (2011) [51] X X X X X X
Satti et al. (2012) [59] X X X X X X X
Waiswa et al. (2015) [49] X X X X X X X X
Zeng et al. (2018) [60] X X X X X X
Total number of Xs 15 19 16 16 9 18 2 21 24 18
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Tabl
e 2
Hum
an re
sour
ces
for h
ealth
inte
rven
tions
and
thei
r effe
cts
on S
RMN
H c
are
qual
ity a
cros
s th
e co
ntin
uum
in lo
w- a
nd lo
wer
-mid
dle-
inco
me
coun
trie
s, 20
20
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Aga
rwal
et a
l. (2
019)
[54]
Indi
aTr
aini
ng a
nd d
eplo
y-m
ent o
f lay
per
son-
nel t
o pr
ovid
e:
heal
th e
duca
tion,
lin
kage
of w
omen
to
hea
lthca
re
faci
litie
s, an
d ho
me-
base
d A
NC
an
d PN
C s
ervi
ces
06 y
ears
Acc
red-
ited
Soci
al
Hea
lth
Act
iv-
ists
(A
SHA
s)
Prim
ary
care
(C
om-
mun
ity
base
d)
Indi
an H
uman
D
evel
op-
men
t Sur
vey
(IHD
S)-II
(2
011–
2012
da
ta):
sec-
onda
ry d
ata
anal
ysis
Expo
sure
to A
SHA
age
nts:
sign
ifica
ntly
ass
ocia
ted
with
AN
C 1
and
SPA
B us
e ac
ross
the
con-
tinuu
m; n
o si
gnifi
cant
impa
ct o
n ≥
4 A
NC
or P
NC
use
bet
wee
n ex
pose
d an
d no
n-ex
pose
d w
omen
; 12%
incr
ease
in w
omen
rece
ivin
g at
leas
t som
e of
the
serv
ices
; 8.8
% d
ecre
ase
in
wom
en re
ceiv
ing
no s
ervi
ces;
it is
not
sig
nific
antly
ass
ocia
ted
with
com
plet
ion
of a
ll se
rvic
es
alon
g th
e co
ntin
uum
Mod
erat
e
Aya
lew
et a
l. (2
017)
[41]
Ethi
opia
Stan
dard
s-Ba
sed
Man
agem
ent
and
Reco
gniti
on
(SBM
-R) a
ppro
ach
(mul
ti-fa
cete
d in
terv
entio
ns):
BEm
ON
C tr
aini
ng;
supp
ortiv
e su
perv
i-si
on; a
udit
and
site
m
ento
ring;
sec
tor-
wid
e le
ader
ship
; qu
ality
impr
ove-
men
t tea
m in
eac
h fa
cilit
y; m
obili
zing
fin
anci
al re
sour
ces;
and
com
mun
ity
invo
lvem
ent
03 y
ears
Doc
tors
, he
alth
offi
cers
, m
id-
wiv
es,
and
nurs
es
Prim
ary
heal
th-
care
(8
Hea
lth
cent
res)
an
d 3
seco
nd-
ary
care
H
ospi
tals
A p
ost-
only
in
terv
entio
n ve
rsus
com
-pa
rison
faci
li-tie
s de
sign
: ob
serv
atio
ns
of s
ervi
ce
deliv
ery
usin
g st
ruct
ured
ch
eckl
ists
to
mea
sure
pr
ovid
er
perf
orm
ance
in
AN
C,
unco
mpl
i-ca
ted
labo
ur
and
deliv
ery
care
, and
im
med
iate
PN
C
A s
igni
fican
t diff
eren
ce o
f 22
pp fo
r eac
h ne
wbo
rn a
nd m
othe
r PN
C s
kill
area
; sig
nific
ant
posi
tive
impa
ct o
n m
ater
nal a
nd n
ewbo
rn h
ealth
pro
vide
rs’ p
erfo
rman
ce d
urin
g la
bour
and
de
liver
y an
d im
med
iate
PN
C s
ervi
ces,
but n
ot d
urin
g A
NC
ser
vice
s
Hig
h
Page 8 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Bala
kris
hnan
et
al.
(201
6)
[55]
Indi
aM
obile
tech
nolo
gy—
a he
alth
sys
tem
st
reng
then
ing
mul
ti-st
akeh
olde
r co
oper
atio
n (m
Hea
lth p
latfo
rm):
com
mun
ity-b
ased
fro
ntlin
e he
alth
w
orke
rs tr
aini
ng o
n m
Hea
lth p
latfo
rm
and
prov
isio
n of
m
ater
nal a
nd c
hild
he
alth
care
; sup
-po
rtiv
e su
perv
isio
n;
and
mob
ilizi
ng
finan
cial
reso
urce
s
02 y
ears
ASH
As,
Ang
an-
wad
i w
ork-
ers,
aux-
iliar
y nu
rse-
mid
-w
ives
, an
d la
dy
heal
th
supe
r-vi
sors
Prim
ary
care
(c
om-
mun
ity
base
d)
A q
uasi
-exp
eri-
men
tal s
tudy
w
ith p
re- a
nd
post
-impl
e-m
enta
tion
eval
uatio
n at
in
terv
entio
n,
and
cont
rol
area
s: co
ver-
age
of q
ualit
y in
dica
tors
of
mat
er-
nal–
child
he
alth
care
co
ntin
uum
co
mpa
red
with
con
trol
ar
ea a
nd th
e pr
evio
us y
ear
Impl
emen
tatio
n bl
ocks
had
hig
her c
over
age
of a
ll th
e 07
qua
lity
indi
cato
rs a
s co
mpa
red
to
the
cont
rol a
nd th
e pr
evio
us y
ear—
inte
rven
tion
area
vs
prev
ious
yea
r vs
cont
rol:
regi
stra
tion
with
in th
e 1s
t trim
este
r (15
% v
s 10
% v
s 10
%),
com
plet
e ≥
3 A
NC
vis
its (5
6% v
s 51
% v
s 48
%),
at le
ast 1
TT v
acci
ne (7
9% v
s 74
% v
s 80
%), ≥
90
Iron
and
Folic
Aci
d Ta
blet
s (6
2% v
s 50
% v
s 49
%),
heal
th fa
cilit
y bi
rth
(84%
vs
59%
vs
67%
), br
east
feed
ing
with
in 1
h o
f birt
h (9
8% v
s 73
%
vs 7
3%),
at le
ast 1
PN
C h
ome
visi
t (28
% v
s 18
% v
s 10
%);
ther
e w
as e
quity
of s
ervi
ces
acro
ss
cast
es fo
r all
indi
cato
rs—
sche
dule
d ca
stes
/trib
es v
s ot
her c
aste
s: re
gist
ratio
n w
ithin
the
1st t
rimes
ter (
15%
vs
15%
), co
mpl
ete ≥
3 A
NC
con
tact
s (5
5% v
s 56
%),
at le
ast 1
TT
vacc
ine
(77%
vs
79%
), ≥ 9
0 Iro
n an
d Fo
lic A
cid
Tabl
ets
(60%
vs
62%
), he
alth
faci
lity
birt
h (7
8% v
s 87
%),
brea
stfe
edin
g w
ithin
1 h
of b
irth
(95%
vs
95%
), at
leas
t 1 P
NC
hom
e vi
sit (
29%
vs
28%
); tim
ely
capt
ure
of d
ata
com
pare
d to
pap
er-b
ased
repo
rtin
g: a
vera
ge ti
me
lag
of 7
2 da
ys (≈
2.
5 m
onth
s) is
ove
rcom
e by
inst
ant d
ata
capt
ure
with
the
mH
ealth
pla
tform
Hig
h
Basi
nga
et a
l. (2
011)
[44]
Rwan
daQ
uart
erly
per
for-
man
ce-b
ased
pay
-m
ent f
or h
ealth
care
pr
ovid
ers,
dire
ctly
ob
serv
ed s
uper
vi-
sion
, lea
ders
hip,
an
d ho
spita
l tea
m
advi
sory
gro
up
18–2
3 m
onth
sD
octo
rs
and
mid
-le
vel
cadr
es
Prim
ary
care
(P
rimar
y he
alth
ce
ntre
s)
Pros
pect
ive
impa
ct
eval
uatio
n be
twee
n P4
P fa
cilit
ies
(inte
rven
-tio
n) a
nd
trad
ition
al
inpu
t-ba
sed
fund
ing
faci
li-tie
s (c
ontr
ols)
; ba
selin
e an
d en
d-lin
e su
rvey
s at
fa
cilit
ies
and
hous
ehol
ds;
diffe
renc
e-in
-di
ffere
nces
an
alys
is
(DiD
) whe
re
p-va
lue
was
th
e cl
uste
r-ad
just
ed
t-te
st
Gre
ates
t effe
ct o
n in
dica
tors
that
had
the
high
est p
aym
ent r
ates
and
nee
ded
the
leas
t effo
rt
from
the
serv
ice
prov
ider
: an
incr
ease
of 0·1
57 s
tand
ard
devi
atio
ns (p
= 0·0
2) in
AN
C q
ualit
y (a
gain
st R
wan
dan
pren
atal
clin
ical
car
e pr
actic
e gu
idel
ines
), 7.
2% in
crea
se in
Tet
anus
vac
cine
in
ject
ions
dur
ing
AN
C (p
= 0·0
57),
no im
prov
emen
ts in
≥ 4
AN
C c
over
age
(p =
0·8
25),
23%
in
crea
se in
faci
lity
birt
h in
the
inte
rven
tion
grou
p (p
= 0·0
17)
Hig
h
Page 9 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Biny
aruk
a et
al.
(201
5)
[46]
Tanz
ania
Bian
nual
P4P
for
heal
th w
orke
rs
and
dist
rict a
nd
regi
onal
hea
lth
man
ager
s ta
rget
-in
g ei
ght s
peci
fic
MC
H c
are
serv
ices
, le
ader
ship
13 m
onth
sSk
illed
pe
rson
-ne
l
Prim
ary
heal
th-
care
(h
ealth
ce
ntre
s, fa
ith-
base
d an
d pa
rast
atal
di
spen
sa-
ries,
and
publ
ic
disp
ensa
-rie
s) a
nd
seco
nd-
ary
care
ho
spita
ls
A C
ontr
olle
d Be
fore
an
d A
fter
ho
useh
old
and
faci
lity
surv
ey s
tudy
: D
iD a
naly
sis
(effe
ct-β
)
A 0
.05
(β: 0
.05;
p =
0.0
3) in
crea
se in
the
patie
nt s
atis
fact
ion
scor
e fo
r non
-tar
gete
d se
rvic
es,
a 5.
0% re
duct
ion
in o
ut-o
f-poc
ket p
aym
ent f
or b
irth
(β: −
5.0
; p =
0.0
23).
