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The Cochrane Database of Systematic Reviews
 
Cochrane Database Syst Rev. 2017 November 17; (11): CD011558.
PMCID: PMC5721625

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

Abstract

Background

In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

Objectives

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

Search methods

Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

Selection criteria

We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

Data collection and analysis

One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

Main results

We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.

Our synthesis pointed to a number of factors affecting SBAs’ provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.

Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.

Skilled birth attendants’ ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs’ morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women’s negative perceptions of the health system could make them reluctant to accept referral.

We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants’ motivation, their decision-making abilities, and the quality of care. Skilled birth attendants’ workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

Authors' conclusions

Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

What factors influence the delivery of care by skilled birth attendants in low- and middle-income countries?

Review aim

The aim of this Cochrane synthesis of qualitative evidence was to identify factors that influence the provision of care by skilled birth attendants. To answer this question, we searched for and analysed qualitative studies of skilled birth attendants’ views, experiences, and behaviour.

This synthesis complements another Cochrane Review assessing the effect of strategies to promote women’s use of healthcare facilities when giving birth.

Key messages

Many factors influence the care that skilled birth attendants provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork, trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to these factors.

What did we study in the synthesis?

In low- and middle-income countries, many mothers still die during childbirth. Women are encouraged to give birth in health facilities rather than at home so they can receive care from skilled birth attendants. A skilled birth attendant is a health worker such as a midwife, doctor, or nurse who is trained to manage a normal pregnancy and childbirth, and refer the mother and newborn when complications arise.

By exploring skilled birth attendants’ views, experiences, and behaviour, this synthesis aimed to identify factors that can influence their ability to provide quality care.

Main findings

We included 31 studies conducted in Africa, Asia, and Latin America. Participants were skilled birth attendants including doctors, midwives, nurses, auxiliary nurses and their managers.

Our synthesis pointed to several factors that affected skilled birth attendants’ provision of quality care. The following factors are based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they sometimes had insufficient training during their education or after they had begun work. Where facilities lacked staff, skilled birth attendants’ workloads could increase, it could become difficult to provide supervision, and mothers could receive poorer care. In addition, skilled birth attendants did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues could lead to stress and affect skilled birth attendants' family life. Some skilled birth attendants felt that managers lacked capacity and skills, and they felt unsupported when their workplace concerns were not addressed.

Possible causes of staff shortages included problems with hiring and assigning health workers to health facilities; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of their work; these included good-quality housing, allowances for extra work, paid vacations, continued education, proper assessments of their work, and rewards.

Skilled birth attendants’ ability to provide quality care was also limited by a lack of equipment, drugs, and supplies; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce skilled birth attendants’ morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for skilled birth attendants to refer women to higher levels of care. In addition, women’s negative perceptions of the health system could make them reluctant to accept referral.

We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants’ motivation, their decision-making abilities, and the quality of care. Skilled birth attendants’ workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

How up-to-date is this review?

We searched for studies published before November 2016.

Summary of findings for the main comparison

Background

The United Nations' fifth Millennium Development Goal (MDG) aimed to reduce maternal death rates by increasing the proportion of births conducted by skilled birth attendants. Low- and middle-income countries promoted the skilled attendance at birth strategy in order to reduce high maternal mortality rates. Globally, from 1990 to 2014, a 12% increase in the proportion of births attended by skilled birth attendants was achieved (UN 2015). But while several low- and middle-income countries managed to improve access to skilled care at birth, several did not manage to reduce their high maternal mortality rates. The sub-Saharan Africa region was reported to have the highest number of maternal deaths (510 deaths per 100,000 live births), while South Asia, Oceania, and the Caribbean each had 190 deaths per 100,000 live births. Whereas attention at the policy level was given to increasing access to skilled care at birth, this was not matched with improvements in the quality of care available at health facilities, and this may have contributed to the slow decline in maternal mortality (Campbell 2016, Koblinsky 2016; Graham 2012).

The United Nations' Sustainable Development Goals represent a renewed call to action to sustain the gains achieved in the MDG era and to further improve priority areas such as maternal health (UN 2015b). Their third goal aims to reduce global maternal mortality ratio to fewer than 70 maternal deaths per 100,000 live births by 2030. The provision of quality maternal care, delivered through a resilient health system with well-staffed health facilities that are capable of managing routine and emergency maternity care, has been identified among the priorities for action over the next five years (Koblinsky 2016).

Description of the condition

In order to provide good-quality care to mothers and their babies, healthcare workers need to possess appropriate skills, attitudes, and behaviours, and also need access to drugs, supplies, and equipment, as well as tools for communication and referral when complications arise. Such components have been referred to as supply-side factors (Gabrysch 2009; Say 2007). When these components are not available at health facilities for mothers in active labour, they contribute to one source of delay in accessing care (Thaddeus 1994). The absence of these components can influence the technical quality of care provided at health facilities and lead to poor maternal and child outcomes. The absence of these components can also influence how care is perceived by mothers and mothers' choice in place of delivery, and can contribute to delays in providing adequate care for mothers in labour.

Description of the intervention

Skilled birth attendance refers to "the process by which a woman is provided with adequate care during labour, delivery and the postpartum period" (SMIAG 2000). This process requires both a skilled attendant and an enabling environment. An enabling environment has been described as one that provides supportive regulation, policies and infrastructure, communication, referral, logistics, and supplies, inputs that are necessary for a skilled attendant to provide care (Maclean 2003). A joint statement from the World Health Organization, the International Confederation of Midwives, and the International Federation of Gynecology and Obstetrics defines a skilled birth attendant as an "accredited health professional such as a midwife, doctor or nurse that is trained to proficiency and has the necessary skills to manage a normal pregnancy, childbirth and provide postnatal care as well as the skills to detect, manage and refer any complications in the mother and neonate" (WHO 2004). Possessing a core set of skills would imply that the health professional is able to manage a normal, uncomplicated vaginal delivery. However, studies have demonstrated great variation between countries in the cadre, as well as the level of skills and competence, possessed by skilled birth attendants (Harvey 2007; Adegoke 2012; Utz 2013). In addition, the scope of practice of the skilled birth attendant varies widely to include a few or all components of basic and comprehensive emergency obstetric care. Basic emergency obstetric care is a package of care that provides the seven signal functions needed to provide lifesaving interventions to women with obstetric complications and their babies (WHO 2008). The seven signal functions are: administration of parental antibiotics; administration of oxytocic drugs; administration of anticonvulsants; manual removal of the placenta; removal of retained products of conception; conducting assisted vaginal deliveries; and performing neonatal resuscitation. In addition to the seven signal functions defined as basic care, comprehensive emergency obstetric care provides blood transfusion and surgery. Skilled birth attendants need to possess advanced skills in order to provide comprehensive emergency obstetric care.

In this synthesis, we have focused on care provided during the intrapartum and postpartum period. This includes normal, uncomplicated maternity care, basic and comprehensive emergency obstetric care, as well as postpartum care. By postpartum care we refer to the period immediately after birth and up to six weeks.

How the intervention might work

The rationale for promoting skilled birth attendance at delivery is based on evidence that at least 75% of maternal deaths occur from late pregnancy to 48 hours following delivery (Abou-Zahr 1998). The scientific evidence of the impact of skilled birth attendance on maternal mortality is weak due to the ethical issues around randomising mothers to non-skilled attendants. The available evidence is obtained from quasi-experimental studies that show a link between reduced maternal mortality rates and skilled attendance at birth (Maine 1996), and challenges related to confounding mean the causal link between maternal mortality and access to skilled birth attendance is not firmly established. Additional evidence from statistical modelling suggests that 16% to 33% of all maternal deaths could be prevented by skilled birth attendance (Graham 2001). Historical data from Sweden, the United States of America, Malaysia, and China also suggest a correlation between the decline in maternal mortality rates and the increase in skilled attendance at birth (De Brouwere 1998; Koblinsky 1999; Loudon 1992). However, the contribution of factors such as the environment under which these births were conducted and other ongoing social and economic changes is difficult to estimate.

The conceptual framework for skilled birth attendance at delivery guided the development of this synthesis (Graham 2001). In this framework, Graham and colleagues suggest key elements that can influence the provision of skilled attendance at birth and thereby maternal, neonatal, and provider outcomes and cost-effectiveness. These elements are organised into structure, inputs, outputs, and outcomes. First, the framework highlights elements in the structure or environment where care is provided, including the political or policy environment and the social/cultural environment. According to the framework, this environment influences the inputs available, such as human resources, education, technical quality of care, financing, and supplies. These inputs in turn influence the process of care such as health facility access or availability; the mix or ratio of providers; interactions, such as between health workers and clients; and referral processes. Finally, these outputs influence the health outcomes (maternal and baby and provider outcomes and cost-effectiveness). See Figure 1 for the Graham 2001 framework.

Why it is important to do this synthesis

By synthesising existing qualitative evidence, we aimed to identify the range of factors, including barriers and facilitators, in low- and middle-income settings that influence the provision of intrapartum and postnatal care by skilled attendants. Evidence on barriers and facilitators is useful for policymakers and managers seeking to develop implementation strategies to improve the quality of maternity care. The evidence generated in this synthesis provides information for understanding the basic needs and experiences of health personnel when providing maternity care. Health workers' experiences may, in turn, influence the quality of maternal health services provided, as well as the success or failure of strategies to promote facility-based deliveries and recruit and retain skilled birth attendants. Information about the experiences of skilled birth attendants, the ways in which they deliver care, as well as other factors influencing the process of care may not be reported in effectiveness studies. While Cochrane intervention reviews are not designed to answer these types of questions, there is growing acknowledgement that syntheses of qualitative research can make important contributions in this area (Glenton 2013). Our synthesis complements the evidence generated by a Cochrane intervention review entitled 'The effectiveness of policies promoting facility-based deliveries in reducing maternal and infant morbidity and mortality in low and middle-income countries' (Dudley 2009).

Objectives

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

Methods

Criteria for considering studies for this synthesis

Types of studies

We included all studies that utilised qualitative methods for data collection (e.g. focus group interviews, individual interviews, observation, document analysis) and that utilised qualitative methods for data analysis (e.g. thematic analysis, framework analysis, grounded theory). We excluded studies that collected data using qualitative methods but did not perform a qualitative analysis (e.g. open-ended survey questions where the responses are analysed using descriptive statistics). We included mixed-methods studies where it was possible to extract findings derived from qualitative research.

Types of participants

Setting

We included studies based in primary, secondary, and tertiary levels of health care in low- and middle-income countries. We utilised the World Bank 2013 definition of low- and middle-income countries. We chose to focus only on low- and middle-income countries because these are the regions where skilled birth attendance was actively promoted by the global health community in response to high maternal mortality rates (UN 2015).

Participants

We included studies of skilled birth attendants providing intrapartum and postnatal care. We defined a skilled birth attendant as an "accredited health professional such as a midwife, doctor or nurse that is trained to proficiency and has the necessary skills to manage a normal pregnancy, childbirth and provide postnatal care as well as the skills to detect, manage and refer any complications in the mother and neonate" (WHO 2004). We also included studies of auxiliary cadres such as auxiliary nurse midwives and associate clinicians (non-physician clinicians) where these staff were employed at the health facility, worked independently or as part of a team, and were recognised within that setting as skilled birth attendants. In some instances, we were not able to tell if health workers fit our definition of skilled birth attendants, in which case we contacted the authors of the study for more information and included these studies as long as the health workers were recognised as skilled birth attendants in that particular setting.

We also included studies that collected data from managers of health units and other providers who support skilled birth attendants as part of the team at a facility. We considered that these providers work closely with skilled birth attendants and have views and experiences of factors that influence the provision of care.

We excluded studies of student nurses' or midwives' attitudes and experiences, as we were concerned with factors affecting the delivery of care in routine settings rather than in teaching settings.

We also excluded studies that focused exclusively on traditional birth attendants, as these are outside the definition of skilled birth attendants (WHO 2008). In addition, we excluded studies that documented women's views and experiences of care, as this topic is covered in another qualitative evidence synthesis (Bohren 2014). Where eligible studies included both women's and health workers' views of care, we included these but only extracted data on health worker views.

Phenomenon of interest

We focused on the views, experiences, and behaviours of skilled birth attendants when providing intrapartum and postnatal care. Of particular interest were their views and experiences of factors that facilitate (or hinder) the provision of high-quality care. We use the term 'quality of care' to imply care that meets technical standards of care, is timely, evidence based, effective, safe, equitable, and provides a good experience of care (Dickson 2014; Donabedian 1978; Hulton 2000; Tunçalp 2015).

Although skilled birth attendants have an important role to play along the continuum of care for reproductive, maternal, and newborn health, in this synthesis we have focused on the intrapartum and postpartum period. Studies on antenatal care are part of a separate, complementary Cochrane qualitative evidence synthesis (Downe 2016). Maternity care may have been provided during a normal vaginal delivery or through basic or comprehensive emergency obstetric care when complications arose. As described above, basic emergency obstetric care is a package of care that provides the seven signal functions needed to provide lifesaving interventions to women and their newborn babies if complications arise. In addition to the seven signal functions, comprehensive emergency obstetric care includes surgery and blood transfusion. By 'postpartum care', we refer to the period immediately after birth and up to six weeks.

We did not include studies on abortion and postabortion care and antenatal care. These studies are likely to focus on factors that differ from those identified in studies that focus on intrapartum and postnatal care.

Search methods for identification of studies

Electronic searches

Our search strategies were based on a search strategy developed for two reviews: the Cochrane Review ‘Effectiveness of policies promoting facility-based deliveries in reducing maternal and infant morbidity and mortality in low and middle-income countries' (Dudley 2009), and a qualitative evidence synthesis by authors at the World Health Organization: ‘Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis’ (Bohren 2014). The search strategy specified key and free text terms related to the perinatal period such as ‘maternal health’, ‘delivery’, ‘obstetric care’ and terms related to ‘doctor’, ‘midwife’, ‘nurse’, or ‘physician’. We included a methodological filter for qualitative evidence syntheses and for low- and middle-income countries (EPOC 2017). See Appendix 1 for all strategies used.

We searched the following databases for eligible studies.

  • MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Daily, and MEDLINE (1946 to 21 November 2016), OvidSP
  • Embase Classic + Embase (1947 to 2016 week 47), OvidSP (searched up to 28 November 2016)
  • PsycINFO (1806 to November week 3 2016), OvidSP (searched up to 30 November 2016)
  • POPLINE, K4Health (1827 to 30 November 2016)
  • CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1980 to 30 November 2016), EBSCOhost
  • ProQuest Dissertations and Theses (1861 to 15 August 2013)
  • Web of Science Conference Proceedings Citation index, ISI Web of Knowledge (1990 to 1 December 2016)
  • World Health Organization Reproductive Health Library (searched up to 16 August 2013)
  • World Health Organization Global Health Library for WHO databases (Regional Indexes) (searched up to 1 December 2016)

Searching other resources

At the time of developing this synthesis, a related Cochrane intervention review was under development (Dudley 2009). We checked the bibliography of effectiveness studies that were included in this review in order to identify any qualitative studies that were linked to these studies. We only searched bibliographies of effectiveness studies published in the last five years (2008 to 2013). Checking recent studies as opposed to older studies was more likely to lead to identification of eligible studies, given the increase in the number of effectiveness studies that also include qualitative research in recent years (O'Cathain 2013).

Data collection and analysis

Selection of studies

We collated records obtained from the searches and removed duplicates. Two review authors then independently assessed titles and abstracts to identify potentially eligible studies. We retrieved the full-text articles of potentially eligible references, and two review authors independently assessed these to determine their eligibility. Any disagreements between review authors were resolved by discussion or by seeking the opinion of a third review author.

Data extraction and management

We developed a data extraction form to guide the collection of data. We extracted data on the following.

  • First author of the study, year of publication, country of study, study setting (urban/rural, level of care).
  • Cadre of skilled birth attendant (e.g. nurse, doctor, midwife, or other cadre identified as a skilled birth attendant)
  • Data describing the views, experiences, and behaviour of skilled birth attendants when providing intrapartum and postnatal care. In this qualitative evidence synthesis, we regarded the authors of the individual studies to be our 'informants' rather than the participants in these studies. The authors’ interpretations, presented for instance through themes and categories, therefore represent our data. While the authors’ interpretations were primarily collected from the results sections of each paper, author interpretations were sometimes also found in the discussion sections, and these were also extracted when relevant and when well-supported by data. We used the Graham 2001 framework on factors that influence skilled birth attendance ((1)1) to organise these data.

One review author extracted the data and another checked the data for any discrepancies. Disagreements were resolved by discussion or in consultation with a third review author.

Appraisal of the methodological limitations of included studies

Our inclusion criteria specified that to be included a study must have used qualitative methods for both data collection and data analysis. This criterion constitutes a basic quality threshold. We discarded studies that did not meet this standard. We used a modified version of the Critical Appraisal Skills Programme qualitative appraisal checklist to assess methodological limitations of each included study (Appendix 2) (Atkins 2008). One review author applied the criteria to each included study, and another review author checked the data for any errors or missing data. Any discrepancies were discussed and agreed upon by the two review authors. We did not exclude any studies on the basis of our assessment of methodological limitations but utilised this information to assess our confidence in the review findings. We were likely to have higher confidence in findings that are drawn from well-conducted studies, as these findings are more trustworthy.

Table 1 includes a summary of the assessment of methodological limitations of included studies.

Table 1.
Methodological limitations of included studies based on modified Critical Appraisal Skills Program (CASP) tool

Assessment of confidence in the review findings

We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to summarise our confidence in the evidence(Lewin 2016). CERQual assesses confidence in the evidence, based on the following four key components.

  1. Methodological limitations of included studies: the extent to which there are concerns about the design or conduct of the primary studies that contributed evidence to an individual review finding.
  2. Coherence of the review finding: an assessment of how clear and cogent the fit is between the data from the primary studies and a review finding that synthesises those data. By cogent, we mean well supported or compelling.
  3. Adequacy of the data contributing to a review finding: an overall determination of the degree of richness and quantity of data supporting a review finding.
  4. Relevance of the included studies to the review question: the extent to which the body of evidence from the primary studies supporting a review finding is applicable to the context (perspective or population, phenomenon of interest, setting) specified in the review question.

After assessing each of the four components, we made a judgement about the overall confidence in the evidence supporting the review finding. We judged confidence as high, moderate, low, or very low. All findings started as high confidence and were then graded down if there were important concerns regarding any of the CERQual components. The starting point of high confidence reflects a view that each review finding should be seen as a reasonable representation of the phenomenon of interest unless there are factors that would weaken this assumption.

Data synthesis

Given that relevant data were likely to be thin and descriptive and not theorised or conceptual (Noyes 2011), we based our data synthesis on a best fit framework approach (Carroll 2011; Carroll 2013), using a 'theory' on how skilled birth attendance influences health outcomes as our framework (see Appendix 3) (Noyes 2016)

'Summary of qualitative findings' table

Our key findings are presented in the Table 1. The table also provides our assessment of confidence in the evidence as well as an explanation of this assessment, based on the GRADE-CERQual approach (Lewin 2016).

Table thumbnail

Supplementing the Cochrane intervention review with synthesised qualitative findings

We explored how the findings from our synthesis related to, and helped to explain, the findings of the related Cochrane intervention review (Dudley 2009). To do this we utilised a matrix model similar to one used previously by Candy 2011 and Ames 2017. Our matrix explored whether the factors that were identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in the related intervention review. This review is in progress, and the data we used in this synthesis were obtained from the review authors.

To create the matrix we undertook the following steps: first, we went through each of the synthesis findings and identified factors identified by health workers as important for providing maternity care. Where we had presented factors as barriers or facilitators, we rephrased these as neutral descriptions of health services inputs.

Secondly, we created a table listing these factors. We then assessed whether these factors were addressed in the interventions evaluated in the studies included in Dudley 2009. As the Dudley review also included interventions targeting mothers and communities, we screened the included studies to identify those where the intervention targeted health workers and health systems. Out of 30 included studies in the Dudley review, 11 targeted health workers or health system issues and were therefore relevant for this synthesis.

Results

Results of the search

We retrieved and screened 17,594 unique titles and abstracts. We assessed 166 full-text articles for inclusion. Thirty-one of these studies fulfilled the inclusion criteria and were included in this synthesis (Figure 2).

Figure 2.
Study flow diagram.

Description of studies

Study respondents

Participants in the included studies were from a broad range of health worker cadre, including obstetricians, intern doctors, general practitioners, and various nurse midwife cadre (see Characteristics of included studies tables). Three studies only included midwives, and three included only nurse midwife (dual-trained) cadre. Other participants were clinical officers and medical assistants, paramedics or lady visitors with six months training in midwifery, nursing assistants or auxiliary nurses, physiotherapist, pharmacist, social welfare staff, surgical assistants, and anaesthetists. A few studies included heads of departments, health facility or program managers among participants.

Skilled birth attendant characteristics

Few studies described the core education of participants or if participants had received any additional training. Two studies indicated that the general practitioners had received additional training, that is eight months training in De Brouwere 2009 and one year of specialised training in maternity care in Molina 2011.

Of the four studies that included clinical officers and medical assistants (Bradley 2009; Graner 2010; Spangler 2012; VSO 2012), only Bradley 2009 reported that clinical officers and medical assistants had shorter pre-service training and lower qualifications compared to doctors, although they conducted most of the major emergency obstetric operations in the hospitals.