No
evid
ence
of
effec
t of P
4P o
n pa
tient
exp
erie
nce
of c
are
for t
arge
ted
serv
ices
: at l
east
2 d
oses
of i
nter
mit-
tent
pre
vent
ive
mal
aria
trea
tmen
t (IP
T) d
urin
g A
NC
(p =
0.0
01),
HIV
trea
tmen
t dur
ing
AN
C
(p =
0.8
93),
heal
th fa
cilit
y bi
rth
(p =
0.0
01),
polio
vac
cine
at b
irth
(p =
0.0
93),
PNC
(p =
0.8
23),
post
nata
l fam
ily p
lann
ing
(p =
0.8
44),
AN
C c
onte
nts
(p =
0.1
18),
inte
rper
sona
l car
e sa
tisfa
c-tio
n du
ring
birt
h (p
= 0
.505
), st
aff k
indn
ess
durin
g bi
rth
(p =
0.0
88),
wai
ting
time
(p =
0.6
36),
cons
ulta
tion
time
(p =
0.6
50)
Hig
h
Bonf
rer,
Poel
and
D
oors
laer
(2
014)
[40]
Buru
ndi
Perf
orm
ance
-bas
ed
finan
cing
(PBF
); qu
arte
rly q
ualit
y as
sess
men
t by
loca
l reg
ulat
ory
auth
oriti
es
01–0
4 ye
ars
Doc
tor,
nurs
e,
and
mid
-w
ife
Prim
ary
heal
th-
care
fa
cilit
ies
Buru
ndi D
emo-
grap
hic
and
Hea
lth
Surv
ey-B
DH
S (2
010–
2011
) da
ta; t
he
diffe
renc
e-in
-di
ffere
nces
an
alys
is;
prov
ince
s w
ith P
BF v
s. w
ithou
t PBF
No
sign
ifica
nt e
ffect
on
first
-trim
este
r AN
C, ≥
1 A
NC
vis
it or
BP
mea
sure
men
t dur
ing
preg
-na
ncy;
sig
nific
ant i
mpa
ct w
ith 1
0 pp
incr
ease
(p <
0.0
01) o
n ≥
1 a
nti-t
etan
us v
acci
natio
n du
r-in
g A
NC
and
with
5 p
p in
crea
se o
n SP
AB
for w
omen
whe
re P
BF w
as in
pla
ce fr
om th
e st
art o
f pr
egna
ncy;
no
sign
ifica
nt e
ffect
on
neon
atal
mor
talit
y; n
o im
pact
on
equi
tabl
e ca
re: h
ighe
r pr
obab
ility
of B
P m
easu
rem
ent d
urin
g pr
egna
ncy
amon
g no
n-po
or; a
sig
nific
ant i
ncre
ase
in
SPA
B (p
< 0
.028
) am
ong
the
non-
poor
, and
no
effec
t on
SPA
B am
ong
the
poor
Hig
h
Page 10 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Duy
sbur
gh
et a
l. (2
016)
[6
1]
Rura
l Bu
rkin
a Fa
so,
Gha
na,
and
Tanz
ania
A c
ompu
ter-
assi
sted
cl
inic
al d
ecis
ion
supp
ort s
yste
m
(eC
DSS
) and
per
for-
man
ce-b
ased
in
cent
ives
: per
for-
man
ce p
rodu
ctiv
-ity
; job
sat
isfa
ctio
n;
finan
cial
and
non
-fin
anci
al in
cent
ives
; in
cent
ive
polic
ies;
loca
l res
earc
h st
akeh
olde
r coo
p-er
atio
n (e
CD
SS
mai
nten
ance
)
02 y
ears
Med
ical
offi
cer,
assi
s-ta
nt
med
ical
offi
cer,
clin
ical
offi
cer,
assi
s-ta
nt
clin
ical
offi
cer,
nurs
e/m
id-
wife
an
d au
x-ili
ary
nurs
e/m
id-
wife
Rura
l pr
imar
y he
alth
-ca
re
faci
litie
s
An
inte
rven
tion
stud
y: 0
6 in
terv
entio
n an
d 06
non
-in
terv
entio
n PH
C fa
cilit
ies
in e
ach
coun
try;
as
sess
men
t of
qua
lity
of
care
in e
ach
faci
lity
by
heal
th fa
cilit
y su
rvey
s, di
rect
obs
er-
vatio
n of
an
tena
tal a
nd
child
birt
h ca
re, p
atie
nt
satis
fac-
tion
exit
inte
rvie
ws,
and
revi
ews
of p
atie
nt
reco
rds
and
mat
erna
l and
ch
ild h
ealth
re
gist
ers;
pre-
vs.
post
-in
terv
entio
n an
d in
terv
en-
tion
vs. n
on-
inte
rven
tion
heal
th fa
cili-
ties’
qual
ity
asse
ssm
ent
No
signi
fican
t diff
eren
ce in
qua
lity
scor
es o
f AN
C an
d de
liver
y ca
re to
pre
-inte
rven
tion
time
or n
on-
inte
rven
tion
faci
litie
s’ sco
res.
Tota
l AN
C ob
serv
atio
n qu
ality
scor
es (p
re- v
s pos
t-int
erve
ntio
n: 0
.83
vs
0.87
, p =
0.06
; inte
rven
tion
vs n
on-in
terv
entio
n fa
cilit
ies a
t end
line:
0.8
7 vs
0.8
6, p
= 0.
33); t
otal
AN
C
satis
fact
ion
surv
ey q
ualit
y sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.4
2 vs
0.7
1, p
= 0.
09; in
terv
entio
n vs
no
n-in
terv
entio
n fa
cilit
ies a
t end
line:
0.7
1 vs
0.5
5, p
= 0.
73); t
otal
AN
C pa
tient
reco
rd re
view
qua
lity
scor
es (p
re- v
s pos
t-int
erve
ntio
n: 0
.75
vs 0
.82,
p =
0.03
; inte
rven
tion
vs n
on-in
terv
entio
n fa
cilit
ies a
t en
d lin
e: 0
.82
vs 0
.71,
p =
0.03
); tot
al c
hild
birth
obs
erva
tion
qual
ity sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.
65 v
s 0.7
5, p
= 0.
01; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.75
vs 0
.68,
p =
0.11
); tot
al
child
birth
satis
fact
ion
surv
ey q
ualit
y sc
ores
: (pre
- vs p
ost-i
nter
vent
ion:
0.7
0 vs
0.8
4, p
= 0.
71; in
terv
en-
tion
vs n
on-in
terv
entio
n fa
cilit
ies a
t end
line:
0.8
4 vs
0.8
3, p
= 0.
90); t
otal
BEm
ON
C sig
nal f
unct
ions
sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.7
5 vs
0.7
2, p
= 0.
09; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at
end
line:
0.7
2 vs
0.6
8, p
= 0.
97); h
istor
y ta
king
on
vagi
nal b
leed
ing—
ANC
obse
rvat
ion
scor
es (p
re- v
s po
st-in
terv
entio
n: 0
.22
vs 0
.32,
p =
0.17
; inte
rven
tion
vs n
on-in
terv
entio
n fa
cilit
ies a
t end
line:
0.3
2 vs
0.
19, p
= 0.
02); c
ouns
ellin
g on
vag
inal
ble
edin
g—AN
C ob
serv
atio
n sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.
49 v
s 0.4
3, p
= 0.
65; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.43
vs 0
.42,
p =
0.80
); hi
stor
y ta
king
on
vagi
nal b
leed
ing—
child
birth
obs
erva
tion
scor
es (p
re- v
s pos
t-int
erve
ntio
n: 0
.32
vs
0.32
, p =
0.20
; inte
rven
tion
vs n
on-in
terv
entio
n fa
cilit
ies a
t end
line:
0.3
2 vs
0.3
1, p
= 0.
54); a
dmin
ister
ox
ytoc
in a
fter c
hild
birth
—ch
ildbi
rth o
bser
vatio
n sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.9
2 vs
0.9
6,
p = 0.
70; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.96
vs 0
.91,
p =
0.72
); mon
itorin
g ut
er-
ine
retra
ctio
n af
ter c
hild
birth
—ch
ildbi
rth o
bser
vatio
n sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.4
1 vs
0.6
0,
p = 0.
02; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.60
vs 0
.56,
p =
0.17
); ass
essin
g va
gina
l bl
eedi
ng a
fter c
hild
birth
—ch
ildbi
rth o
bser
vatio
n sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.6
0 vs
0.7
8,
p = 0.
10; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.78
vs 0
.72,
p =
0.38
); AN
C sa
tisfa
ctio
n sc
ores
—co
unse
lling
on v
agin
al b
leed
ing
(pre
- vs p
ost-i
nter
vent
ion:
0.4
4 vs
0.4
7, p
= 0.
91; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.47
vs 0
.17,
p =
0.79
); wom
en w
ho re
ceiv
ed o
xyto
cin
(%)—
child
birth
reco
rd re
view
(pre
- vs p
ost-i
nter
vent
ion:
89
vs 8
9, p
= 0.
96; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 8
9 vs
96,
p <
0.01
); che
ckin
g BP
—AN
C ob
serv
atio
n sc
ores
(pre
- vs p
ost-
inte
rven
tion:
0.9
8 vs
0.9
7, p
= 0.
96; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.97
vs 0
.93,
p =
0.77
); lab
pro
tein
uria
exa
min
atio
n—AN
C ob
serv
atio
n sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.3
2 vs
0.
47, p
= 0.
03; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.47
vs 0
.22,
p <
0.01
); cou
nsel
ling
on h
yper
tens
ive
diso
rder
s dan
ger s
igns
—AN
C ob
serv
atio
n sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.4
5 vs
0.
43, p
= 0.
68; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.43
vs 0
.37,
p =
0.57
); mon
itorin
g BP
—ch
ildbi
rth o
bser
vatio
n sc
ores
(pre
- vs p
ost-i
nter
vent
ion:
0.5
3 vs
0.6
8, p
= 0.
04; in
terv
entio
n vs
no
n-in
terv
entio
n fa
cilit
ies a
t end
line:
0.6
8 vs
0.6
2, p
= 0.
30); c
ouns
ellin
g on
hyp
erte
nsiv
e di
sord
er
dang
er si
gns—
ANC
satis
fact
ion
scor
es (p
re- v
s pos
t-int
erve
ntio
n: 0
.02
vs 0
.42,
p =
0.17
; inte
rven
tion
vs
non-
inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.42
vs 0
.19,
p =
0.90
); lab
pro
tein
uria
exa
m—
ANC
reco
rd re
view
(p
re- v
s pos
t-int
erve
ntio
n: 0
.51
vs 0
.69,
p =
0.11
; inte
rven
tion
vs n
on-in
terv
entio
n fa
cilit
ies a
t end
line:
0.
69 v
s 0.2
9, p
= 0.
01); p
arto
grap
h co
rrect
ly u
sed—
child
birth
obs
erva
tion
(pre
- vs p
ost-i
nter
vent
ion:
0.
58 v
s 0.7
5, p
= 0.
03; in
terv
entio
n vs
non
-inte
rven
tion
faci
litie
s at e
nd lin
e: 0
.75
vs 0
.60,
p =
0.15
); de
liver
ies w
ith c
orre
ctly
com
plet
ed p
arto
grap
h (%
)—re
cord
revi
ew (p
re- v
s pos
t-int
erve
ntio
n: 4
2 vs
70
, p <
0.01
; inte
rven
tion
vs n
on-in
terv
entio
n fa
cilit
ies a
t end
line:
70
vs 4
8, p
< 0.
01)
Hig
h
Page 11 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Edw
ards
an
d Sa
hab
(201
1) [5
0]
Rura
l Ban
g-la
desh
Skill
s-ba
sed
trai
ning
; co
llabo
ratio
n an
d te
amw
ork
at a
ll le
vels
; com
mun
ity
invo
lvem
ent;
mon
thly
sup
-po
rtiv
e su
perv
isio
n;
lead
ersh
ip
06 y
ears
Villa
ge
heal
th
volu
n-te
ers,
com
-m
unity
he
alth
w
ork-
ers,
com
-m
unity
he
alth
as
sis-
tant
s, an
d co
m-
mun
ity
skill
ed
pers
on-
nel
Prim
ary
care
(h
ealth
-ca
re
cent
res
and
com
-m
unity
ba
sed)
, an
d G
ener
al
hosp
ital
(Com
pre-
hens
ive
esse
ntia
l ob
stet
ric
and
new
born
ca
re)
Coun
try
case
st
udy:
Lu
ther
an A
id
to M
edic
ine
in B
angl
a-de
sh (L
AM
B)
Inte
grat
ed
Rura
l Mat
er-
nal a
nd C
hild
H
ealth
care
’ H
ome-
to-
Hos
pita
l, Co
ntin
uum
-of
-Car
e’ ap
proa
ch
LAM
B ar
eas
vs. n
atio
nal s
ampl
e: c
are
rece
ived
by
wom
en (≥
1 A
NC
: 81%
vs.
52%
; SPA
B: 3
2.2%
vs
. 18%
; cae
sare
an s
ectio
n ra
te: 4
.8%
vs.
2.7%
; and
PN
C: 8
5% v
s. 22
%);
a hi
gher
pro
port
ion
of
poor
wom
en (i
n w
ealth
qui
ntile
-1) r
ecei
ved
AN
C, S
PAB,
cae
sare
an s
ectio
n, a
nd P
NC
; the
gap
in
ser
vice
use
bet
wee
n th
e po
ores
t and
the
riche
st w
omen
is m
uch
smal
ler
Mod
erat
e
Engi
neer
et a
l. (2
016)
[39]
Afg
hani
-st
anQ
uart
erly
Pay
-for-
Perf
orm
ance
(P4P
) fo
r hea
lth w
orke
rs;
mob
ilizi
ng fi
nanc
ial
reso
urce
s
23–2
5 m
onth
sSk
illed
pe
rson
-ne
l
Prim
ary
heal
th-
care
fa
cilit
ies
A c
lust
er-
rand
omiz
ed
tria
l: en
d lin
e ho
useh
old
surv
ey a
nd
qual
ity
asse
ssm
ent
in h
ealth
fa
cilit
ies
in
P4P
and
com
paris
on
area
s
The
P4P
had
no s
igni
fican
t im
pact
on
incr
easi
ng c
over
age
or e
quity
(by
wea
lth in
dex)
of t
ar-
gete
d M
CH
ser
vice
s at
pop
ulat
ion
leve
l (P4
P vs
com
paris
on):
mod
ern
cont
race
ptio
n (1
0.7%
vs
11.
2%; p
= 0
.90)
; AN
C (5
6.2%
vs
55.6
%; p
= 0
.94)
; SPA
B (3
3.9%
vs
28.5
%, p
= 0
.17)
; PN
C
(31.