A few studies reported varying levels of information regarding the core/additional training of midwives. In Hassan-Bitar 2011, midwives had university degrees, while midwives in Fränngård 2006 had two to three years' midwifery training after secondary school. Other studies indicated that midwives had two to three years of nurse training and one year of midwifery following primary or secondary school education (Blum 2006; Ith 2012; Lugina 2001; Mathole 2006).

Two studies reported that nurses held university-level degrees (DeMaria 2012; Khalaf 2009). In DeMaria 2012, nurses had a four-year university-level training that included one year of midwifery training. In other studies, nurses had two to three years of nursing training, while a few had diploma-level or certificate-level training in midwifery (Mathole 2006; Mondiwa 2007).

Other studies that mentioned core/additional training of participants indicated that auxiliary nurse midwives had one-year training in nursing after high school (Foster 2006; Pettersson 2006); surgical assistants were auxiliary nurses trained in surgical assistance for three months (De Brouwere 2009); and lady visitors were paramedics with at least six months' midwifery training (Blum 2006).

Few studies provided information on the years of experience of the participants, which ranged from a few months to 33 years (see Characteristics of included studies tables).

Very few studies reported any information on participants' remuneration or salaries. For the few studies where this information was available, monthly salaries ranged from USD 170 to USD 700.

Setting

Sixteen of the studies were conducted in low-income countries: Bangladesh (Afsana 2001; Anwar 2009; Blum 2006; Pitchforth 2006), Benin (Fujita 2012), Ethiopia (Pitchforth 2010), Malawi (Bradley 2009; Mondiwa 2007; Thorsen 2012), Mozambique (Pettersson 2006), Tanzania (Lugina 2001; Penfold 2013; Spangler 2012), Uganda (Fränngård 2006; VSO 2012), and Zimbabwe (Mathole 2006).

Fifteen of the studies were conducted in middle-income countries: Brazil (de Carvalho 2012), Cambodia (Ith 2012), Colombia (Conde-Agudelo 2008; Molina 2011), Dominican Republic (Foster 2006), India (Barua 2011), Iran (Tabatabaie 2012), Jordan (Khalaf 2009), Mexico (DeMaria 2012), Palestine (Hassan-Bitar 2011), Senegal (De Brouwere 2009), South Africa (Lester 2003; Maputle 2010), and Vietnam (Graner 2010). One study was conducted in Argentina and Uruguay (Belizan 2007). Argentina is a middle-income country. Uruguay is now categorised as a high-income country, but was categorised as middle-income country at the time of the study.

Most studies did not indicate whether the studies were based in urban or rural settings. Eight studies indicated that participants were based in urban areas, seven studies indicated rural areas, while four studies indicated both urban and rural areas.

Level of care

Most of the studies were conducted among participants who worked at tertiary, secondary, or both levels of care, for example national referral hospitals or district hospitals (Anwar 2009; Barua 2011; Belizan 2007; Bradley 2009; Conde-Agudelo 2008; de Carvalho 2012; De Brouwere 2009; DeMaria 2012; Foster 2006; Fujita 2012; Hassan-Bitar 2011; Lugina 2001; Maputle 2010; Mondiwa 2007; Pettersson 2006; Pitchforth 2006; Pitchforth 2010; Thorsen 2012). A few studies included participants from primary levels of care, including health centres or dispensaries (Afsana 2001; Fränngård 2006; Graner 2010; Khalaf 2009; Mathole 2006; Molina 2011; Penfold 2013; Spangler 2012; VSO 2012). Participants in two studies provided care at home, but health providers were based at primary care units or private clinics (Blum 2006; Tabatabaie 2012). In one study, participants worked at a primary care unit located in a hospital (Lester 2003).

Focus of the included studies

The studies described health workers’ views and experiences of a wide range of issues when providing maternity care. These included the delivery of obstetric or perinatal care and/or priorities for improving maternity care (Afsana 2001; Anwar 2009; Graner 2010; Hassan-Bitar 2011; Maputle 2010; Molina 2011; Pettersson 2006; Pitchforth 2010; Spangler 2012); the provision of postpartum care (Khalaf 2009; Lugina 2001); the management of postpartum haemorrhage, (Foster 2006), or eclampsia (Barua 2011); and the provision of care to HIV-infected mothers (Mathole 2006; Mondiwa 2007).

Participants in some studies described their perceptions of human resource issues, including factors affecting retention, motivation, and performance (Bradley 2009; Ith 2012), professional life (Fränngård 2006), and training/scope of practice (DeMaria 2012); and conditions underlying unethical behaviour and service inadequacies (VSO 2012). One study described health workers' experiences of task shifting of emergency obstetric services (De Brouwere 2009).

Participants in some studies described their experiences of different models of care, including humanised care (Fujita 2012), home–based versus facility-based care (Blum 2006), and midwife-led obstetric unit in a hospital setting (Lester 2003). Some studies described health workers' perceptions of evidence-based care. In one study this was explored as part of the development of guidelines (Belizan 2007), while another study described the state of practice in relation to evidence-based guidelines (Conde-Agudelo 2008). Participants in one study described reasons for the continued use of harmful birth practices (de Carvalho 2012).

Other studies described health workers' perceptions of the functionality and availability of equipment, drugs, and supplies (Penfold 2013); barriers to facility births among private providers (Tabatabaie 2012); health workers' decision-making processes to enable women access to financial assistance (Pitchforth 2006); and facility-based factors that contribute to maternal deaths (Thorsen 2012).

Few studies provided any information on the range of specific tasks delivered by health workers. Where these were reported, the tasks varied widely by cadre and are reported in the Characteristics of included studies tables.

Methodological limitations of the included studies

Most of the included studies did not report in detail the sampling or data analysis methods used, or researcher reflexivity (see Table 1). In addition, some studies did not report ethical considerations.

Confidence in the review findings

Out of 51 findings, we graded two as high confidence, 16 as moderate confidence, and the remaining findings as low or very low confidence using the CERQual approach. (See Summary of findings for the main comparison). Our explanation for each CERQual assessment is shown in the Evidence Profiles (See Table 2 to Table 53).

Table 2.
CERQual evidence profile: finding 1

Synthesis findings

In this section we have reported the categories identified in the synthesis and the findings from the synthesis that belong in each category.

As described above, our analysis was guided by Graham's conceptual framework for skilled birth attendance at delivery (Graham 2001). We did not make major changes to the categories in Graham’s framework. However, while Graham grouped these categories as either "structure", "inputs", "outputs", or "outcomes", we chose not to group the categories in this way. This was because we experienced overlap of some categories (e.g. referral processes and mechanisms could be categorised as inputs or outputs), and because grouping the categories in this way downplayed the interrelationships between the categories. We instead chose to group the categories according to the level at which they operate; namely, the macro-environment or the meso- or microenvironment. We did not use two of Graham’s categories. We did not find any studies that reported data on the “financing” category. We did not consider the second category, “technical quality of care”, to be a separate category, as it is relevant to all other categories as an immediate outcome of the process of providing care. Figure 3 represents our adaptation of Graham's conceptual framework for skilled birth attendance at delivery (Graham 2001), and reflects the findings from this synthesis as well as the categories for which we had no data. Factors tied to the macro-, meso-, and microenvironment may influence available quality of care and health worker performance and motivation; maternal experiences of care; as well as health facility functionality or capability. Some of the maternal experiences of care included satisfaction and participation in decision-making. These factors are discussed further in the section below.

Figure 3.
Factors that influence the delivery of intrapartum and postpartum care by skilled birth attendants.

Factors tied to the meso- and microenvironment

We have used the terms 'meso-' and 'microenvironment' to refer to elements within the intermediate and immediate work environment that influenced the delivery of care by health workers. These elements are often interrelated, and separating them would be artificial.

Human resources

Staff shortages were widely reported as a problem (Anwar 2009; Barua 2011; Conde-Agudelo 2008; Fränngård 2006; Graner 2010; Maputle 2010; Spangler 2012), and led to increased workloads (Barua 2011; Hassan-Bitar 2011; Khalaf 2009; VSO 2012), which in turn sometimes compromised quality of care (moderate confidence; Table 2) (Barua 2011 ,De Brouwere 2009, Khalaf 2009 , Maputle 2010 , Mathole 2006). For instance, one study reported that heavy workloads limited the time that health workers had for conducting thorough assessments of women, and only women suspected to have complications were examined (Khalaf 2009). Heavy workloads could also lead midwives to omit some aspects of care, such as changing gloves or hand hygiene (Hassan-Bitar 2011,Ith 2012, Mathole 2006), potentially increasing the risk of cross-transmission of infection (Mondiwa 2007). Doctors in one study reported incomplete history-taking and examination of women as a result of heavy workloads (Hassan-Bitar 2011). Health workers’ ability to provide timely care (Thorsen 2012), and to manage routine care as well as emergency cases could also be jeopardised (Barua 2011, VSO 2012). When faced with heavy workloads, health workers were sometimes not able to provide privacy to all mothers but only to those who requested it (Khalaf 2009), or felt unable to provide personalised care (Fujita 2012). In addition, shortage of staff could lead health workers to exceed their scope of practice (Bradley 2009), and could influence a facility's ability to provide 24-hour care (Anwar 2009, Fränngård 2006). Women’s motivation to attend clinics could also be influenced by heavy workloads and busy clinics (Lugina 2001).

A lack of specialists or experienced staff or teams trained in obstetrics surgery and anaesthesia presented a particular challenge for the delivery of maternity care and supervision of junior staff (moderate confidence; Table 3). For instance, certain tasks, such as emergency obstetric care (Afsana 2001, Anwar 2009, De Brouwere 2009), were not delivered at all in some cases, or were transferred to health workers who were not properly qualified or trained to deliver them (Pitchforth 2010, VSO 2012). When health workers exceeded their scope of practice (informal task-shifting), this could again lead to increased workloads, fear of blame from their managers, as well as poor community relations whenever poor outcomes occurred (VSO 2012). In a number of studies, where experienced health workers were not available, health workers lacked supervision (Blum 2006, Bradley 2009,Fränngård 2006, Hassan-Bitar 2011,Ith 2012, Pitchforth 2010, Spangler 2012), and staff appraisal was not done (Bradley 2009). Where senior staff were available, supervision was reported as being inadequate, largely negative, and corrective in nature, focusing on mistakes and gaps in work rather than quality of work (Blum 2006, Bradley 2009,Fränngård 2006, Hassan-Bitar 2011, Penfold 2013,Spangler 2012). Reasons that were given for poor or lack of supervision included lack of staff and lack of time (Bradley 2009, Fränngård 2006, Hassan-Bitar 2011). Health workers who sometimes attended home deliveries reported that verbal reporting or indirect supervision after conducting home delivery was inadequate, and expressed a need for supervision while in the field so as to enhance their competence, foster confidence in working in difficult conditions, and remove potential blame from the risk during home deliveries (Blum 2006). In another study, a lack of supervision was believed to lead to a climate that fostered inappropriate behaviour (Spangler 2012).

Table 3.
CERQual evidence profile: finding 2

In settings where staff shortages were a major problem, informal task-shifting was possible because health workers had vague job descriptions that led them to perform tasks that were beyond their expertise or scope of practice (very low confidence; Table 4) (Bradley 2009). In one study, health workers were given jobs where the contract included a clause that allowed a manager to assign any job to an employee. As a result, some health workers exceeded their scope of practice (Bradley 2009).

Table 4.
CERQual evidence profile: finding 3

Staff shortages and work overload could jeopardise health workers’ ability to display support, empathy, and friendliness to women in labour (very low confidence; Table 5) (Conde-Agudelo 2008, Maputle 2010). For instance, some midwives had limited time to verify women's preferences when providing care to more than two women at the same time (Maputle 2010). Studies described midwives and nurses as feeling stretched to the limit (VSO 2012), resulting in burnout, reducing staff motivation, and leaving them feeling unable to meet the demands of work (Lugina 2001). Other studies described midwives that felt overwhelmed by expectations to provide postpartum care as well (Khalaf 2009); nurses referring to themselves as machines and describing their work as insane and a cause of stress (Hassan-Bitar 2011); and paramedics describing their work as hectic with long hours and constant responsibility (Afsana 2001).

Table 5.
CERQual evidence profile: finding 4

Staff shortages and increased workloads, combined with difficult living and work conditions, sometimes caused stress and frustration, affected health workers' family life, and led to concerns about personal safety (moderate confidence; Table 6). Staff shortages and increased workloads meant that health workers often worked alone and for long hours (Anwar 2009, Fränngård 2006, VSO 2012), with limited collegial support when emergencies arose, and health workers reported feeling frustrated and stressed (Graner 2010, VSO 2012). A manager in one study described how one midwife had worked alone for five months (VSO 2012). Heavy workloads also had implications for health workers' family life, as they sometimes had to stay at health centres away from husbands and family members (Fränngård 2006), or slept with their children in disused wards to allow them to attend to mothers late into the night (VSO 2012). Limited space and privacy for midwives' accommodation as well as long distances to husbands' work stations could result in relationship problems between spouses (Fränngård 2006). Family relations were further constrained by long work hours and busy schedules (Fränngård 2006, Graner 2010), lack of money for transport to meet partners, and poor communication between villages (Fränngård 2006). Some health workers reported fearing for their personal safety, for instance when working alone in the community (Blum 2006), and felt that they might be at increased risk of HIV transmission due to the pressure of work (Lester 2003).

Table 6.
CERQual evidence profile: finding 5

A wide range of interlinked reasons for staff shortages were suggested. These included limited funds to recruit health workers (Graner 2010 , VSO 2012); bureaucracy in the recruitment process (e.g. absence of committees responsible for recruitment at the district level) (VSO 2012); scarcity of health workers, especially in rural areas (VSO 2012); and other factors that deterred the retention of health workers once recruited (moderate confidence; Table 7) (see also section below on factors that influence recruitment, retention, motivation, or performance of health workers) (Anwar 2009). Other reasons for staff shortages were institutional arrangements, for instance when health facilities hired contract staff in order to reduce labour costs (Molina 2011), and inefficient deployment of available staff that created a perception of staff shortages (Pitchforth 2010). Facilities with staff shortages and high workloads were also seen as unattractive places to work, making it difficult for managers to transfer staff from well-served to underserved areas (VSO 2012), thus compounding the problem.

Table 7.
CERQual evidence profile: finding 6

Health workers considered their salaries and benefits to be insufficient for the work done (Fränngård 2006, Hassan-Bitar 2011), for the responsibility and personal risk (Graner 2010), and for the additional responsibilities assigned to them, for instance through informal task-shifting (De Brouwere 2009). In addition, salaries were regarded as insufficient for their personal needs, such as sending their children to school and paying for transport costs to visit their husbands (Fränngård 2006). Low salaries and incentives sometimes led to a lack of motivation and poor performance, absenteeism, and increased rates of dual practice (moderate confidence; Table 8) (Ith 2012, Molina 2011). To supplement their income, health workers sometimes took on other jobs apart from their job at the health facility (i.e. 'dual practice') (Belizan 2007, Ith 2012,Molina 2011), which could also lead to long working hours and fatigue (Molina 2011). Some health workers demanded informal payments for certain procedures, referred mothers on to their own private practice, or provided unnecessary services for a fee (Ith 2012). Dual practice also led to absenteeism (Anwar 2009, Ith 2012), which increased the staffing problem at the health facility, and because doctors spent little time in public hospitals, sometimes led to lack of agreement on clinical practice (Belizan 2007).

Table 8.
CERQual evidence profile: finding 7

Apart from salaries, the following factors were considered by health workers or their managers to facilitate recruitment, retention, motivation, or performance of health workers: good-quality accommodation for health workers (Fränngård 2006, VSO 2012); allowances for extra project-related work (Fränngård 2006); paid vacations for one month of the year (Fränngård 2006); improved access to and funding for continued education/in-service training (Bradley 2009 , De Brouwere 2009, Fränngård 2006 , VSO 2012); career progression (Bradley 2009 , De Brouwere 2009 ); non-biased evaluations(Hassan-Bitar 2011 ); performance-related rewards or promotions for those doing better, working longer, or taking on added responsibilities (Anwar 2009 ,Bradley 2009 , De Brouwere 2009, VSO 2012); and verbal recognition by supervisors and management (Ith 2012). Conversely, the following factors were reported as discouraging health workers from working in rural or remote health facilities: facilities that lacked good equipment and did not provide sufficient work experience needed to maintain clinical skills (De Brouwere 2009); poor staff accommodation (VSO 2012); lack of family amenities (Anwar 2009); limited opportunities for private practice (Anwar 2009); and lack of electricity, TV, or internet, coupled with poor roads and lack of transport (VSO 2012). In addition, interference in treatment decisions by local politicians, VSO 2012, and mismanagement by national level officers of posting and transfer to new workstations, were demotivating to health workers working in rural facilities (moderate confidence; Table 9) (Anwar 2009). Health workers therefore preferred to work in urban areas to provide their children access to better schools, and for better amenities such as communication, water, and electricity. An exception was reported in one study, where a midwife preferred to work in a rural area where her family lived (Fränngård 2006).

Table 9.
CERQual evidence profile: finding 8

Heath workers' working environments were sometimes worsened by poor management. For instance, health workers perceived managers as lacking in management capacity and skills, felt unsupported in their work (Bradley 2009 , Lester 2003), and complained that concerns about the workplace were sometimes left unheard and no solutions or feedback were given (moderate confidence; Table 10) ( Ith 2012, Lester 2003). Health workers complained about unfair duty rosters that led to heavy workloads (VSO 2012), and were also concerned about management bias when staff were selected for promotion (Bradley 2009). Some studies reported that supervisors and management rarely conducted recognition and positive performance appraisal (Ith 2012), leaving health workers with low motivation and low career advancement opportunities (Ith 2012).

Table 10.
CERQual evidence profile: finding 9

Funding mechanisms to provide financial assistance to mothers for out-of-pocket payments were sometimes in place, for instance through government social welfare funds or informal systems established by doctors in obstetric wards. However, bureaucratic processes sometimes denied mothers, especially those facing emergencies, access to the funds they needed to obtain care, and health workers' time was sometimes wasted as they helped mothers to access these funds (very low confidence, Table 11) (Pitchforth 2010).

Table 11.
CERQual evidence profile: finding 10

Health worker education and training

Inadequate pre-service and in-service training sometimes limited health workers' skills and their ability to provide care (high confidence; Table 12). Some studies described how health workers sometimes lacked training in communication and were thus limited in their ability to share information with mothers (Afsana 2001); and sometimes also lacked sufficient training to attend home births (Blum 2006), to manage complicated pregnancies or deliveries, such as HIV in pregnancy (Afsana 2001, Barua 2011, Mathole 2006), and to provide loading doses of magnesium sulphate when managing pre-eclampsia and eclampsia (Barua 2011). Some doctors lacked training in non-pharmacological pain management (Graner 2010), and were thus limited in their ability to manage pain, while others lacked the training to conduct Caesarean sections or repair extensive lacerations (DeMaria 2012). Specialist doctors were therefore necessary to manage complicated cases. Midwives' basic education did not always provide them with the practical skills to work independently in midwife-led obstetric units (Lester 2003), or to manage labour in positions other than the supine position (Afsana 2001). In contrast, one study showed how training and allowing midwives to practice assisting women in delivering in non-supine positions enabled them to get accustomed to this practice (Fujita 2012).

Table 12.
CERQual evidence profile: finding 11

Health worker competencies and opportunities for on-the-job training were sometimes limited by poor scheduling of education sessions, high cost, inequitable selection of participants, lack of ongoing training and follow-up, and shortage of instructors (moderate confidence; Table 13). For instance, midwives did not benefit from classes that were inappropriately scheduled, such as after working a night shift (Pettersson 2006), or when the content did not apply to midwives' daily reality. Midwives sometimes missed opportunities to upgrade from enrolled to registered midwifery when they lacked adequate funds (Fränngård 2006). Professional status and hierarchy sometimes also meant that the selection of candidates for training was not fair; junior midwives in one study often missed opportunities to upgrade their skills for this reason (Ith 2012). In the same study, training programs were often not combined with support supervision and feedback for improving performance among health workers (Ith 2012), and in another study had a shortage of instructors for upgrading courses in midwifery (Spangler 2012). In addition, the variation in quality of pre-service training resulted in varying levels of need for in-service training, and these needs were not always met, resulting in wide variation in proficiency among health workers (Pettersson 2006, Spangler 2012). In contrast, learning through practical application was reported as facilitating the acquisition of skills and confidence. The experience gained through, for example, internship, social service year, and working in the community was identified as important for building doctors' and midwives' practical experience and confidence in providing care (very low confidence; Table 14) (DeMaria 2012).

Table 13.
CERQual evidence profile: finding 12
Table 14.
CERQual evidence profile: finding 13

Health workers reported several barriers to implementing recommended practice. Firstly, health workers were sometimes unaware of current recommended effective practices (Conde-Agudelo 2008). Secondly, health workers' flexibility, attitudes, and beliefs about medical knowledge and skills sometimes influenced their receptivity to new practice knowledge (Belizan 2007). For example, some health workers were reported as being inflexible or unwilling to implement alternative positions of delivery even though these were preferred by women (Afsana 2001, Pettersson 2006); having attitudes that did not view medical knowledge as dynamic; or holding beliefs that no significant progress had been made and that clinical practice was similar to techniques learnt many years ago (low confidence; Table 15) (Belizan 2007). The lack of knowledge of current recommended practice was not always viewed as problematic by health workers since they had textbook knowledge on case management (Pitchforth 2010). In some cases, health workers were reported as being ignorant of the effectiveness of certain practices or sceptical about the use of evidence-based medicine in obstetrics (Conde-Agudelo 2008). Although conferences provided an opportunity for learning, these were considered by some health workers as repetitive, offering basic information, and leaving them unmotivated to seek new practice knowledge (Belizan 2007). In situations where health workers were unaware of recommended effective practice, the culture of practice was sometimes based on "norms and routines dictated by opinion leaders" (Conde-Agudelo 2008).