2% v
s 30
.3%
, p =
0.9
8); e
quity
in S
PAB
/con
cent
ratio
n in
dex
(0.1
758
vs 0
.100
0; p
= 0
.3);
Qua
lity
of c
are
(P4P
vs
com
paris
on):
Ove
rall
Clie
nt S
atis
fact
ion
and
Perc
eive
d Q
ualit
y of
Car
e In
dex
(76.
5% v
s 75
.1%
; p =
0.2
); H
ealth
Wor
ker S
atis
fact
ion
Inde
x (6
3.8%
vs
63.4
%; p
= 0
.9);
Hea
lth W
orke
r Mot
ivat
ion
Inde
x (7
2.7%
vs
72%
; p =
0.4
); qu
ality
of c
are/
his
tory
taki
ng a
nd
phys
ical
exa
min
atio
ns in
dex
(76.
4% v
s 72
.3%
; p =
0.0
1); q
ualit
y of
car
e/cl
ient
cou
nsel
ling
inde
x (3
5.3%
vs
29.3
%; p
= 0
.01)
; qua
lity
of c
are/
time
spen
t with
clie
nt in
dex
(14.
5% v
s 8.
6%;
p =
0.0
5)
Sele
ctio
n: L
RPe
rfor
-m
ance
: LR
Att
ritio
n: L
RD
etec
tion:
LR
Repo
rtin
g:
LR
Page 12 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Gho
sh R
. et a
l. (2
019)
[56]
Indi
aM
ulti-
face
ted
onsi
te
nurs
e m
ento
ring
and
sim
ulat
ion
(dia
gnos
is a
nd
man
agem
ent
of in
trap
artu
m
asph
yxia
and
PPH
): sk
ills
dem
onst
ra-
tions
, did
actic
se
ssio
ns, h
igh-
fidel
ity s
imul
atio
n,
beds
ide
men
torin
g,
and
team
trai
ning
du
ring
actu
al
patie
nt c
are
wer
e th
e m
ento
ring
activ
ities
; wee
kly
nurs
e-m
ento
ring,
PR
ON
TO In
tern
a-tio
nal’s
sim
ulat
ion,
te
am tr
aini
ng; N
GO
co
llabo
ratio
n
20 m
onth
sA
uxili
ary
Nur
ses
and
gene
ral
nurs
e-m
id-
wiv
es
BEm
ON
C
faci
litie
s at
Prim
ary
care
A q
uasi
-exp
er-
imen
tal (
b/n
faci
litie
s) a
nd
a lo
ngitu
dina
l (w
ithin
fa
cilit
ies)
co
mpa
rison
st
udie
s ov
er
time
Betw
een-
faci
lity
com
paris
ons
acro
ss p
hase
s: di
agno
sis
was
hig
her i
n fin
al w
eek
of in
terv
en-
tion
(intr
apar
tum
asp
hyxi
a: 4
.2–5
.6%
, PPH
: 2.5
–5.4
%) r
elat
ive
to th
e 1st
wee
k (in
trap
artu
m
asph
yxia
: 0.7
–3.3
%, P
PH: 1
.2–
2.1%
); w
ithin
-faci
lity
com
paris
ons:
intr
apar
tum
asp
hyxi
a D
x am
ong
all l
ive
birt
hs in
crea
sed
from
2.5
% in
wee
k-1
to 4
.8%
in w
eek-
5, a
fter
whi
ch it
redu
ced
to 4
% th
roug
h w
eek-
7, P
PH D
x in
crea
sed
from
wee
k-1
thro
ugh
5 (fr
om 1
.6%
to 4
.4%
) aft
er
whi
ch it
dec
reas
ed th
roug
h w
eek-
7 (3
.1%
); fa
cilit
y pe
rfor
man
ce in
dex—
on a
sca
le o
f 100
fro
m b
asel
ine
(1st
3 w
ks.)
to e
nd li
ne (≥
4 w
ks.):
med
ian
intr
apar
tum
car
e sc
ore
(IQR)
= [2
1 (8
–29)
—58
(42–
67)],
med
ian
new
born
car
e sc
ore
(IQR)
= [4
2 (3
5–50
) 71
(58–
79)];
dia
gnos
is
per a
dditi
onal
wee
k of
men
torin
g, a
djus
ted
inci
denc
e ra
te ra
tios
(IRR,
95%
CI):
asp
hyxi
a (W
ks.
1–5:
1.2
1(1.
13, 1
.29)
, p <
0.0
01; w
ks. 5
–7: 0
.91(
0.82
, 1.0
1), p
= 0
.073
; PPH
(Wks
. 1–5
: 1.1
7 (1
.05,
1.
31), p =
0.0
06; w
ks. 5
–7: 0
.86
(0.7
7, 0
.97)
, p =
0.0
17; m
anag
emen
t per
add
ition
al w
eek
of
men
torin
g (IR
R, 9
5%C
I): a
sphy
xia
[(rad
iant
war
mer
: 1.0
5 (1
.01,
1.0
9), p
= 0
.005
; dry
ing-
stim
-ul
atio
n: 1
.05
(1.0
2, 1
.08)
, p =
0.0
03; s
uctio
ning
: 1.0
3 (0
.99,
1.0
6), p
= 0
.127
; pos
itive
pre
ssur
e ve
ntila
tion
(PPV
):1.0
9 (1
.02,
1.1
5), p
= 0
.007
] and
PPH
[IV
fluid
s: 1.
01 (0
.97,
1.0
4), p
= 0
.688
; ut
erot
onic
s: 0.
99 (0
.95,
1.0
3), p
= 0
.700
]
Hig
h
Gom
ez e
t al.
(201
8) [5
2]G
hana
On-
site
, low
-dos
e,
high
-freq
uenc
y tr
aini
ng in
BE
mO
NC
of r
egis
-te
red
or c
ertifi
ed
skill
ed p
erso
n-ne
l: tw
o 4-
day
low
-dos
e se
ssio
ns,
high
-freq
uenc
y pr
actic
e se
ssio
ns
usin
g an
atom
ic
mod
els
and
men
torin
g w
ith
SMS
rem
inde
r mes
-sa
ges
and
quiz
zes;
clin
ical
sim
ulat
ion;
fo
llow
-up
men
tor-
ship
and
app
rais
al
(mob
ile o
r ons
ite);
mob
ilizi
ng fi
nanc
ial
reso
urce
s
18 m
onth
sM
idw
ives
40 s
econ
d-ar
y ca
re
publ
ic
and
mis
-si
onar
y ho
spita
ls
A c
lust
er-r
and-
omiz
ed tr
ial:
pros
pect
ive
intr
apar
tum
st
illbi
rths
an
d 24
-h
new
born
m
orta
lity
for
12 m
onth
s. Ba
selin
e m
orta
lity
rate
s w
ere
colle
cted
ret-
rosp
ectiv
ely
6 m
onth
s pr
e-in
terv
en-
tion
36%
redu
ctio
n (A
RR: 0
.64;
95%
CI:
0.53
–0.7
7; p
< 0
.001
) in
1st 1
–6 m
onth
s of
impl
emen
ta-
tion
and
52%
redu
ctio
n (A
RR: 0
.48;
95%
CI:
0.36
–0.6
3; p
< 0
.001
) in
seco
nd 7
–12
mon
ths
of im
plem
enta
tion
in in
trap
artu
m s
tillb
irth
rate
s as
com
pare
d to
pre
-inte
rven
tion
perio
d,
resp
ectiv
ely;
59%
redu
ctio
n (A
RR: 0
.41;
95%
CI:
0.32
–0.5
1; p
< 0
.001
) in
1st 1
–6 m
onth
s an
d 70
% re
duct
ion
(ARR
: 0.3
0; p
< 0
.001
) in
2nd
7–12
mon
ths
in 2
4-h
new
born
mor
talit
y ra
tes
as
com
pare
d to
pre
-inte
rven
tion
perio
d, re
spec
tivel
y
Sele
ctio
n: S
CPe
rfor
-m
ance
: LR
Att
ritio
n: L
RD
etec
tion:
LR
Repo
rtin
g:
LR
Page 13 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Kam
bala
et a
l. (2
017)
[42]
Rura
l M
alaw
iRB
F fo
r Mat
erna
l and
N
ewbo
rn H
ealth
in
itiat
ive:
qua
rter
ly
perf
orm
ance
-ba
sed
finan
cing
(s
uppl
y-si
de
finan
cial
ince
ntiv
e up
on a
ttai
nmen
t of
a pr
e-de
fined
set
of
indi
cato
rs, 7
0%
for s
taff
bonu
ses
and
30%
for h
ealth
fa
cilit
y’s
oper
atio
nal
activ
ities
, hea
lth
man
agem
ent
team
s w
ere
rew
arde
d w
ith
finan
cial
ince
ntiv
es
base
d on
the
over
all p
erfo
r-m
ance
of a
dis
tric
t as
a m
easu
re o
f th
e ad
equa
cy o
f su
perv
isio
n) a
nd
finan
cial
ince
ntiv
es
to w
omen
for d
eliv
-er
ing
in a
hea
lth
faci
lity
(dem
and-
side
ince
ntiv
e,
cond
ition
al c
ash
tran
sfer
s to
mot
h-er
s fo
r giv
ing
birt
h in
a h
ealth
faci
lity)
; he
alth
wor
kers
ad
viso
ry g
roup
; m
obili
zing
fina
ncia
l re
sour
ces;
refre
sher
in
-ser
vice
trai
ning
on
ant
enat
al
man
agem
ent,
obst
etric
car
e, a
nd
qual
ity a
ssur
ance
; RB
F po
licy
03 y
ears
Hea
lth-
care
m
anag
-er
s, sk
illed
pe
rson
-ne
l
33 p
rimar
y an
d se
cond
-ar
y Em
OC
fa
cilit
ies
(Bas
ic a
nd
com
pre-
hens
ive)
Mix
ed m
etho
d pr
ospe
ctiv
e se
quen
tial
cont
rolle
d pr
e- a
nd
post
-tes
t st
udy
over
in
terv
entio
n vs
. con
trol
fa
cilit
ies:
clie
nt e
xit
inte
rvie
ws,
in-d
epth
in
terv
iew
s an
d FG
Ds
with
wom
en
and
In-d
epth
in
terv
iew
s w
ith h
ealth
se
rvic
e pr
ovid
ers;
diffe
renc
e-in
-di
ffere
nces
an
alys
is (D
iD)
End-
term
vs
base
line
coho
rts
(DiD
adj
uste
d): m
ean
effec
t est
imat
e of
wom
en’s
perc
eptio
ns
on in
terp
erso
nal r
elat
ions
(AN
C: −
0.2
, p =
0.5
6; L
&D: −
0.1
, p =
0.7
0; P
NC
: − 0
.3, p
= 0
.45)
; m
ean
effec
t est
imat
e of
wom
en’s
perc
eptio
ns o
n qu
ality
of a
men
ities
(AN
C: −
0.2
, p =
0.5
4;
L&D
: − 0
.3, p
= 0
.45;
PN
C: −
0.4
9, p
= 0
.14)
; mea
n eff
ect e
stim
ate
of w
omen
’s pe
rcep
tions
on
tech
nica
l car
e (A
NC
: − 0
.2; p
= 0
.39;
L&D
: − 0
.1, p
= 0
.85;
PN
C: −
0.3
1, p
= 0
.38)
. No
sign
ifica
nt
effec
t on
wom
en’s
perc
eptio
ns o
f tec
hnic
al c
are,
qua
lity
of a
men
ities
, and
inte
rper
sona
l re
latio
ns fo
r any
of t
he th
ree
sets
of s
ervi
ces
obse
rved
(AN
C, L
&D, a
nd P
NC
); in
crea
sed
the
prop
ortio
n of
wom
en re
port
ing
to h
ave
rece
ived
med
icat
ions
/tre
atm
ent d
urin
g ch
ildbi
rth.
Q
ualit
ativ
e in
terv
iew
s: m
ost w
omen
repo
rted
impr
oved
hea
lth s
ervi
ce p
rovi
sion
as
a re
sult
of th
e in
terv
entio
n; d
rugs
, equ
ipm
ent,
and
supp
lies
wer
e re
adily
ava
ilabl
e du
e to
the
RBF4
MN
H; i
nsta
nces
of n
egle
ct, d
isre
spec
t, an
d ve
rbal
abu
se d
urin
g th
e pr
oces
s of
car
e;
incr
ease
d w
orkl
oad
resu
lting
from
an
incr
ease
d nu
mbe
r of w
omen
see
king
ser
vice
s at
RB
F4M
NH
faci
litie
s
Mod
erat
e
Page 14 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Lars
on e
t al.