Table 15.
CERQual evidence profile: finding 14

Lack of time, skills, and infrastructure limited health workers' ability to seek knowledge and practice new clinical skills (low confidence; Table 16). For instance, chronic staff shortages meant less time available for health workers to seek information (Belizan 2007 ,Conde-Agudelo 2008). This was sometimes further compounded by a lack of information sources such as internet access, and poorly facilitated hospital libraries (Belizan 2007). In addition, lack of training and skills in networking, epidemiology, research appraisal, or critical thinking about clinical practice could limit health workers' awareness and receptivity to clinical practice changes (Belizan 2007, Conde-Agudelo 2008, Lugina 2001). In addition, professionals sometimes preferred old, familiar procedures when they lacked the skills to adopt new practices (Afsana 2001, Belizan 2007). In contrast, some doctors, such as those in university residence programmes, hesitated to use methods that did not require interventions, and preferred new technologies and skills and wanted to implement them. University residency programmes were therefore viewed as an opportunity for residents to practice new procedures, but were also a disadvantage when motivated residents did not follow recommendations about when these interventions, such as selective episiotomies, should be used (Belizan 2007). Other factors that health workers considered important for introducing and maintaining new clinical practices were management support, training in implementation of clinical guidelines, the extent to which the changes were promoted by doctors who were considered well informed by their peers, and how those changes were perceived by their peers (Belizan 2007).

Table 16.
CERQual evidence profile: finding 15

Standards and protocols

Where guidelines and protocols were lacking or were inconsistent, or where health workers were not aware or were uncertain of them, patient care and outcomes could be impacted and harm caused (low confidence; Table 17 ). The included studies showed examples of health workers lacking guidelines and protocols (de Carvalho 2012), for instance for the management of complications in pregnancy such as pre- and posteclampsia (Barua 2011, Mathole 2006); for uncommon diseases in pregnancy and childbirth (Mathole 2006); and for postpartum care (Lugina 2001). This could lead to a lack of direction (Lugina 2001), and inconsistent and harmful care (de Carvalho 2012). Different hospital units sometimes followed different guidelines/protocols for the same procedures (Barua 2011). Occasionally, guidelines were contradicted in the media (Mathole 2006), for instance health workers who were implementing World Health Organization (WHO) guidelines on breastfeeding for the prevention of mother-to-child HIV transmission were confused when the media gave contradictory messages. In another study, health workers were unaware of health standards of care for reproductive care (Khalaf 2009).

Table 17.
CERQual evidence profile: finding 16

Health workers did not always comply with protocols and guidelines, even when aware of them. For example, when providing postpartum care, health workers did not always monitor bleeding and uterine involution, or check vital signs every 15 minutes (low confidence; Table 18) (Molina 2011). Guidelines and protocols were not followed for a number of reasons. Some health workers felt that guidelines were insufficient without consensus from staff (Belizan 2007). Some studies described how health workers continued to practice ineffective procedures because they were considered routine (Conde-Agudelo 2008); due to lack of time (Lester 2003); because health workers lacked the autonomy not to follow what they knew to be inappropriate care (de Carvalho 2012); because the resources at the institution were not aligned with the protocols for postpartum care (Mathole 2006); or when it was unclear who was responsible for carrying out specific tasks, such as using a partograph (Pettersson 2006).

Table 18.
CERQual evidence profile: finding 17

Health worker compliance with protocols and guidelines was also guided by health workers' perceptions of the consequences of their practice. For example, health workers sometimes used unnecessary diagnostic tests and did not follow recommended practice when they feared malpractice suits. This fear could lead to practitioners retaining practices they believed were ‘safer’ (very low confidence; Table 19) (Belizan 2007 ). Some health workers did not use recommended interventions when delivering care due to concerns about negative outcomes for the baby or the mother. Examples included the use of magnesium sulphate administered with anaesthesia during Caesarean sections or when monitoring of serum magnesium sulphate levels was not possible (very low confidence; Table 20) (Barua 2011). Health workers were sometimes reluctant to admit their lack of skills in delivering care for fear of blame and criticism from managers (Barua 2011, Lugina 2001 , Pettersson 2006 ,Thorsen 2012), and were fearful of admitting ignorance about childbearing when they were expected to be knowledgeable (Lugina 2001). This fear of criticism could undermine health worker confidence and performance (low confidence; Table 21) (Pettersson 2006).

Table 19.
CERQual evidence profile: finding 18
Table 20.
CERQual evidence profile: finding 19
Table 21.
CERQual evidence profile: finding 20

Commodities and health services infrastructure

Insufficient stock or lack of drugs and supplies, or both, sometimes influenced the quality of care provided to mothers and their babies (moderate confidence; Table 22). For instance, studies reported insufficient stock and/or lack of drugs such as hydralazine, magnesium sulphate, oxytocin, misoprostol, or antiretrovirals (Anwar 2009 , de Carvalho 2012, Fränngård 2006 ,Ith 2012, Penfold 2013 , Pitchforth 2006 , Pitchforth 2010). Supplies such as gloves were likewise reported to be insufficient or out of stock in several studies (Fränngård 2006 , Graner 2010 , Lester 2003, Mathole 2006 , Pitchforth 2006 , Pitchforth 2010 , Spangler 2012 ,VSO 2012). Health workers in one study had to use less effective alternative drugs such as diazepam instead of magnesium sulphate when managing eclampsia (Pitchforth 2010). In other studies, a lack of supplies limited good hygiene practices and practice of aseptic techniques (Graner 2010, Mathole 2006), resulting in unsafe practices such as the reuse of disposable gloves, potentially increasing the risk of HIV infection (Graner 2010, Lester 2003), leading to poor outcomes and increasing the length of stay in health facilities (Bradley 2009). The lack of supplies and drugs was attributed in part to the long time it took to replenish these and the wastage that occurred when health facilities received supplies that they had not requested (Penfold 2013). As a result of this lack of drugs or supplies, mothers or their carers had to purchase their own (Foster 2006, Fränngård 2006, VSO 2012), which sometimes led to wasted time in procuring the drug and the creation of informal markets and corruption at health facilities (low confidence; Table 23) (Barua 2011; Spangler 2012).

Table 22.
CERQual evidence profile: finding 21
Table 23.
CERQual evidence profile: finding 22

Lack of equipment also limited health workers' ability to provide quality care to mothers and their babies (high confidence; Table 24). For instance, studies reported a lack of stethoscopes and blood pressure machines (Pettersson 2006), cord clamps and delivery kits (Fränngård 2006, VSO 2012), complete vacuum evacuation sets (Pitchforth 2010), instruments to repair lacerations (Graner 2010), Ambu bags (and oxygen) for neonatal resuscitation (Pettersson 2006), sterilising equipment such as autoclaves (Anwar 2009, Graner 2010), and laboratory and diagnostic tools (Barua 2011). Some mothers and their babies received poor quality care as a result of this lack of equipment. In some studies, obstetricians managed eclamptic mothers without adequate investigative support (Barua 2011); neonates were not resuscitated due to lack of Ambu bags or oxygen (Pettersson 2006); monitoring of mothers and their babies was insufficient due to lack of equipment (Pettersson 2006); and lacerations were left unrepaired due to lack of instruments (Graner 2010).

Table 24.
CERQual evidence profile: finding 23

Lack of blood or poor infrastructure to manage blood transfusion limited health workers' ability to provide appropriate care (moderate confidence; Table 25) (Afsana 2001 ,Anwar 2009 , Ith 2012). Lack of blood sometimes led to unnecessary referral (Afsana 2001), and in one study, resulted in death (Ith 2012). Where blood was available, some rural health facilities lacked the laboratory personnel or facilities for grouping and cross-matching that are necessary for blood transfusion (Anwar 2009). In that study, blood was managed at the district-level health facilities, and mothers needed to attend private diagnostic centers for grouping and cross-matching.

Table 25.
CERQual evidence profile: finding 24

Lack of equipment, supplies, or drugs sometimes wasted health workers' time, increased their workloads and risk of infection, and led to low morale (moderate confidence; Table 26). For instance, a lack of supplies could increase workloads when health workers had to source items from other facilities (Penfold 2013), or could increase the workloads of health workers at receiving facilities whenever unnecessary referrals occurred. Health workers also wasted time trying to improvise in order to provide care (Bradley 2009, Lester 2003,VSO 2012), in the process sometimes using unrecommended practices that increased their fear as well as the risk of cross-transmission of infection (Bradley 2009, Graner 2010, Lester 2003, Penfold 2013). The lack of supplies could lead to feelings of frustration and hopelessness among health workers and could wear them out (Belizan 2007; Foster 2006). In one study, the lack of antiretroviral therapy in particular left health workers feeling helpless when they watched mothers and their infants die (Mathole 2006).

Table 26.
CERQual evidence profile: finding 25

Poor, incomplete, and non-systematised patient information could lead to delayed or incorrect management of high-risk mothers (Pettersson 2006), or interfere with continuity of care (low confidence; Table 27) (Molina 2011). For instance, when maternity records were missing, incomplete, or non-systematised, high-risk mothers did not always receive timely treatment (Pettersson 2006), or mothers might not be followed as they move from one facility to another (Molina 2011).

Table 27.
CERQual evidence profile: finding 26

Apart from essential equipment, drugs, and supplies, a lack of or unreliable supply of electricity (Anwar 2009 , Pitchforth 2010 , Spangler 2012 , VSO 2012), including a lack of fuel to run generators, and lack of water (Spangler 2012 ), influenced health workers' ability to provide quality care (moderate confidence; Table 28). In some studies, electricity was described as non-existent, unreliable, or irregular (Anwar 2009, Spangler 2012, VSO 2012), and this interrupted the use of equipment such as ultrasound scans or hospital communication systems, interfered with the warming of babies, and placed health workers at increased risk of infection while working in the dark. In one study, health workers reported delaying repairs of episiotomies to daytime. One study reported that lower-level health centres had no indoor running water and used water from outdoor wells (Spangler 2012).