(201
9) [4
7]Ru
ral T
an-
zani
aIn
-ser
vice
trai
ning
; m
ento
ring;
sup
-po
rtiv
e su
perv
isio
n;
peer
out
reac
h
04 y
ears
Mid
-leve
l ca
dres
Prim
ary
care
(c
om-
mun
ity-
base
d an
d pr
imar
y ca
re c
lin-
ics)
A c
lust
er-
rand
omiz
ed
stud
y: b
ase-
line
(201
2)
and
end
line
(201
6)
hous
ehol
d su
rvey
s in
co
ntro
l and
in
terv
entio
n ca
tchm
ents
; di
ffere
nce-
in-
diffe
renc
es
anal
ysis
(DiD
)
Tota
l stu
dy p
opul
atio
n-D
iD: i
mpr
oved
qua
lity
of A
NC
/con
tent
s of
AN
C [A
djus
ted
(A) R
R:
1.64
; 95%
CI:
1.00
–2.7
1]; p
erce
ived
qua
lity
of A
NC
(ARR
: 1.1
4; 9
5% C
I: 0.
88–1
.47)
; per
ceiv
ed
obst
etric
car
e qu
ality
at i
nter
vent
ion
faci
lity
(ARR
: 1.1
3; 9
5% C
I: 0.
79–1
.62)
; red
uced
pay
men
t fo
r obs
tetr
ic c
are
at in
terv
entio
n fa
cilit
y (A
RR: −
3.7
6; 9
5% C
I: −
7.0
2 to
− 0
.49)
. Pre
viou
s ho
me
birt
hs-D
iD: i
mpr
oved
qua
lity
of A
NC
/con
tent
s of
AN
C (A
RR: 2
.31;
95%
CI:
1.44
–3.7
1);
impr
oved
per
ceiv
ed q
ualit
y of
AN
C (A
RR: 1
.57;
95%
CI:
1.07
–2.3
1); p
erce
ived
obs
tetr
ic c
are
qual
ity a
t int
erve
ntio
n fa
cilit
y (A
RR: 1
.12;
95%
CI:
0.78
–1.5
9); r
educ
ed p
aym
ent f
or o
bste
tric
ca
re a
t int
erve
ntio
n fa
cilit
y (A
RR: −
2.2
4; 9
5% C
I -4.
76—
0.28
)
Sele
ctio
n: L
RPe
rfor
-m
ance
: SC
Att
ritio
n: L
RD
etec
tion:
LR
Repo
rtin
g:
LR
(Mag
ge e
t al.
(201
7) [4
5]Rw
anda
Mon
thly
ons
ite, r
egu-
lar c
linic
al m
ento
r-sh
ip a
nd tr
aini
ng
on e
vide
nce-
base
d lif
e-sa
ving
mat
erna
l an
d ne
wbo
rn
care
; lea
rnin
g co
l-la
bora
tive
to b
uild
he
alth
care
wor
kers
’ le
ader
ship
in d
ata
utili
zatio
n fo
r co
ntin
uous
qua
lity
impr
ovem
ent (
QI);
m
obili
zing
fina
ncia
l re
sour
ces;
proc
ure-
men
t and
dis
trib
u-tio
n of
ess
entia
l eq
uipm
ent a
nd
supp
lies
18 m
onth
sN
urse
s, co
m-
mun
ity
heal
th
supe
r-vi
sors
, da
ta
office
rs,
and
heal
th
faci
lity
and
dist
rict
lead
er-
ship
Prim
ary
care
(C
om-
mun
ity-
base
d an
d he
alth
ce
ntre
s),
and
seco
nd-
ary
care
ho
spita
ls
A re
tros
pect
ive
case
stu
dy
usin
g th
e qu
antit
ativ
e m
etho
d:
pre–
post
in
terv
entio
n ev
alua
tion
Pre-
vs
post
-inte
rven
tion:
≥ 4
AN
C (2
3% v
s 38
%);
1st t
rimes
ter A
NC
(23%
vs
34%
); pr
egna
nt
wom
en w
ith p
rem
atur
e ru
ptur
e of
mem
bran
e (P
ROM
) tre
ated
with
ant
ibio
tics
(24%
vs.
38%
); pr
egna
nt w
omen
with
pre
term
labo
ur tr
eate
d w
ith c
ortic
oste
roid
s (2
6% v
s 75
%);
SPA
B (8
7%
vs. 9
5%);
time
to C
-sec
tion
in m
inut
es [m
edia
n, (I
QR)
: 99
(50–
195)
vs.
72 (5
9–77
)]; im
med
iate
sk
in-t
o-sk
in c
are
afte
r del
iver
y (1
9% v
s. 87
%);
new
born
s ch
ecke
d fo
r dan
ger s
igns
with
in 2
4 h
of b
irth
(47%
vs.
98%
)
Mod
erat
e
Page 15 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Mar
u et
al.
2017
) [43
]Ru
ral,
rem
ote
Nep
al
Acc
ount
able
pub
lic–
priv
ate
part
ners
hip
thro
ugh
inte
grat
-in
g co
mm
unity
he
alth
wor
kers
into
fa
cilit
y-ba
sed
care
: C
HW
s co
nduc
t su
rvei
llanc
e of
co
nditi
ons
in th
e co
mm
unity
, tria
ge,
refe
rral
, and
car
e co
ordi
natio
n w
ith
heal
thca
re fa
cilit
ies;
gove
rnm
ent’s
pe
rfor
man
ce-
base
d ac
coun
tabl
e pa
ymen
t
18 m
onth
sCo
m-
mun
ity
heal
th
wor
k-er
s
Prim
ary
heal
th-
care
(C
om-
mun
ity-
base
d,
villa
ge
clin
ics/
heal
th
post
s)
and
seco
nd-
ary
care
di
stric
t ho
spita
ls
A p
rosp
ectiv
e pr
e–po
st
pilo
t stu
dy: a
ho
useh
old-
leve
l cen
sus
surv
ey to
co
mpa
re
popu
latio
n-le
vel m
ater
-na
l, ne
wbo
rn,
and
child
he
alth
care
in
dica
tors
to
the
base
line
Pre-
vs
post
-inte
rven
tion:
≥ 4
AN
C [(
Incr
ease
d by
6.4
pp)
; cov
erag
e in
crea
sed
(83%
vs
90%
)];
heal
th fa
cilit
y bi
rth
[(inc
reas
ed b
y 11
.8 p
p; p
< 0
.001
); co
vera
ge in
crea
sed
(81%
vs
93%
)];
post
nata
l con
trac
eptio
n [(r
ate
incr
ease
d by
27.
5 pp
; p <
0.0
01);
cove
rage
incr
ease
d (1
9% v
s 47
%)];
infa
nt m
orta
lity
rate
(18.
3/10
00 v
s 12
.5/1
000)
; 95%
rece
ived
ultr
asou
nd e
xam
inat
ion
by m
onth
8 o
r 9 o
f pre
gnan
cy
Mod
erat
e
McD
ouga
l et
al.
(201
7)
[57]
Indi
aTr
aini
ng, m
obili
zing
, m
onito
ring,
and
em
pow
erin
g go
v-er
nmen
t Fro
ntlin
e w
orke
rs (F
LWs)
an
d co
mm
unity
ou
trea
ch (h
ome-
base
d) in
terv
en-
tions
: job
aid
s an
d to
ols;
mob
ile
serv
ice
trai
ning
co
urse
for F
LWs
to
expa
nd a
nd re
fresh
th
eir k
now
ledg
e of
lif
e-sa
ving
RM
NC
H
beha
viou
rs; c
om-
mun
ity in
volv
e-m
ent;
mob
ilizi
ng
finan
cial
reso
urce
s; lo
cal p
olic
y
02 y
ears
ASH
As,
aux-
iliar
y nu
rse
mid
-w
ives
, an
d A
ngan
-w
adi
(Soc
ial
Serv
ice)
w
ork-
ers
Prim
ary
care
(c
om-
mun
ity-
base
d an
d pr
imar
y he
alth
-ca
re
faci
litie
s)
A tw
o-ar
med
qu
asi-e
xper
i-m
enta
l stu
dy
(inte
rven
tion
vs. c
ontr
ol
area
s); h
ouse
to
hou
se
surv
ey o
f w
omen
age
d 15
–49
with
a
0–5-
mon
th-
old
child
at
base
line
and
follo
w-u
p;
diffe
renc
e-in
-di
ffere
nces
(D
iD)
anal
yses
The
mea
n nu
mbe
r of s
ervi
ces/
beha
viou
rs u
sed
alon
g th
e RM
NH
con
tinuu
m o
f car
e (C
oC) w
as
sign
ifica
ntly
hig
her i
n in
terv
entio
n ar
eas
as c
ompa
red
to c
ontr
ol a
reas
at f
ollo
w-u
p (0
.94
vs. 0
.51
heal
th s
ervi
ces/
beha
viou
rs; p
< 0
.000
1); o
vera
ll RM
NH
CoC
cov
erag
e in
inte
rven
tion
area
s in
crea
sed
by 0
.41
(Coe
ffici
ent:
0.41
; 95%
CI 0
.24–
0.59
; p <
0.0
01) h
ealth
ser
vice
s/be
hav-
iour
s as
com
pare
d to
the
cont
rol a
reas
: DiD
: ≥ 4
AN
C (p
= 0
.23)
; SPA
B (p
= 0
.98)
; not
hing
ap
plie
d to
the
cord
(p =
0.0
1); s
kin-
to-s
kin
care
(p =
0.0
3); fi
rst b
ath
dela
yed
by ≥
2 d
ays
(p =
0.2
6); b
reas
tfed
child
with
in 1
h o
f birt
h (p
= 0
.39)
; PN
C v
isit
for m
othe
r or b
aby
with
in
48 h
(p =
0.6
9); p
ostp
artu
m c
ontr
acep
tion
(p <
0.0
1); c
hild
exc
lusi
vely
bre
astfe
d (p
= 0
.47)
; ge
nder
equ
ity in
tera
ctio
n an
alys
is s
how
ed d
imin
ishe
d in
terv
entio
n eff
ects
on
AN
C, S
PAB
and
excl
usiv
e br
east
feed
ing
for w
omen
mar
ried
as m
inor
s
Hig
h
Page 16 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Mw
anik
i et a
l. (2
014)
[58]
Rura
l Ken
yaQ
ualit
y im
prov
e-m
ent ‘c
olla
bora
tive’
heal
th w
orke
r ad
visi
ng: r
egul
ar
mee
ting
of a
gro
up
of h
ealth
wor
kers
fro
m d
iffer
ent
heal
th fa
cilit
ies
that
w
ork
on th
e sa
me
set o
f qua
lity
indi
-ca
tors
to e
xam
ine
perf
orm
ance
gap
s in
ser
vice
del
iver
y,
the
caus
es o
f the
se
gaps
, and
sol
u-tio
ns to
add
ress
th
em; e
mpl
oyee
re
latio
ns; l
eade
r-sh
ip; c
omm
unity
in
volv
emen
t
20 m
onth
sH
ealth
-ca
re
man
ag-
ers,
skill
ed
pers
on-
nel,
com
-m
unity
he
alth
w
ork-
ers,
and
trad
i-tio
nal
birt
h at
tend
-an
ts
Prim
ary
care
(3
hea
lth
cent
res
and
17
disp
en-
sarie
s),
and
1 go
vern
-m
ent-
run
seco
nd-
ary
care
ho
spita
l
A p
re- a
nd
post
-impl
e-m
enta
tion
eval
uatio
n:
data
wer
e co
llect
ed a
nd
ente
red
into
ro
utin
e go
vt.
regi
ster
s da
ily
by th
e te
ams
and
wer
e th
en u
sed
to
eval
uate
20
indi
cato
rs o
f ca
re q
ualit
y im
prov
emen
t ac
tiviti
es
mon
thly
AN
C v
isits
in th
e fir
st tr
imes
ter (
< 1
6 w
eeks
G.A
) inc
reas
ed s
igni
fican
tly (8
% to
24%
; p =
0.0
02),
and
thos
e m
akin
g ≥
4 A
NC
vis
its s
igni
fican
tly in
crea
sed
(37%
to 6
4%; p
< 0
.001
); A
NC
vis
its
per m
onth
with
sta
ndar
dize
d ca
re s
ubst
antia
lly in
crea
sed
(< 4
0% to
80–
100%
; p <
0.0
01)
with
in 0
3 to
06
mon
ths;
SPA
B si
gnifi
cant
ly in
crea
sed
per m
onth
from
(33%
to 5
2%; p
= 0
.012
); pr
egna
nt w
omen
act
ivel
y re
ferr
ed fr
om th
e co
mm
unity
(by
com
mun
ity re
pres
enta
tives
) to
hea
lth fa
cilit
ies
for A
NC
, and
birt
h ca
re s
igni
fican
tly in
crea
sed
(13
per m
onth
to 8
1 pe
r m
onth
; p <
0.0
01)
Mod
erat
e
Oka
wa
et a
l. (2
019)
[53]
Rura
l G
hana
Orie
ntat
ion
of s
uper
-vi
sors
and
hea
lth-
care
pro
vide
rs in
th
e co
ntin
uum
of
care
(CoC
); di
strib
u-tio
n of
CoC
car
ds
to w
omen
, hom
e vi
sits
to p
rovi
de
PNC
with
in 4
8 h
for
thos
e w
ho m
isse
d th
e fir
st 2
4 h
visi
t; m
obili
zing
fina
ncia
l re
sour
ces;
mon
thly
su
perv
isio
n an
d m
onito
ring;
ca
paci
ty b
uild
ing
to le
ad s
ecto
r-w
ide
colla
bora
tion
12 m
onth
sD
octo
r, m
id-
wife
, nu
rse,
co
m-
mun
ity
heal
th
office
r, an
d co
m-
mun
ity
heal
th
nurs
e,
and
heal
th
assi
s-ta
nt
Prim
ary
heal
th-
care
(c
om-
mun
ity-
base
d,
priv
ate
clin
ics,
heal
th
cent
res)
an
d se
cond
-ar
y ca
re
dist
rict
hosp
ital
A c
lust
er
rand
omiz
ed
cont
rolle
d tr
ial:
base
line
and
follo
w-
up s
urve
y to
mea
sure
ad
equa
te
cont
acts
(≥ 4
A
NC
, SPA
B,
and
thre
e tim
ely
con-
tact
s w
ithin
6
wee
ks
post
nata
l) an
d qu
ality
ca
re (s
ix
com
pone
nts
durin
g A
NC
, 3
durin
g pe
ri-pa
rtum
car
e (P
PC),
and
14 d
urin
g po
stna
tal);
di
ffere
nce-
in-
diffe
renc
es
anal
ysis
(DiD
)
The
inte
rven
tions
impr
oved
con
tact
s w
ith h
ealth
care
pro
vide
rs a
nd q
ualit
y of
car
e du
ring
PNC
, not
in A
NC
or I
PC, r
egul
ar c
onta
cts
with
hea
lthca
re p
rovi
ders
did
not
gua
rant
ee q
ualit
y of
car
e: 1
2.6%
of w
omen
in th
e in
terv
entio
n gr
oup
rece
ived
all
6 ite
ms
durin
g A
NC
(4.9
%
base
line)
, 33.
6% re
ceiv
ed a
ll 3
item
s du
ring
PPC
(23.
8% b
asel
ine)
and
41.
5% o
f wom
en a
nd
thei
r new
born
s re
ceiv
ed a
ll 14
item
s du
ring
PNC
(11.
5% b
asel
ine)
; adj
uste
d D
iD e
stim
a-to
rs: n
o si
gnifi
cant
cha
nges
acr
oss
the
thre
e ph
ases
: AN
C (p
= 0
.61)
, PPC
(p =
0.6
9) a
nd P
NC
(p
= 0
.35)
; the
per
cent
age
of a
dequ
ate
cont
acts
with
hig
h-qu
ality
car
e in
the
inte
rven
tion
grou
p in
the
follo
w-u
p su
rvey
and
the
adju
sted
DiD
est
imat
ors
(with
bas
elin
e ad
equa
te
cont
acts
for A
NC
, PPC
and
PN
C o
f 4.9
%, 2
0.2%
and
1.3
%, r
espe
ctiv
ely)
wer
e 12
.6%
and
2.2
(p
= 0
.61)
at A
NC
, 31.
5% a
nd 1
.9 (p
= 0
.73)
at P
PC a
nd 3
3.7%
and
12.
3 (p
= 0
.13)
at P
NC
in
the
inte
ntio
n-to
-tre
at d
esig
n (re
al w
orld
-effe
ctiv
enes
s of
the
inte
rven
tion)
, whe
reas
13.
0%
and
2.8
(p =
0.5
4) a
t AN
C, 3
4.2%
and
2.7
(p =
0.6
6) a
t PPC
and
38.
1% a
nd 1
8.1
(p =
0.0
2) a
t PN
C in
the
per-
prot
ocol
des
ign
(idea
l wor
ld-d
esig
nate
d by
pos
sess
ion
of c
ontin
uum
-of-
care
ca
rd);
in in
tent
ion-
to-t
reat
des
ign,
76.
9% o
f wom
en in
the
inte
rven
tion
grou
p in
the
follo
w-
up s
urve
y ha
d ad
equa
te c
onta
cts
durin
g A
NC
; how
ever
, onl
y 12
.6%
had
qua
lity-
adju
sted
ad
equa
te c
onta
cts;
82.0
% S
PAB,
whi
le o
nly
31.5
% h
ad S
PAB
with
hig
h-qu
ality
car
e; d
urin
g PN
C, 6
2.2%
of w
omen
and
thei
r new
born
s ha
d ad
equa
te c
onta
cts,
how
ever
, onl
y 33
.7%
had
qu
ality
-adj
uste
d ad
equa
te P
NC
con
tact
s
Sele
ctio
n: L
RPe
rfor
-m
ance
: LR
Att
ritio
n: L
RD
etec
tion:
LR
Repo
rtin
g:
LR
Page 17 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Oku
ga e
t al.
(201
5) [4
8]U
gand
aRe
crui
tmen
t, tr
ain-
ing,
imm
edia
te
depl
oym
ent a
nd
ince
ntiv
izat
ion
of
CH
Ws;
skill
ed p
er-
sonn
el’s
in-s
ervi
ce
trai
ning
and
pro
vi-
sion
of e
ssen
tial
equi
pmen
t and
su
pplie
s: se
lect
ed
by th
e co
mm
unity
; 07
day
s tr
aini
ng
on id
entif
ying
pr
egna
nt w
omen
, an
d m
ake
two
preg
nanc
y ho
me
visi
ts a
nd th
ree
post
nata
l hom
e vi
s-its
in th
e fir
st w
eek
afte
r birt
h; fi
nanc
ial
and
non-
finan
cial
in
cent
ives
(t-s
hirt
, br
iefc
ase
and
cer-
tifica
te, a
nd tr
ans-
port
allo
wan
ce);
dire
ctly
obs
erve
d su
perv
isio
n vi
sits
by
nurs
es/
mid
wiv
es a
nd
grou
p su
perv
isio
n m
eetin
gs m
onth
ly
then
qua
rter
ly;
mob
ilizi
ng fi
nanc
ial
reso
urce
s
02 y
ears
Com
-m
unity
he
alth
w
orke
rs
and
skill
ed
pers
on-
nel
Prim
ary
care
(c
om-
mun
ity-
base
d an
d pr
imar
y he
alth
-ca
re
faci
litie
s)
A c
omm
unity
-ba
sed
clus
ter-
rand
omiz
ed
cont
rol t
rial:
in-d
epth
in
terv
iew
s (ID
Is) a
nd
focu
s gr
oup
disc
ussi
ons
(FG
Ds)
in
volv
ing
faci
lity-
base
d he
alth
wor
k-er
s, m
embe
rs
of th
e D
istr
ict
Hea
lth T
eam
, vi
llage
lead
-er
s, m
othe
rs
with
chi
ldre
n le
ss th
an
6 m
onth
s of
age
, and
C
HW
s bo
th
from
urb
an
and
rura
l ar
eas
CH
Ws
high
ly a
ppre
ciat
ed in
the
com
mun
ity a
nd s
een
as im
port
ant c
ontr
ibut
ors
to m
ater
nal
and
new
born
hea
lth a
t a g
rass
root
s le
vel;
mor
e w
omen
att
endi
ng A
NC
dur
ing
the
first
tr
imes
ter;
husb
ands
/par
tner
s sa
ve m
oney
, pro
vide
wom
en w
ith m
oney
for e
mer
genc
ies,
tran
spor
t, an
d ba
bies
’ nee
ds; w
omen
att
end
to th
eir h
ealth
nee
ds d
urin
g pr
egna
ncy;
wom
en
reco
gniz
e da
nger
sig
ns; m
ore
birt
hs a
t hea
lth fa
cilit
ies;
wom
en e
xper
ienc
e a
carin
g at
titud
e fro
m h
ealth
wor
kers
; wom
en w
ith C
HW
refe
rral
slip
s ar
e se
en fa
ster
at h
ospi
tal o
r hea
lth u
nit;
wom
en p
ut o
nly
salty
wat
er o
n th
e ba
by’s
umbi
lical
cor
d ra
ther
than
ani
mal
dun
g an
d he
rbs;
bath
ing
is d
elay
ed in
stea
d of
imm
edia
tely
pra
ctic
ed; m
ore
wom
en ta
king
thei
r new
born
ba
bies
to h
ealth
faci
litie
s fo
r PN
C a
nd im
mun
izat
ion;
imm
edia
te b
reas
tfeed
ing
at b
irth
and
cont
inuo
us b
reas
tfeed
ing;
mor
e w
omen
giv
ing
colo
stru
m
Mod
erat
e
Page 18 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Pirk
le e
t al.
(201
3) [6
2]M
ali a
nd
Sene
gal
Mat
erna
l dea
th
revi
ew (a
uditi
ng
mat
erna
l dea
ths
in th
e fa
cilit
y),
wor
ksho
ps o
n ob
stet
rical
bes
t ex
perie
nces
, and
pe
riodi
c vi
sits
by
inte
rnat
iona
l ex
pert
s: a
6-da
y w
orks
hop
to
trai
n an
d ce
rtify
he
alth
pro
fess
iona
l le
ader
s in
Em
OC
be
st p
ract
ice,
au
dit t
echn
ique
s, an
d se
xual
and
re
prod
uctiv
e rig
hts;
a m
ultid
isci
plin
ary
audi
t com
mit-
tee
esta
blis
hed
in e
ach
faci
lity
to u
nder
take
a
mon
thly
aud
it ac
cord
ing
to th
e W
HO
gui
delin
es;
staff
trai
ned
in b
est
prac
tice
obst
etric
ca
re; e
duca
tiona
l ou
trea
ch s
essi
ons
ever
y th
ree
mon
ths
and
re-c
ertifi
catio
n;
inte
rnat
iona
l ob
serv
ator
ies;
lead
ersh
ip; s
up-
port
ive
supe
rvis
ion;
m
obili
zing
fina
ncia
l re
sour
ces
02 y
ears
Doc
tors
, m
id-
wiv
es,
and
nurs
es
Refe
rral
ho
spita
ls
(Com
pre-
hens
ive
EmO
C
cent
res)
A c
lust
er-
rand
omiz
ed
cont
rolle
d tr
ial:
one
pre-
inte
rven
tion
year
and
two
inte
rven
-tio
n ye
ars
to m
easu
re
obst
etric
car
e qu
ality
in th
e po
st-in
ter-
vent
ion
year
. A
crit
erio
n-ba
sed
clin
ical
au
dit (
CBC
A)
to m
easu
re
patie
nt h
is-
tory
, clin
ical
ex
amin
atio
n,
labo
rato
ry
exam
inat
ion,
bi
rth
care
, an
d PN
C;
revi
ewin
g pa
tient
ch
arts
; t-t
est
anal
ysis
Wom
en tr
eate
d at
inte
rven
tion
hosp
itals
hav
e, o
n av
erag
e, 5
pp
grea
ter C
BCA
sco
res
than
th
ose
trea
ted
at c
ontr
ol h
ospi
tals
(β: 0
.052
; 95%
CI:
0.00
3–0.
102;
p =
0.0
4): i
nter
vent
ion
vs
cont
rol h
ospi
tals
: ini
tial i
nter
view
CBC
A s
core
s (8
2.3%
vs
81.1
%);
first
clin
ical
exa
m C
BCA
sc
ores
(86.
4% v
s 80
.5%
; p <
0.0
5); l
abor
ator
y ex
ams
CBC
A s
core
s (3
3.3%
vs
31.7
%);
birt
h ca
re
CBC
A s
core
s (6
3.3%
vs
62.8
%);
post
nata
l mon
itorin
g C
BCA
sco
res
(56.
2% v
s 46
.1%
; p <
0.0
5);
sign
ifica
ntly
mor
e w
omen
rece
ived
goo
d qu
ality
car
e (>
70%
crit
eria
att
ainm
ent)
: (44
.1%
vs
29.7
%; p
< 0
.001
); si
gnifi
cant
ly g
reat
er C
BCA
sco
res
in w
omen
trea
ted
(68.
2 vs
64.
5; p
< 0
.05)
Sele
ctio
n: L
RPe
rfor
-m
ance
: LR
Att
ritio
n: L
RD
etec
tion:
LR
Repo
rtin
g:
LR
Page 19 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Rahm
an e
t al.