Table 28.
CERQual evidence profile: finding 27

Lack of space and amenities as well as poor physical layout and organisation of wards also limited the provision of quality care (moderate confidence; Table 29) (Fränngård 2006 , Khalaf 2009 ,Lester 2003,Molina 2011 , Pettersson 2006 ,Pitchforth 2010). For instance, lack of space meant that some women had to deliver on the floor in corridors, and it was not possible to have companions in labour wards (Belizan 2007, Pitchforth 2010). Lack of space could also compromise women's privacy and dignity during labour (Khalaf 2009, Pitchforth 2010). The physical layout and separation of wards was sometimes counteractive to teamwork among health workers and interfered with the observation of mothers and their babies (Pettersson 2006). The lack of space and poor layout of wards could be further worsened by the large demand for delivery care (Molina 2011), in part due to unnecessary referrals from lower-level facilities (Pettersson 2006), or policy changes that did not consider staffing and resources (Lester 2003). The large demand for delivery care could lead to overcrowding in health facilities. Together, overcrowding and limited physical infrastructure sometimes led to poor hand hygiene Ith 2012), a poor, stressful working environment for health workers (Fränngård 2006, Lester 2003), and incorrect diagnoses and medical errors (Khalaf 2009). A shortage of beds and overcrowding sometimes resulted in an increased risk of cross-infection (Pettersson 2006), for instance when mothers and their babies had to share beds or use the floor. Overcrowding and limited infrastructure could also interfere with personalised care (Khalaf 2009), and limit the mobility of women in labour (Conde-Agudelo 2008, DeMaria 2012). Health workers perceived hierarchical management between local health facility management teams and the national Ministry of Health; poor communication between these levels; and a lack of funds as barriers to the reorganisation of maternal wards (Pettersson 2006). Lack of funds and material resources sometimes prevented health facility managers from regularly maintaining physical infrastructure (low confidence; Table 30) (Ith 2012, Pitchforth 2010). Managers in one study queried the continued expansion of infrastructure when existing health facilities were not fully functional to provide good-quality care (VSO 2012).

Table 29.
CERQual evidence profile: finding 28
Table 30.
CERQual evidence profile: finding 29

Health facilities varied in the availability, functionality, and quality of interventions assigned as signal functions for obstetric care (very low confidence; Table 31) (Afsana 2001, Spangler 2012). In one study, most of these functions, including provision of parenteral antibiotics, anticonvulsants, or neonatal resuscitation, were not available at lower-level facilities (Spangler 2012). In the same study, some of these functions appeared to be available at higher-level facilities, but functionality varied, for instance due to drug stock-outs or unqualified providers of care.

Table 31.
CERQual evidence profile: finding 30

One included study reported health worker perceptions on providing maternity care in health facilities compared to home (Blum 2006). These health workers felt it was easier to deliver care in facilities than at home (very low confidence; Table 32). Some of the positive aspects about delivering care at the health facility were that they were able to do other work while monitoring labour and provide care for several mothers, and that work schedules were more regular and care was available 24 hours a day. Furthermore, at facilities other skilled providers were available to assist when needed and some procedures, such as episiotomies, were easier to perform. In addition, health facilities could provide a secure, controlled, hygienic work environment, where electricity, equipment, and medications were always available.

Table 32.
CERQual evidence profile: finding 31

Referral mechanisms

When primary healthcare workers lacked the knowledge and skills to determine the need for referral or were unable to provide emergency care, poor-quality care could result, such as mothers not being referred or inadequate care being offered at lower-level facilities (very low confidence; Table 33) (Molina 2011).

Table 33.
CERQual evidence profile: finding 32

When health workers referred mothers and their babies to higher levels of care, several factors were reported by health workers to interfere with the referral process. For instance, lack of trust and professional rivalries between midwives, doctors, and obstetrician gynaecologists could delay referral of mothers and their babies (Tabatabaie 2012). Midwives sometimes felt blamed by doctors when complications arose and hesitated to seek support from the medical teams at the receiving facilities (Tabatabaie 2012). Some midwives did not travel with mothers to the referring facility for fear of blame for any negative occurrences during the referral process (although this was also attributed to the scarcity of other health workers at the lower level) (low confidence; Table 34) (Ith 2012).

Table 34.
CERQual evidence profile: finding 33

Respondents also felt that mothers' perceptions of the health system could also make them reluctant to accept referral (moderate confidence; Table 35). For instance, mothers were reported as being sceptical about the cost of care (Blum 2006, Graner 2010, Tabatabaie 2012); concerned about poor management and care at the next-level facility, the procedures used, and the high levels of Caesarean sections; and fearful of complications (Barua 2011, Blum 2006, Graner 2010, Tabatabaie 2012). Mothers may also have already travelled far to reach the facility they perceived as a good one (Lester 2003), or feared unfamiliar urbanised settings (Blum 2006). As a result of mothers' reluctance to accept referral, health workers could spend a lot of time convincing reluctant mothers or their families (Blum 2006), or could feel pressured to conduct high-risk deliveries or unnecessary procedures such as ultrasound scans to assess foetal condition (Graner 2010). In one study, health workers did ultrasound scans at seven to nine months to rule out deformity of the foetus and avoid blame by the mother and her family.

Table 35.
CERQual evidence profile: finding 34

The presence of trust between mothers and midwives could influence mothers' willingness to be referred. Referral could be delayed when facilities lacked trusted midwives or other primary care workers to convince mothers of the need for referral ( very low confidence; Table 36) (Tabatabaie 2012). Where midwives or other primary care workers were available, they sometimes lacked the knowledge and communication skills to manage women's reluctance (Tabatabaie 2012).

Table 36.
CERQual evidence profile: finding 35

Lack of transport was reported to hinder referral of women and their babies to higher levels of care (Graner 2010), for instance when health facilities lacked ambulances (Molina 2011), or health facility budgets were insufficient to purchase fuel for vehicles (moderate confidence; Table 37) (Fränngård 2006 , VSO 2012). Lack of fuel for vehicles when the need for referral arose was frustrating to nurses and midwives and left them feeling helpless when mothers' and babies' lives were at risk (very low confidence; Table 38) (VSO 2012). When health facilities lacked fuel for vehicles, mothers and their families were sometimes asked to pay their own transport costs, which many families could not afford (low confidence; Table 39) (Fränngård 2006 , VSO 2012).

Table 37.
CERQual evidence profile: finding 36
Table 38.
CERQual evidence profile: finding 37
Table 39.
CERQual evidence profile: finding 38

Several situations could lead health workers to refer mothers and shift responsibility to higher levels of care, including when they lacked the skills or confidence to provide care or when they worked in isolation (Blum 2006); when they were concerned about the facility's reputation when poor patient outcomes arose (Barua 2011); or when they lacked supplies, drugs, or equipment to provide care (low confidence; Table 40) (Ith 2012, Penfold 2013). When secondary-level care was not available, mothers were sometimes referred to tertiary levels of care, which could result in congestion at the receiving facilities (very low confidence; Table 41) (Molina 2011). Unnecessary referrals resulted in increased workloads at higher levels of care (Penfold 2013).

Table 40.
CERQual evidence profile: finding 39
Table 41.
CERQual evidence profile: finding 40

Administrative processes, including approval of mothers' insurance coverage, and poor communication, could influence the efficient referral of mothers and their babies to receiving units (very low confidence; Table 42) (Molina 2011). Lack of feedback from receiving to referring health facilities could influence midwives' practice and patient outcomes. Midwives perceived this information as useful for their practice and patient outcomes (very low confidence; Table 43) (Fränngård 2006).

Table 42.
CERQual evidence profile: finding 41
Table 43.
CERQual evidence profile: finding 42

Interaction between mothers, community members, and health workers

Poor attitudes and unethical behaviour among health workers could influence the quality of care. Examples of this included when health workers were harsh, rude, or impatient with mothers (Afsana 2001, Hassan-Bitar 2011 , VSO 2012); when they displayed poor cultural sensitivity, for instance by not maintaining women's privacy (Afsana 2001,Spangler 2012); or when they were absent from their duty stations or involved in the illegal sale of drugs and supplies or expected "back door" payments for services (low confidence; Table 44) (Spangler 2012). Study participants suggested several reasons for these behaviours, including wrong intrinsic reasons for joining the nursing profession (VSO 2012), long, solitary working hours, physical exhaustion, and the perpetual responsibility of looking after mothers (Hassan-Bitar 2011, VSO 2012). These could lead midwives to show tough/harsh behaviour and lack of patience with mothers (Hassan-Bitar 2011, VSO 2012), or could lead them to be absent when expected to provide 24-hour care in health centres (Spangler 2012, VSO 2012). System-wide behavioural and attitudinal problems were thought to explain why health workers displayed underdeveloped cultural sensitivity and weak interpersonal communication (Spangler 2012).

Table 44.
CERQual evidence profile: finding 43

Mothers' participation in decision-making during labour could be limited by health worker attitudes and authoritarian behaviour. Health workers sometimes conducted procedures without asking mothers for their opinion (de Carvalho 2012), or did not seek feedback from mothers about practices or outcomes (Belizan 2007), but expected mothers to co-operate (DeMaria 2012). One reason for this lack of participation appeared to be health workers’ attitudes and assumptions about the mother's capabilities, preferences, and role during delivery of her baby (low confidence; Table 45). Health workers in some studies believed that certain decisions about care did not concern the mother (de Carvalho 2012), and did not want to be restrained by the mother's or her companion's preferences (Belizan 2007, Conde-Agudelo 2008). These health workers believed that the woman in labour was in no condition to give her opinion about what was best for her and the baby (de Carvalho 2012), or that her low socioeconomic status, lack of information, or family problems made her unwilling or unable to provide input (Belizan 2007, Maputle 2010), and that women were comfortable leaving decision-making to health workers (Maputle 2010). Some midwives found this lack of participation stressful, for example when mothers did not voice their opinions about their care (Maputle 2010). Some midwives indicated that they promoted, supported, and respected mothers' preferences as long as they were not harmful to mother and baby (Maputle 2010).

Table 45.
CERQual evidence profile: finding 44

Some health workers did not value communication with mothers, communicated poorly, or said they had problems with communication. Poor communication and interaction could threaten the trust between health workers and mothers (very low confidence; Table 46). Some studies reported that health workers considered communication with mothers as a waste of time (Hassan-Bitar 2011), and described situations where there was insufficient communication between staff and families (de Carvalho 2012,Hassan-Bitar 2011), or where skilled birth attendants were abrasive and demeaning in their interaction with women and showed no concern for women's families, for instance women were reprimanded when they arrived late in labour, refused to expose their genitalia, or had too many children (Blum 2006). Language barriers could interfere with effective communication between mothers and health workers (Maputle 2010, DeMaria 2012). As a result, mothers sometimes appeared not to listen to health workers while health workers mechanically worked through the process of providing care (Maputle 2010) . Some health workers acknowledged the need to respect and involve men, women's families, and the community in maternal health, for example in understanding cultural beliefs related to postpartum care (Lugina 2001).

Table 46.
CERQual evidence profile: finding 45

In contrast, other health workers described how they valued the appreciation, respect, trust, and praise they received from mothers (Bradley 2009 , VSO 2012), making friends among mothers, or working with the community (Bradley 2009 , Fränngård 2006). Midwives in particular were delighted when a baby was given their name and to see the baby grow (low confidence; Table 47) (VSO 2012).

Table 47.
CERQual evidence profile: finding 46

Some studies reported how a mismatch between peoples' expectations of health workers and what health workers were actually able to deliver or thought was appropriate could lead to antagonism. For instance, health workers that delivered home-based care could experience social pressure from families and communities, such as to give injections to speed up delivery as opposed to waiting for labour to progress normally (Blum 2006). Families might not understand why a health worker had to refer the mother to hospital, or the community might prefer a different delivery practice from what the health worker could provide (Blum 2006). Health workers providing maternity care at health facilities were sometimes treated harshly by people from the community when there was a lack of supplies and materials (Hassan-Bitar 2011). In addition, misconceptions that midwives were not working when they took a break from their work (VSO 2012), or that health workers sold drugs threatened the trust between health workers and the community (low confidence; Table 48) (Blum 2006).

Table 48.
CERQual evidence profile: finding 47

In one study, midwife-led shared care was perceived to improve the interaction between mothers, families, and health workers, and could improve health workers' self esteem and lead to a change in hospital culture with respect to service provision (very low confidence; Table 49) (Fujita 2012). In this study, midwife-led shared care increased communication between midwives, women, and their families; enabled the presence and participation of family members; and increased satisfaction in the care provided. As a result, the need for medication during delivery was minimised, which in turn reduced the financial burden experienced by families. The supportive environment for mothers, the good interaction between mothers and health workers, as well as recognition of professional expertise among midwives increased self esteem. Midwife-led shared care enabled other hospital staff to reflect on their own routine activities and manner of communication with families and clients, leading to a change in hospital culture with respect to service provision (Fujita 2012).

Table 49.
CERQual evidence profile: finding 48

Interaction between health workers

Disrespectful communication, lack of trust, poor teamwork and co-ordination, and inadequate opportunities to discuss clinical practice could lead to poor interprofessional relations. Tensions could also arise when health workers did not recognise each others' capabilities or when they acted in a way that reinforced clinical hierarchies (low confidence; Table 50). Some studies reported instances of disrespectful interprofessional communication (Hassan-Bitar 2011, Pettersson 2006). For instance, when doctors shouted at midwives, midwives could feel humiliated and lack confidence, and lead them to believe that they were not trusted, or that their opinions were not welcomed and could delay the delivery of care (Pettersson 2006). Midwives with lower levels of training reported feeling marginalised and less motivated to provide care because midwives with higher levels of training and doctors used their qualifications, status, and roles to dominate clinical practice (Ith 2012). Tensions were also reported between doctors and clinical officers due to differences in salary, benefits, workload, and status (Bradley 2009). Some studies reported a lack of understanding of competencies and alternative models of care. For instance, doctors did not always have a clear understanding of the midwifery profession, which could result in conflict or professional jealousy (DeMaria 2012). Teamwork could also be threatened when doctors worked in a small number of shifts, and had minimal contact with other professionals (Belizan 2007), or when staff meetings were infrequent (Hassan-Bitar 2011). This sometimes resulted in lack of co-ordination and varying decision-making procedures and standards of care (Belizan 2007, Hassan-Bitar 2011).

Table 50.
CERQual evidence profile: finding 49

Nurses and midwives valued and were motivated by a good team dynamic where health workers provided feedback, supported, and co-operated to ensure all shifts were covered (low confidence; Table 51) (Bradley 2009 , Fränngård 2006). For instance, midwives in one study valued good interprofessional collaboration, which made them feel accepted as part of the professional team and provided an opportunity to improve their competence through on-the-spot education provided by obstetricians (Pettersson 2006). In another study, midwives worked together in a team led by midwives, which increased their ability to share experiences and new practices and their decision-making responsibility, improved their self esteem, provided quality assurance, and improved the quality of care provided (Lester 2003). In one study, researchers observed that nurses had a strong teamwork ethic and functioned well together to complete work (Foster 2006).

Table 51.
CERQual evidence profile: finding 50

Factors tied to the microenvironment

We have used the term 'microenvironment' to describe the broad structural context within which health workers and those who support them deliver maternity care. Some of the included studies reported data on health workers' views and perceptions of professional associations and sociocultural factors. None of the studies reported data on health worker views and perceptions of legislation, regulation, financing, or broader governance or policy issues.

Professional associations

Health workers had conflicting views on the role of professional councils (very low confidence; Table 52). For instance, some perceived professional councils as advocates for their members, while others perceived them as a regulatory bodies with punitive functions (VSO 2012).

Table 52.
CERQual evidence profile: finding 51

Social/cultural environment

Sociocultural barriers sometimes hindered mothers from receiving care in hospitals (low confidence; Table 53). For instance, some women preferred not to be examined by male health providers (Khalaf 2009), or preferred a particular position in which to deliver for cultural reasons, but preference for that birthing position may not have been accepted by the health worker (Blum 2006). In other instances, mothers did not divulge information that was needed for their care for religious reasons (Thorsen 2012).

Table 53.
CERQual evidence profile: finding 52

On the other hand, professional midwives and obstetric nurses perceived themselves as empathetic and having a gender advantage for delivering maternity care. They therefore considered themselves better placed than male providers to attend low-risk births (DeMaria 2012).

Integrating the findings from this synthesis with the findings of relevant Cochrane intervention reviews

Our synthesis identified a number of factors that were considered important by health workers for the delivery of intrapartum and postpartum care. We classified several of these factors as health service inputs, including health worker training; available human resources; access to equipment, drugs, supplies, blood, electricity, water, and transport for referral; physical infrastructure, in particular available space and layout of wards; and interprofessional communication and teamwork. In Table 54 we have presented our matrix model mapping these factors against the interventions in studies included in Dudley 2009. At the time of publication of this synthesis, the Dudley review was not yet completed, so this synthesis includes a matrix table based on the studies that have been included to date. The findings in the matrix may change when the full effectiveness review findings are available. We will consider the data on effects of the intervention when the related review is completed.

Table 54.
Table integrating key findings from this synthesis with interventions in selected studies included in Dudley 2009 review

Whereas the studies included in this synthesis were conducted among health workers based at health facilities, studies in the Dudley review were largely community-based studies that targeted pregnant women and their families. The studies in the intervention review focused on a different phase of skilled birth attendance, that is demand generation, whereas studies in our synthesis focused on the supply side. Therefore, when linking the findings from this synthesis to the Dudley review, we considered only 11 intervention studies that included health system strengthening components as part of the intervention. We considered these 11 studies comparable to the studies included in this synthesis given the focus on supply-side factors for providing maternity care.

Overall, very few of the factors identified as important in our synthesis appear to have been specifically addressed in the 11 studies in the Dudley review. Most of the studies addressed between one and four of these factors. Eight of these studies included health worker training as part of the intervention. This training was focused largely on the technical skills of the health workers, apart from one study that provided training in project management and another on appreciative inquiry. None of the studies included training on communication for health workers. Additional factors that were included by at least one intervention study were the recruitment of additional health workers, the use of task-shifting or pay for performance approaches, improvement in supplies and provision of equipment, improvements in physical infrastructure such as renovation, and the establishment of emergency obstetric care (EmOC) centres and the upgrading of units to provide 24-hour care.

Only one of the intervention studies included a broad range of health system changes (Pardeshi 2011). This study assessed the trend in facility deliveries following a seven-year programme to improve access and strengthen health services in rural India. In this study, delivery rooms were constructed, repairs and renovations at the primary healthcare level were done, a blood storage facility was provided at first referral levels, inverters and solar heaters (electricity backup) were made available at the primary care level, vacant positions were filled, funds were provided for referral transport, and equipment, including oxygen cylinders and baby warmers, was provided.

It is perhaps unsurprising that most interventions included training, given that training courses may be easier to organise and demand less time and resources than other inputs such as infrastructural changes. However, we suggest that future intervention studies also take into account other factors identified by our synthesis. The presence or absence of these factors could also serve as the basis for subgroup analyses in systematic reviews of the effectiveness of these types of interventions.

Discussion

Summary of main results

This synthesis included evidence from 31 studies from low- and middle-income countries on factors that influence the provision of intrapartum and postnatal care among skilled birth attendants and those who support them. Key findings for which we had high or moderate confidence focused on education, human resources, health services infrastructure, referral mechanisms, and interaction between health workers.

The synthesis shows that inadequate pre-service and in-service training limited health workers' skills and their ability to provide quality care (high confidence). While on-the-job training provided opportunities for improving these skills, opportunities were limited by the cost, availability, and varying quality of training (moderate confidence).

The problem of staff shortages was widely reported and could increase health workers' workloads and compromise their ability to provide care. A lack of specialists or experienced staff could lead to problems with supervision and situations where emergency obstetric care was not provided or was provided by less qualified staff. These issues, coupled with poor living and working conditions, caused health workers stress and frustration, and affected their family life. The synthesis highlights a number of possible causes for staff shortages, including inadequate hiring and deployment of staff, limited funding, poor management and bureaucracy, poor salaries, and other factors that influence retention of health workers. In addition, health workers perceived managers as lacking in management capacity and skills and sometimes felt unsupported when concerns about the workplace were left unheard. We had moderate confidence in these findings.

Lack of equipment, insufficient supply, and/or lack of drugs; lack of blood or the limited infrastructure to manage blood transfusion; lack of or unreliable supply of electricity, including a lack of fuel to run generators; and lack of water limited health workers' ability to provide quality care to mothers and their babies. Lack of equipment, supplies, or drugs resulted in low morale among health workers, wasted health workers' time, and increased their workload and risk of infection. The lack of space and amenities as well as poor physical layout and organisation of maternity wards also limited the provision of quality care. We had high confidence in the finding that lack of equipment limits health workers ability to deliver care, and moderate confidence in all other findings.

Respondents felt that maternal perceptions of the health system sometimes made them reluctant to accept referral. Lack of transport including lack of ambulances or funds to fuel vehicles for transport to higher levels of care hindered referral. We had moderate confidence in these findings.

Health worker interprofessional relations were sometimes limited by disrespectful communication, lack of trust, poor teamwork and co-ordination, and inadequate opportunities to discuss clinical practice. Tensions arose when health providers did not recognise each others' capabilities, and when they acted in ways that reinforced clinical hierarchy. We had moderate confidence in these findings.