(201
1) [5
1]Ba
ngla
desh
Com
mun
ity in
volv
e-m
ent i
n bi
-mon
thly
pr
egna
ncy
surv
eil-
lanc
e, h
ome-
base
d ca
re th
roug
h C
HW
s; he
alth
fa
cilit
y-ba
sed
trai
n-in
g on
man
age-
men
t of n
orm
al
and
com
plic
ated
de
liver
ies
and
new
born
com
plic
a-tio
ns fo
r doc
tors
an
d m
idw
ives
, st
anda
rd g
uide
lines
de
velo
pmen
t and
im
plem
enta
tion
for m
anag
emen
t of
mat
erna
l and
ne
wbo
rn c
ompl
ica-
tions
; mob
ilizi
ng
finan
cial
reso
urce
s
02 y
ears
Doc
tors
, m
id-
wiv
es,
and
CH
Ws
Prim
ary
care
(c
om-
mun
ity-
base
d,
heal
th-
care
ce
ntre
), se
cond
-ar
y ca
re
dist
rict
hosp
ital,
and
ter-
tiary
car
e ho
spita
ls
Pre-
and
pos
t-in
terv
entio
n co
mm
unity
-ba
sed
surv
ey a
t in
terv
entio
n an
d co
m-
paris
on a
reas
; di
ffere
nce-
in-
diffe
renc
es
anal
ysis
Inte
rven
tion
area
: per
inat
al m
orta
lity
decr
ease
d by
odd
s of
36%
as
com
pare
d to
pre
-inte
r-ve
ntio
n pe
riod
(AO
R: 0
.64;
95%
CI 0
.52–
0.78
); si
gnifi
cant
redu
ctio
n in
per
inat
al m
orta
lity
in
inte
rven
tion
area
as
com
pare
d to
the
com
paris
on a
rea
(p =
0.0
18);
post
-inte
rven
tion
area
: ea
rly p
regn
ancy
(GA
: 12–
14 w
eeks
) AN
C h
ome
visi
t: 94
.3%
, lat
e pr
egna
ncy
(GA
: 32–
34 w
eeks
) A
NC
hom
e vi
sit:
77%
; pos
t- v
s pr
e-in
terv
entio
n ar
ea: h
ealth
faci
lity
AN
C v
isits
(AN
C 3
+ : 7
8%
vs 3
8%, A
NC
2: 1
2% v
s 43
%, A
NC
1: 6
% v
s 15
%),
heal
th fa
cilit
y bi
rth
(72%
vs
55%
; p <
0.0
01),
cesa
rean
sec
tion
rate
s (1
6% v
s 8%
; p <
0.0
01), <
1 d
ay ti
min
g of
firs
t new
born
bat
h (4
% v
s 30
%; p
< 0
.001
), co
lost
rum
as
first
new
born
food
(96%
vs
83%
; p <
0.0
01); <
30
min
tim
ing
of
first
bre
ast f
eedi
ng (8
1% v
s 61
%; p
< 0
.001
), pr
eter
m b
irths
(bef
ore
37-w
eek
gest
atio
n) s
igni
fi-ca
ntly
dec
reas
ed (1
2.3%
vs
16.8
%; p
< 0
.001
); in
terv
entio
n vs
com
paris
on a
reas
: stil
l birt
h ra
te
(23/
1000
birt
hs v
s 31
/100
0 bi
rths
), ea
rly n
eona
tal d
eath
s (1
7/10
00 li
ve b
irths
vs
27/
1000
live
bi
rths
); pe
rinat
al m
orta
lity
rate
(3.2
% v
s 5.
6%)
Hig
h
Satt
i et a
l. (2
012)
[59]
Rura
l m
oun-
tain
ous
Leso
tho
Trai
ning
and
pe
rfor
man
ce-
base
d in
cent
ives
: 3
mon
ths
trai
ning
of
100
wom
en,
mos
tly T
BAs,
to
iden
tify
preg
nant
w
omen
and
ac
com
pany
them
to
a h
ealth
cen
tre
for A
NC
, birt
h ca
re, a
nd P
NC
se
rvic
es (c
linic
-affi
liate
d m
ater
nal
heal
th w
orke
rs);
depl
oym
ent o
f a
nurs
e-m
idw
ife to
th
e he
alth
cen
tre
to p
rovi
de A
NC
an
d bi
rth
care
an
d su
perv
ise
the
mat
erna
l hea
lth
wor
kers
; pub
lic–
priv
ate
sect
ors
part
ners
hip
02 y
ears
Trad
i-tio
nal
birt
h at
tend
-an
ts
(TBA
s),
nurs
e-m
id-
wife
Prim
ary
care
(c
om-
mun
ity-
base
d an
d pr
imar
y he
alth
-ca
re
cent
re)
Befo
re a
nd a
fter
se
cond
ary
data
ana
lysi
s of
AN
C a
nd
deliv
ery
regi
ster
s
The
aver
age
num
ber o
f AN
C 1
vis
it in
crea
sed
from
20
to 3
1 pe
r mon
th; 5
20 w
omen
test
ed
for H
IV d
urin
g th
e A
NC
1 v
isit,
whe
re 9
4% w
ere
with
unk
now
n st
atus
com
pare
d to
18
new
PM
TCT
clie
nts
regi
ster
ed in
the
year
pre
cedi
ng th
e pr
ogra
m; V
DRL
(syp
hilis
) tes
ting
for 6
44
wom
en (8
6% o
f AN
C 1
vis
it); h
aem
oglo
bin
test
ing
for 6
37 w
omen
(85%
of A
NC
1 v
isit)
; 218
m
othe
rs (1
22 in
yea
r 2) a
dmitt
ed to
mat
erna
l wai
ting
hous
es (5
5% o
f hea
lth fa
cilit
y bi
rth)
; 17
8 he
alth
faci
lity
birt
h in
the
1st y
ear o
f the
pro
gram
and
216
in th
e 2n
d ye
ar, c
ompa
red
to
46 in
the
year
pre
cedi
ng th
e pr
ogra
m; 4
9 w
omen
with
com
plic
atio
ns s
ucce
ssfu
lly tr
ansf
erre
d to
the
dist
rict h
ospi
tal;
no m
ater
nal d
eath
s am
ong
the
wom
en in
the
prog
ram
Mod
erat
e
Page 20 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Wai
swa
et a
l. (2
015)
[49]
Rura
l U
gand
aTr
aini
ng C
HW
s fo
r 5
days
on
the
iden
tifica
tion
of
preg
nant
wom
en
in th
eir c
omm
unity
, an
d un
dert
akin
g tw
o ho
me
visi
ts
durin
g pr
egna
ncy
and
thre
e vi
sits
af
ter b
irth
at o
r as
clos
e to
day
s 1,
3,
and
7 re
info
rced
by
dire
ctly
obs
erve
d su
perv
isio
n; 6
day
s in
-ser
vice
trai
ning
fo
r SA
Bs in
20
publ
ic a
nd p
rivat
e he
alth
faci
litie
s on
go
al-o
rient
ed A
NC
, m
anag
ing
mat
erna
l co
mpl
icat
ions
, in
fect
ion
prev
en-
tion,
man
agin
g no
rmal
labo
ur a
nd
part
ogra
ph u
se,
neon
atal
resu
scita
-tio
n, c
are
of th
e si
ck n
ewbo
rn,
and
extr
a ca
re fo
r sm
all b
abie
s us
ing
kang
aroo
mot
her
care
; com
mun
ity
invo
lvem
ent;
non-
finan
cial
ince
ntiv
es
(t-sh
irt, b
riefc
ase,
ce
rtifi
cate
); tr
avel
re
fund
; mob
ilizi
ng
finan
cial
reso
urce
s
02 y
ears
Com
-m
unity
he
alth
w
orke
rs
and
skill
ed
pers
on-
nel
Prim
ary
care
(c
om-
mun
ity-
base
d an
d pr
imar
y he
alth
-ca
re
faci
litie
s)
A c
lust
er-
rand
omiz
ed
cont
rolle
d tr
ial:
com
mu-
nity
-bas
ed
base
line
and
end-
line
surv
eys;
t-te
st
anal
ysis
(p)
for c
ompa
ri-so
n be
twee
n in
terv
entio
n an
d co
ntro
l en
d lin
es
The
inte
rven
tions
pro
vide
d im
prov
ed m
ater
nal a
nd e
ssen
tial n
ewbo
rn c
are
prac
tices
to p
oore
r fa
mili
es—
inte
rven
tion
vs c
ontr
ol c
lust
ers: ≥
4 A
NC
vis
its (4
7% v
s 43
.6%
; p =
0.1
65);
mot
hers
w
ith k
now
ledg
e of
two
or m
ore
preg
nanc
y-re
late
d da
nger
sig
ns (3
2.7%
vs
38%
; p =
0.1
26);
mot
hers
rece
ived
≥ 1
hom
e vi
sit d
urin
g pr
egna
ncy
(68.
2% v
s 7.
3%; p
< 0
.001
); SP
AB
(79.
6%
vs 7
8.9%
; p =
0.8
26);
use
of T
BAs
drop
ped
by (5
.7%
vs
0%);
wom
en v
isite
d by
a C
HW
in
the
first
wee
k af
ter b
irth
(62.
8% v
s 5.
8%; p
< 0
.001
); ne
wbo
rn p
ut to
the
brea
st w
ithin
1 h
of
birt
h (7
2.6%
vs
66%
; p =
0.0
116)
; new
born
giv
en c
olos
trum
(93.
4% v
s 91
.2%
; p =
0.0
86);
baby
exc
lusi
vely
bre
astfe
d in
firs
t mon
th o
f life
(81.
8% v
s 75
.9%
; p =
0.0
42);
new
born
pla
ced
skin
-to-
skin
with
mot
her w
ithin
1 h
of b
irth
(80.
7% v
s 74
.2%
; p =
0.0
71);
new
born
wra
pped
im
med
iate
ly a
fter
birt
h (9
9.6%
vs
99.8
%; p
= 0
.562
); fir
st b
ath
dela
yed ≥
24
h af
ter b
irth
(49.
6% v
s 35
.5%
; p <
0.0
01);
cord
cut
with
cle
an in
stru
men
t (88
.1%
vs
84.4
%; p
= 0
.074
); no
thin
g ap
plie
d to
um
bilic
al c
ord
afte
r cut
ting
(63.
9% v
s 53
.1%
; p =
0.0
02);
LBW
bab
ies
give
n ka
ngar
oo m
othe
r car
e (2
2.4%
vs
9.3%
; p =
0.0
89)
Sele
ctio
n: L
RPe
rfor
-m
ance
: LR
Att
ritio
n: L
RD
etec
tion:
LR
Repo
rtin
g:
LR
Page 21 of 28Negero et al. Hum Resour Health (2021) 19:54
Tabl
e 2
(con
tinue
d)
Refe
renc
esCo
ntex
tsH
RH in
terv
entio
nsD
urat
ion
of th
e
inte
rven
tions
Type
of
heal
th
wor
kers
Inte
rven
tion
sett
ings
Met
hods
Effec
ts o
f the
inte
rven
tions
Qua
lity
of
the
stud
y
Zeng
et a
l. (2
018)
[60]
Rura
l Za
mbi
aRe
sults
-bas
ed a
nd
inpu
t-ba
sed
finan
c-in
g; m
obili
zing
fin
anci
al re
sour
ces:
with
the
RBF,
heal
th
faci
litie
s w
ere
prov
ided
with
in
cent
ives
tied
to
perf
orm
ance
on
pre-
agre
ed M
CH
ca
re in
dica
tors
. Si
xty
perc
ent o
f the
in
cent
ive
paym
ent
was
use
d fo
r sta
ff bo
nuse
s, an
d 40
%
was
use
d fo
r ope
ra-
tiona
l act
iviti
es. I
n IB
F, he
alth
faci
litie
s re
ceiv
ed fu
ndin
g on
ly fo
r ope
ratio
nal
activ
ities
that
wer
e no
t tie
d to
per
for-
man
ce
27 m
onth
sSk
illed
pe
rson
-ne
l
Prim
ary
heal
th-
care
fa
cilit
ies
A tr
iple
-m
atch
ed
clus
ter-
rand
omiz
ed
tria
l: be
fore
an
d af
ter t
rial
hous
ehol
d an
d fa
cilit
y su
rvey
s; di
ffere
nce
in
Diff
eren
ces
(DiD
) ana
lysi
s
RBF
dist
ricts
-DiD
: cov
erag
es w
ere
impr
oved
by
19.5
% fo
r inj
ecta
ble
cont
race
ptiv
es (p
< 0
.05)
, −
1.5
% A
NC
, 3%
IPT
in p
regn
ancy
(p <
0.0
5), 1
2.8%
SPA
B (p
< 0
.01)
, 8.2
% P
NC
(p <
0.0
5) a
nd
6.1%
to 2
0.4%
infa
nt v
acci
natio
ns a
s co
mpa
red
to c
ontr
ols;
IBF
dist
ricts
-DiD
: cov
erag
es w
ere
impr
oved
by −
2.3
% fo
r inj
ecta
ble
cont
race
ptiv
es, 0
% A
NC
, 0.7
% IP
T in
pre
gnan
cy, 1
7.5%
SP
AB
(p <
0.0
1), 1
3.2%
PN
C (p
< 0
.01)
and
0.3
% to
5.6
% in
fant
vac
cina
tions
as
com
pare
d to
co
ntro
ls; R
BF d
istr
icts
-DiD
: cov
erag
es w
ere
impr
oved
by
21.8
% fo
r inj
ecta
ble
cont
race
ptiv
es
(p <
0.0
5), −
1.5
% A
NC
, 2.3
% IP
T in
pre
gnan
cy, −
4.9
% S
PAB,
− 5
.1%
PN
C a
nd −
1%
to 1
8.6%
in
fant
vac
cina
tions
as
com
pare
d to
IBF
dist
ricts
; RBF
dis
tric
ts: q
ualit
y of
car
e in
dex-
DiD
: im
prov
ed b
y 9.
7% fo
r inj
ecta
ble
cont
race
ptiv
es, 2
.9%
for A
NC
, 3.1
% fo
r SPA
B, 2
.3%
for P
NC
an
d 3.
8% fo
r inf
ant v
acci
natio
ns a
s co
mpa
red
to th
e co
ntro
ls; I
BF d
istr
icts
: qua
lity
of c
are
inde
x-D
iD: i
mpr
oved
by
4.8%
for i
njec
tabl
e co
ntra
cept
ives
, 2.8
% fo
r AN
C, 2
.4%
for S
PAB,
3%
fo
r PN
C a
nd 0
.6%
for i
nfan
t vac
cina
tions
as
com
pare
d to
the
cont
rols
; RBF
dis
tric
ts: q
ualit
y of
car
e in
dex-
DiD
: im
prov
ed b
y 4.
9% fo
r inj
ecta
ble
cont
race
ptiv
es, 0
% fo
r AN
C, 0
.7%
for
SPA
B, −
0.8
% fo
r PN
C a
nd 3
.2%
for i
nfan
t vac
cina
tions
as
com
pare
d to
IBF
dist
ricts
; pre
gnan
t w
omen
and
chi
ldre
n <
5 y
ears
in R
BF d
istr
icts
gai
ned
604
and
14,5
74 Q
ALY
s, re
spec
tivel
y,
whi
le p
regn
ant w
omen
and
chi
ldre
n <
5 y
ears
in IB
F di
stric
ts g
aine
d 30
2 an
d 8,
274
QA
LYs,
resp
ectiv
ely,
as
com
pare
d to
the
cont
rols
; pre
gnan
t wom
en a
nd c
hild
ren
< 5
yea
rs in
RBF
dis
-tr
icts
gai
ned
302
and
6,30
0 Q
ALY
s, re
spec
tivel
y, a
s co
mpa
red
to th
e IB
F di
stric
ts; i
ncre
men
tal
cost
–effe
ctiv
enes
s ra
tios
of U
S$ 8
09 a
nd 4
13 p
er Q
ALY
gai
ned
for R
BF a
nd IB
F di
stric
ts,
resp
ectiv
ely,
as
com
pare
d to
con
trol
s. In
crem
enta
l cos
t-eff
ectiv
enes
s ra
tio o
f US$
132
4 pe
r Q
ALY
gai
ned
for R
BF d
istr
icts
as
com
pare
d to
the
IBF
dist
ricts
Sele
ctio
n: L
RPe
rfor
-m
ance
: LR
Att
ritio
n: L
RD
etec
tion:
LR
Repo
rtin
g:
LR
Page 22 of 28Negero et al. Hum Resour Health (2021) 19:54
Afghanistan. Doctors and mid-level cadres were pro-vided with quarterly bonuses based on the delivery of nine MCH related indicators. There was no direct com-munication with health workers about the bonuses, nor were there any demand-side interventions (raising or creating demand in communities). The intervention posi-tively affected history taking and physical examinations, and client counseling quality of care indices across the SRMNH care continuum. The intervention, however, had no significant impact on equitable access to the tar-geted MCH services use between poor and rich families or on the adequacy of time spent with a client along the SRMNH care continuum. It did not also improve client satisfaction and the perceived quality of care along the SRMNH care continuum.
Zeng et al. [60] investigated the effect of results-based financing (RBF), an approach to incentivize healthcare providers and operational activities based on perfor-mance, on SRMNH care quality in line with input-based financing (IBF), a traditional approach of increasing funding not tied to performance, in Zambia. Both the RBF and IBF interventions significantly improved the quality of injectable contraceptives, ANC, IPC, and PNC services, respectively, compared to their respective con-trols (without additional financing). Pregnant women and children in RBF districts gained 604 and 14,574 quality-adjusted life years (QALYs), respectively, while pregnant women and children in IBF districts gained 302 and 8,274 QALYs, respectively, as compared to the controls.
ANC, IPC, and PNC continuumThirteen studies focused on improving SRMNH care quality across ANC, IPC, and PNC continuum. Six studies featured interventions to improve the perfor-mance of CHWs. Okuga et al. and Waiswa et al. [48, 49] evaluated the effect of community-based recruit-ment, training, deployment, supervision, modest finan-cial and non-financial incentives for CHWs, and their integration into the healthcare system on maternal and newborn healthcare in rural Uganda. Health facility strengthening was undertaken at all facilities. Qualita-tive interviews with key stakeholders found that CHWs were positively received and used their social networks to identify and refer pregnant women and involve men in health education. Okuga et al. (2015) showed reduced delays in healthcare service delivery at health facilities; and improvements in compassionate and respectful care, and cord care. In addition, there were improvements in the early initiation of breastfeeding and feeding new-borns on colostrum and delayed bathing of newborns. [48]. Waiswa et al. (2015) found improved maternal and essential newborn care practices among poorer families. Significant, positive impacts of the intervention were
identified, including increased health worker home visit-ing during pregnancy and the first week after birth. There were improvements in early breastfeeding initiation, delayed bathing of newborns (≥ 24 h), and cord care [49].
In the study by Edwards et al. [50], village and com-munity health workers recruited from their respective communities were given skills-based training on mater-nal and newborn health (MNH) and primary healthcare. They received monthly supportive supervision in rural Bangladesh. Health workers from villages to the general hospital and the community worked in collaboration and team. Confidential, no-blame perinatal and mater-nal death audit was also implemented. A higher propor-tion of poor women in intervention areas received ANC, skilled personnel-assisted birth (SPAB), caesarean sec-tion, and PNC services than poor women living in the non-intervention, nationally sampled study areas across the SRMNH care continuum. There was also a reduction in the gap in service use between the poorest and richest women in intervention areas than in the national sam-pled study areas along the SRMNH care continuum. In the study by Agarwal et al. [54], Accredited Social Health Activists (ASHAs) were trained to provide health educa-tion and connect women to healthcare facilities and pro-viding home-based ANC and PNC. Exposure to ASHA program compared to non-exposure had no significant effect on completing all services across ANC, IPC, and PNC care continuum.
Mobile technology was the focus of study by Bal-akrishnan et al. [55] who examined the effect of a mobile phone app (mHealth platform) used by trained commu-nity-based frontline health workers (ASHAs, Anganwadi Workers and Auxiliary nurse-midwives) to track services delivered to women and their newborns in India. The intervention villages were found to have an increased uptake of ≥ 90 iron and folic acid tablets during preg-nancy, early initiation of breastfeeding, and PNC home visits as compared to the non-intervention control areas. There was equity in the coverage of all quality indicators of SRMNH care across all casts (scheduled vs. others). However, there were no differences between intervention and control areas regarding the uptake of tetanus toxoid injections during pregnancy after a year of intervention. Maru et al. [43] evaluated the effect of a public–private partnership that involved developing an accountable care framework that integrated CHWs through companion and home visits to deliver health facility-based care in rural Nepal. The intervention showed an increase in ≥ 4 ANC visits by 6.4 pp, health facility birth by 11.8 pp, and postnatal contraception by 27.5 pp. Ninety-five percent of pregnant mothers received an ultrasound examination by month 8 or 9 of pregnancy. Infant mortality decreased from 18.3/1000 to 12.5/1000 live births.
Page 23 of 28Negero et al. Hum Resour Health (2021) 19:54
Seven studies featured interventions to improve the performance of skilled personnel. Out of these, educa-tional interventions were focused on five studies. Okawa et al. [53] examined the effect of doctors and mid-level cadres training and supervision on adequate contacts and SRMNH care quality in rural Ghana. The inter-vention had a significant, positive effect on the quality of PNC (p = 0.02). The intervention, however, did not significantly improve the quality of ANC or IPC. Hav-ing adequate contact with healthcare providers did not guarantee a high quality of care. In the study by McDou-gal et al. [57], community-based frontline workers were trained, mobilized, and empowered to improve the qual-ity and effectiveness of home visits in India. The interven-tion had a significant, positive effect for nothing applied to cord after birth, kangaroo mother care, and postna-tal contraception use. Ayalew et al. [41] examined the effect of multi-faceted interventions, including the Basic Emergency Obstetric and Newborn Care (BEmONC) training, supportive supervision, audit and site mentor-ing, and health facility-based quality improvement team-work in Ethiopia. It had a significant, positive impact on healthcare provider performance during labour and birth (p = 0.002) and immediate PNC services (p = 0.001) compared to the comparison facilities. Magge et al. [45] studied the effect of clinical mentorship, training, and collaborative district-wide learning and leadership on maternal and newborn care quality in Rwanda. Post- ver-sus pre-intervention outcomes showed pregnant women with premature rupture of membrane (PROM) treated with antibiotics of (38% vs. 24%); pregnant women with preterm labour treated with corticosteroids of (75% vs. 26%); waiting time to C-section in minutes (72 vs. 99); immediate kangaroo mother care (87% vs. 19%); and newborns checked for danger signs within 24 h of birth (98% vs. 47%). Rahman et al. [51] assessed the effect of an integrated packaged interventions, including community participation and onsite training on the management of deliveries and newborn complications on perinatal mor-tality in Bangladesh. Early pregnancy ANC home visits, caesarean section rates, early initiation of breastfeeding, colostrum as first newborn food, and delayed first new-born bathing were significantly, positively higher in the post-intervention period as compared to two years pre-intervention (p < 0.001). In intervention areas, perinatal mortality decreased by odds of 36%; less than 24 h tim-ing of first newborn bath and preterm births significantly decreased.
Two studies examined financial and policy interven-tions. Binyaruka et al. (2015) and Kambala et al. [42, 46] described the effect of the P4P program (Tanzania) and RBF (rural Malawi) on SRMNH care quality along the continuum. The P4P had a significant, positive impact on
one of the eight targeted indicators: anti-malarial treat-ment during ANC visits (p = 0.001). However, there was no evidence of the effect of the P4P program on women’s satisfaction with care. There was no significant effect on non-targeted services either (satisfaction with inter-personal care and waiting and consultation times) [46]. Kambala et al. [42] showed that the RBF had no signifi-cant, positive impact on women’s perceptions of techni-cal care, quality of amenities, or interpersonal relations during ANC, IPC, and PNC. Women reported instances of neglect, disrespect, and verbal abuse by health per-sonnel while receiving care. The health personnel noted an increased workload due to the increased number of women seeking care at intervention facilities.
ANC and IPC continuumSix studies focused on improving outcomes across ANC and IPC continuum. Five studies featured interven-tions to enhance the performance of skilled personnel. Of these, financial and policy interventions were the focus of the two studies. In the study by Basinga et al. [44], the Rwandan government launched a national P4P scheme in health centres based on 14 key MCH-care quality indicators. Quarterly audits of care were made at each health centre based on direct observation and a review of patients’ records using a standardized assess-ment tool on an unannounced, randomly chosen day. The intervention had the greatest effect on indicators that only had the highest payment rates and needed the least effort from the service provider. The intervention had a significant, positive impact on standardized total ANC’s quality, the number of high-risk pregnancies referred to district hospital for delivery during pregnancy, and the number of emergency transfers to hospital for obstetric care during delivery. The intervention, however, didn’t improve the uptake of tetanus toxoid injections during ANC visits. Bonfrer et al. [40] assessed the effect of the performance-based financing (PBF) policy and quarterly quality assessment by local regulatory authorities on the quality of pregnancy and IPC in Burundi. The PBF policy is the one with financial incentives for healthcare provid-ers based on their performance, excluding operational activities. The program had a significant, positive effect on the coverage of ≥ 1 tetanus toxoid injections dur-ing ANC; and SPAB among the non-poor (p < 0.028) but the poor in provinces with PBF program as compared to those without it.
Two studies focused on partnership and manage-ment interventions. Mwaniki et al. [58] evaluated the effect of a collaborative health worker advisory group-ing in improving maternal healthcare quality in rural Kenya. The intervention, at the end line compared to the baseline, had significantly increased ANC contacts
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per month with standardized care (p < 0.001), and preg-nant mothers actively referred from the community to health facilities for ANC and IPC services (p = 0.012). Duysburgh et al. [61] reported on the effect of a com-puter-assisted clinical decision support system and per-formance-based financial and non-financial incentives in Burkina Faso, Ghana, and Tanzania. The interven-tion showed a significant improvement in the number of lab proteinuria examinations during ANC, history taking on vaginal bleeding during pregnancy, births with correctly completed partograph, blood pressure monitoring during childbirth, and oxytocin for women after childbirth. Larson et al. [47] focused on educa-tional and management interventions in rural Tanza-nia. Providers from 12 primary care clinics received in-service training, mentoring, supportive supervision and infrastructure support, and community members received peer outreach services. The intervention had a significant, positive, and negative effect on ANC’s qual-ity and obstetric care cost, respectively.
The TBA educational and management interven-tions were featured in a study by Satti et al. [59] in rural Lesotho. In this research, one hundred women, mostly TBAs, were trained and provided with incentives to identify pregnant women in the community and accom-pany them to a health centre for ANC and delivery. A nurse-midwife was deployed to the health centre to provide care and supervise the TBAs. Pregnant women from isolated communities were accommodated at a maternal waiting room two weeks before delivery. The intervention resulted in that the HIV testing, syphi-lis testing, and haemoglobin testing during ANC visit increased, as did the number of women with complica-tions who were successfully transferred to the district hospital for obstetric care during delivery. There were no maternal deaths among the women in the program.
IPC and PNC continuumThree studies focused on improving outcomes across the IPC and PNC continuum that featured educational and management interventions. Ghosh et al. [56] stud-ied the effect of a multi-faceted, onsite nurse-mentor-ing and simulation program on nurses’ and midwives’ skills in the diagnosis and management of intrapar-tum asphyxia and postpartum haemorrhage (PPH) in India. The mentoring had a significant, positive effect on the diagnosis of asphyxia and PPH and management of asphyxia per additional week of mentoring. Gomez et al. [52] investigated the impact of an onsite, low-dose, high-frequency, and clinical simulation-assisted midwives’ BEmONC training in Ghana. The interven-tion significantly reduced the intrapartum stillbirth and
24-h newborn mortality rates by 52% and 70%, respec-tively, during the 7–12 months of implementation com-pared to the baseline. Pirkle et al. [62] evaluated the effect of maternal death reviews in 32 referral hospitals on the quality of obstetrical care in Mali and Senegal. Women treated at intervention hospitals had, on aver-age, higher quality of care scores than those treated at control hospitals.
DiscussionThis study represents the first systematic review to examine HRH interventions and their impact on SRMNH care quality across the continuum in LLMICs. Our findings identified the key elements to successful HRH interventions and the areas for future research regarding HRH interventions.
Respectful, woman‑centred care as a criterion of RBFThe RBF, based on a pre-defined and communicated set of indicators and its policy, significantly improved the quality of targeted SRMNH care services across the continuum given the increasing human resources, equipment, and supply demands are fulfilled [39, 40, 42, 44, 60]. However, these interventions had no signifi-cant, positive effect on clients’ perception of quality or equity in care [39, 40, 42, 44, 46]. This signals the criti-cal importance of including respectful, woman-centred care. A systematic review suggests that continuous, personalized care provided by the usual midwife and delivered within a family or a specialized setting, gen-erates the highest level of satisfaction [64]. Woman-centred care fosters the woman’s psychological and physiological recovery, often surpassing clinical action, and is associated with lower intervention rates [64, 65]. A systematic review from low- and middle-income countries states a positive effect of P4P on history tak-ing, physical examination, blood pressure measure-ment, and blood and urine testing during ANC visits, and on provider’s adherence to explaining medicine intake for children under five years, children are given medicines and children follow-up treatment. How-ever, there was weak evidence for P4P’s positive effect on maternal and neonatal health outcomes and out-of-pocket expenses [66].
Local budgeting and administration to deliver financial incentivesThis review revealed that local budgeting, administration, and policy to deliver financial incentives and improve operational activities, were more effective than mobi-lizing direct funds from donors for financial incentives,
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operational activities and incentivizing users, and its policy in improving SRMNH care quality along the con-tinuum and maternal and/or neonatal health outcomes [39, 40, 44, 46, 57, 59, 61]. Reliance on donor funding and donor-driven initiatives may reduce the responsibility for the delivery of care and increase dependence on outside funds. Another study found that despite extensive invest-ment from donors, in-service training and supportive supervision to improve health workers’ performance in providing quality antenatal and sick child care in seven countries in sub-Saharan Africa (SSA) did not improve the quality of care [67].
Training, health worker empowerment, and the integration into the healthcare systemCommunity-based recruitment, training, deployment, empowerment, supportive supervision, technology assis-tance, and modest financial and non-financial incentives for CHWs in rural hard-to-reach areas had a significant, positive effect on the quality and equity of SRMNH care services across the continuum. The social networks that CHWs had were a valuable asset enabling the building of rapport and relationships with pregnant women to facili-tate referral to nearby health facilities and the provision of home-based life-saving ANC and PNC services [43, 48, 54, 55, 57, 59]. This finding identifies the importance of training for CHWs, and policy initiatives to ensure their empowerment and integration into the healthcare system. A Cochrane trial’s review demonstrates that TBA training significantly reduced stillbirth and perinatal and neonatal deaths [22]. There is a need for policy to recog-nize the important cultural and social roles CHWs ful-fill in their local communities that can positively affect maternal and neonatal health outcomes [68].
BEmONC training, supportive supervision, teamwork, and collaboration for skilled personnelIn-service BEmONC training, supportive supervision, mentoring, audit, quality improvement advisory team, collaboration with CHWs, and community participation for skilled personnel had a significant, positive effect on quality ANC and IPC, and decreased perinatal mortal-ity and preterm births [41, 45, 51, 58]. In a review from Africa, implementing comprehensive interventions that strengthen the health system’s different compo-nents, both in the community and at the health facilities, directly or indirectly improved the quality of maternal healthcare and morbidity and mortality outcomes [69].
Skills‑based, on‑site, regular, and clinical simulation training for nurses and midwivesOn-site, short, frequent, regularly run, and clinical sim-ulation-assisted training and mentorship of nurses and
midwives had a significant, positive effect on the qual-ity of ANC, IPC, and PNC along the continuum. This, in turn, significantly reduced the intrapartum stillbirth and 24-h newborn mortality rates [45, 52, 56]. On the other hand, in-service training, orientation, mentoring and supportive supervision, and peer outreach services implemented in two studies in support of the continuum-of-care package had only a modest effect on the quality of ANC, IPC, or PNC [47, 53]. Analysis of the Service Provi-sion Assessment data from seven countries in SSA shows that in-service training and supportive supervision had a modest effect on ANC and sick child care quality. Pro-viders were observed performing fewer than half of the recommended clinical actions for pregnant women and sick children on average [67]. Accordingly, skills-based, regular, focused, onsite, and clinical simulation and/or mobile technology-assisted in-service training of skilled personnel are more effective than the knowledge-based, irregular, and ineffective donor-funded training or super-vision in LLMICs.
Maternal and perinatal death audits in all health facilitiesMaternal death reviews in 32 referral hospitals in Mali and Senegal, coupled with training and certification of skilled personnel, had a significant, positive effect on ANC and IPC’s quality across the continuum [62]. Confi-dential, no-blame perinatal and maternal death audits in rural Bangladesh improved the equity for poor women in receiving life-saving maternal healthcare services along the SRMNH care continuum [50]. A systematic review of effective non-drug interventions for improving outcomes and quality of maternal healthcare in SSA also found that facility-based clinical audits and maternal death reviews supported by demand and supply-side financial incen-tives, health systems strengthening interventions, com-munity mobilization and peer-based programs, and task shifting directly or indirectly improved quality of mater-nal healthcare and morbidity and mortality outcomes in SSA [69].
Involving skilled and lay personnel in primary careIn primary care, HRH interventions involving both skilled and lay personnel were more effective than those involving either skilled or lay personnel alone on improv-ing quality or health outcomes [39, 40, 47–49, 55, 61]. A systematic review that focused on IPC found that increas-ing the use of skilled personnel where TBAs are providers of birth care suggested that deploying midwives closer to communities, financial incentives for providers and users, mobilizing the community, and partnering with TBAs decreased maternal mortality [70].
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Comprehensive HRH interventions targeting different components of the healthcare systemThere is no single effective HRH intervention: ≥ 4 com-prehensive HRH interventions had a more positive effect on quality SRMNH care continuum and/or health out-comes than those studies with fewer HRH interventions [39, 41, 45, 47–50, 52, 55, 57–59, 62], suggesting a cumu-lative effect. A systematic review from SSA also indicates that comprehensive HRH interventions implemented at the healthcare system’s different components, both in the community and health facilities, improve maternal health [69].
Inclusion of PCC in the SRMNH care continuumThe PCC, any intervention to optimize a woman’s health before pregnancy to improve maternal, new-born, and child health outcomes, effectively improves pregnancy outcomes: including smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining ANC; and lower rates of neonatal mortal-ity [71, 72]. This vital component of the SRMNH care continuum lacks our studies reviewed. This review sug-gests an urgent need to include PCC in the SRMNH care continuum and studies in LLMICs.
The review has several limitations. Despite the inclu-sion of methodologically moderate- to high-quality intervention studies retrieved from seven databases, some studies may have been missed as our search terms may not have been sufficient to retrieve them. The use of a deductive qualitative content analysis guided by the WHO-HRH action framework may have resulted in the loss of contextual nuances that may have provided insight into the processes that enabled the successful delivery of HRH interventions across the SRMNH care continuum. On the other hand, the number of stud-ies with HRH interventions having a positive effect on SRMNH care quality across the continuum was more than those reporting negative effects, and hence there might be a potential publication bias.
ConclusionsPolicy-makers in LLMICs should include respect-ful, woman-centred care as a key part of RBF ini-tiatives and ensure healthcare workers’ incentives are locally administered and CHWs are integrated into the healthcare system. Skills-based, regularly run, effec-tiveness focused, onsite, and clinical simulation and/or mobile phone-assisted in-service training of skilled personnel are needed. Besides, facility-based mater-nal and perinatal death audits in all health facilities, involving skilled and lay personnel, the implementa-tion of ≥ 4 HRH interventions that target the different
components of the healthcare system, and the inclusion of PCC in the SRMNH care continuum and studies are recommended.
AbbreviationsASHA: Accredited Social Health Activist; ANC: Antenatal Care; BEmONC: Basic Emergency Obstetric and Newborn Care; CHW: Community Health Worker; CBCA: Criterion-based clinical audit; DiD: The difference-in-differences analysis; HRH: Human Resources for Health; IBF: Input-based financing; IPC: Intrapartum care; LLMICs: Low- and lower-middle-income countries; MNH: Maternal and Newborn Health; PNC: Postnatal care; PCC: Preconception care; RCTs: Rand-omized controlled trials; pp: Percentage points; RBF: Results-based financing; SPAB: Skilled personnel-assisted birth; SRMNH: Sexual, reproductive, maternal, and newborn health; SSA: Sub-Saharan Africa; SDGs: Sustainable Develop-ment Goals; WHO: World Health Organization.
Supplementary InformationThe online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12960- 021- 00601-3.
Additional file 1. Tables and additional files.
AcknowledgementsThe authors would like to extend gratitude to the UTS public health research librarians, Helen Chan and Rosie Glynn, for their significant contribution in developing, refining, and testing the review’s protocol and its search strategy. We would also like to thank the UTS library for searching for and providing articles that were not available in the open access.
Authors’ contributionsMG and AD conceived the review question, developed the study protocol and design; MG and AD led the review and analysis with input from DS. MG and AD led the writing of the manuscript, and all authors provided input and feedback. All authors read and approved the final manuscript.
FundingThe authors received no funding for this work.
Availability of data and materialsTable S1. HRH interventions and areas of intervention. Table S2. Definitions of skilled health personnel and lay health personnel. Table S3. Inclusion criteria. Table S4. Search strategy and keywords. Table S5. Quality of Randomized controlled trials (RCTs). Table S6. Quality of quasi-experimental, prospective (pre/post), post-only and comparison, and post-only studies. Table S7. Quality of qualitative and mixed-method studies.
Declarations
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Competing interestsThe authors declare that they have no competing interests.
Author details1 School of Public Health, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia. 2 School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia.
Received: 20 February 2021 Accepted: 12 April 2021
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