Other factors that we considered to be important, but for which we had low or very low confidence in the findings, are as follows:

  • how staff shortages and heavy workload interfered with health workers' interaction with mothers;
  • lack of protocols/standards of practice or guidelines, or where they were inconsistent or health workers were unaware of them could influence patient care and cause harm;
  • lack of time, limited infrastructure and skills in research appraisal influenced health workers' ability to seek knowledge on current recommended practice;
  • lack of health worker knowledge and skills to determine the need for referral;
  • lack of trust between health workers and mothers and lack of interprofessional trust between health workers at referring and receiving health facilities may delay referral of mothers to higher levels of care. Good interprofessional collaboration and teamwork, e.g. through midwife-led shared care, influenced health worker motivation, decision-making ability, quality of care, and hospital culture with respect to service provision.

Overall completeness and applicability of evidence

This synthesis found that poor quality of pre-service training and other barriers to on-the-job training were among the reasons for variations in health workers' competence and skills. This finding implies that health workers who have had poor-quality pre-service training may not improve their skills during in-service training. Furthermore, a lack of supervision and follow-up of trainees means that the benefits of training may not be fully obtained. Although on-the-job training courses are often available in many settings, managers need to consider how to fully maximise benefits from this training, for instance by ensuring that it reflects the needs of health workers and by developing a coherent strategy to support and follow up trainees. Some of the training needs identified from this synthesis included: management of complicated pregnancies or deliveries, management of home births, alternative delivery positions, epidemiology, research appraisal, or critical thinking about clinical practice.

This synthesis also illustrates how health workers' abilities to provide care to mothers and their babies were limited by the poor equipment, drugs, supplies, and physical infrastructure available at the health facilities. Our findings reflect system-wide challenges, and how these deficiencies influence the technical quality of care provided by health workers; health worker morale and their sense of personal safety; and show the extra financial costs to mothers and their families. In addition, our synthesis reflects how these systemic challenges influence the implementation of patient-centred, dignified, 24-hour care, and how they can lead to the creation of informal markets at health facilities and other health system challenges such as corruption, absenteeism, and dual practice. The importance of an enabling environment in order for health workers to deliver good-quality care has been emphasised previously (Maclean 2003). Although the United Nations' fifth Millennium Development Goal (MDG) era promoted access to health facilities and skilled birth attendance, basic infrastructure and logistics management at health facilities remain a challenge in several settings (Adair-Rohani 2013).

Our findings suggest that the shortage of personnel and resulting workload led health workers to increase their scope of practice or task-shifting to another cadre. This may have been made possible in part through vague job descriptions that allowed managers to assign any job to a health worker. Whereas formal task-shifting is seen as a remedy for human resource shortages, our findings suggest that informal task-shifting may have implications for quality of care, for example when specialists are lacking and emergency maternity care is provided by poorly trained or unqualified health workers. In addition, our findings indicate that task-shifting may further increase workload for a workforce that already feels underpaid for work done. The review by Colvin 2013 similarly identified inadequate training, unclear job descriptions, and health worker concerns about increased workload as among the challenges to implementing task-shifting. These factors are important for managers to consider when implementing task-shifting.

Several of our findings suggested the importance of building trust between health workers, mothers, and communities, as well as between health worker teams. In a study by Sheppard 2004, health worker communication skills and women’s perceptions of institutional barriers are identified as factors that may influence the building of trust between patients and health workers. With regard to trust between health workers, a review by Zwarenstein 2009 suggests that incorporating routines such as interprofessional meetings and ward rounds into clinical practice supports health worker interaction and can improve healthcare processes and outcomes.

At the start of this synthesis process, we did not intend to document health worker perceptions regarding respectful care of women during childbirth. However, there was increasing interest in this topic among the global health community during the development of this synthesis (Bohren 2015). While it is neither ethical nor acceptable for health workers to disrespect women, our findings may at least partly explain why this phenomenon occurs. Our findings indicate that poor training and harsh working conditions, a lack of supplies, long, solitary hours of work, and disrespect from colleagues may jeopardise health workers’ abilities to display support, empathy, and friendliness to women in labour.

Stress, physical exhaustion, and the emotional demands of the job may leave health workers emotionally worn out, and therefore incapable of providing social support to mothers under their care. Other studies have described a similar phenomenon, where health workers distance themselves from their patients, for example by not emotionally connecting with patients under their care as a coping strategy for stressful work conditions (Van Der Walt 1999), or where the health system does not provide health workers with support for such emotional care (Petersen 2002). We also hypothesise that when working under difficult conditions, health workers may place good social interaction and care lower in the hierarchy of quality of care than other medical interventions. In addition, most health workers that provide maternity care are female and may have experienced several forms of disempowerment in the workplace, and are therefore not able to advocate within the health system for better treatment of the women they care for. As a result, poor health worker-mother interaction may be normalised as part of the 'culture' of the health system in some settings, and both health workers and mothers may come to accept this as the norm (Bohren 2017, Rominski 2017, Sadler 2016). The perspective of Leape and colleagues on the nature and causes of disrespectful behaviour by physicians supports this hypothesis (Leape 2012). Here, the authors argue that when some practices become ingrained in the health system, they may not be recognised as wrong and may become routine. Our finding that health workers themselves experienced disrespectful interprofessional communication at the health facility supports this hypothesis.

This synthesis included studies that represented a broad range of cadre and settings in low- and middle-income countries. Participants were drawn from a broad range of cadre from tertiary, secondary, and primary settings, and included managers and others who support health workers to deliver maternity care. Two studies were conducted among facility-based health workers that delivered care in the community or at private clinics. Most studies were conducted in settings that used mixed models of maternity care; two studies were conducted in midwifery-led units. However, several of the findings were only drawn from a narrow range of cadre and settings, which may have influenced our confidence in these findings.

Our synthesis included few studies that addressed health worker perceptions of sociocultural barriers and professional associations, factors in the broad macroenvironment that influence health workers' delivery of care. This synthesis was based on a broad search, but did not retrieve or include studies that addressed health worker perceptions of upstream system-level factors on governance, policy, financing, logistics, or legislation. Some of these studies may be published in grey literature, which we did not search. These data are important since the broader issues influence the work and life of a health worker at the front-line of the health service, for example how policies or policy changes, or different financing models affect health workers' ability to provide maternity care.

Our synthesis focused on intrapartum and postnatal care. However, most of the included studies focused on intrapartum care, with only two focusing on postpartum care. This may reflect the body of literature and attention given to intrapartum care. We did not intend to include qualitative studies that focused on antenatal care, as this topic is covered in a separate review (Downe 2016). In addition, we sought to extract data on both barriers as well as facilitators reported by health workers. However, the included studies largely reported data on barriers, and we identified minimal data on facilitators. Whereas it has been suggested that facilitators are the opposite of barriers, this may not always be the case. However, we did not find sufficient data to support or refute this argument.

We used the CERQual approach to assess relevance and adequacy of data from the included studies that contributed to individual findings (see Methods section). These assessments reflect the applicability and completeness of data contributing to a finding. See additional information in the section below.

Confidence in the findings

Based on our CERQual assessments, we had high confidence in two findings and moderate confidence in 16 findings that the studies were a good representation of the phenomenon of interest. We had several findings where we had low or very low confidence that the studies were a good representation of the phenomenon of interest, and it was therefore difficult to draw conclusions from these findings. Our main concerns were connected to the methodological limitations of the studies, and the relevance and adequacy of the data. Common methodological limitations included a lack of researcher reflexivity as well as poor reporting of ethical considerations, sampling, and data analysis methods. We often assessed the data as being only partially relevant, mainly because the included studies represented few regions, with a focus on hospital settings, and few populations, with a focus on midlevel health workers. Finally, our concerns about adequacy were mainly tied to the limited number of studies and the thinness of the data contributing to many of the findings.

Agreements and disagreements with other studies or reviews

Table 55 summarises the scope of other related reviews when compared to this synthesis. Our findings are complementary to the findings in the Filby 2016 review. We agree that barriers to providing good quality midwifery care arise from the quality of education of health providers, for example in the regulation of pre-service education, and that this limits professional development. However, our synthesis considers health services infrastructural barriers (e.g. limited staff numbers, lack of transport, weak facility management, and poor working conditions) separately from education or training (all categorised professional barriers in Filby 2016). We likewise found that salaries were low or insufficient for skilled birth attendants' personal needs, work done, and personal risk. Our finding for instance that health workers fear for their personal safety when they work alone, and that long, lonely hours of work affect their spousal relations, provide additional evidence of social barriers reported in the Filby review 2016.

Table 55.
Table comparing the scope of other related reviews to our synthesis

While our synthesis focused on intrapartum and postnatal care, Downe 2016 covered antenatal care and is therefore complementary to our synthesis. The Downe 2016 review indicated that positive interpersonal behaviour of health providers as well as their clinical, cultural, and social skills and competence are important for pregnant women. Pregnant women also required private spaces that facilitated their interaction with health providers. Our synthesis identifies some of the factors that may undermine health providers ability to provide this care, such as lack of skills in communication, heavy workload, and limited and poorly organised space. In addition, Downe 2016 found that shortage of staff, low salaries and heavy workload, lack of medicines and equipment, and poor conditions in clinics including lack of water and electricity prevented providers from providing good-quality antenatal care.

The Bradley 2016 review suggests that midwives attempted to assert power and control over women in their care, for example when they controlled how women behaved during labour, and that midwives' behaviour was part of a strategy to maintain their professional, technical, and social status. Our finding that health workers did not let mothers participate in decision-making because of health worker attitudes about women's preferences and role during delivery of her baby, and health workers' authoritarian behaviour, supports this hypothesis. However, Bradley 2016 briefly identifies work environments and resources as part of the health system structural drivers underpinning disrespect of mothers. Our synthesis provides additional evidence that points to structural challenges health workers experience when providing care. We hypothesise that these structural challenges in part influence health worker behaviour.

The typology in Bohren 2015 identified health systems conditions and constraints such as physical condition of facilities, shortage of staff and supplies, and lack of privacy as a form of mistreatment of women. Our synthesis supports the Bohren 2015 finding on health systems constraints and likewise identified several barriers in health services infrastructure and human resources that interfered with health workers ability to provide good-quality maternity care.

In addition, Bohren 2015 identified poor rapport between women and providers as another form of mistreatment of women. Included in this category was ineffective communication such as poor communication, dismissal of women's concerns, poor staff attitudes, and language barriers. Our finding that health workers did not value communication, or communicated poorly or had problems with communication (Table 50), supports this finding.

Also included in the poor rapport between women and providers category of the Bohren 2015 review were lack of supportive care, for instance denial of birth companions, and lack of autonomy when women preferred an alternative birth position. Our synthesis provided some explanations for these findings. For instance, health workers may not allow companions in delivery rooms when physical space is limited, and in order to provide privacy to other mothers in labour (see Results section on health services and infrastructure). In addition, lack of training in alternative positions of delivery may limit health workers' ability to provide care in positions other than the supine delivery position. However, we also found that health workers had poor attitudes about the labouring mother's role in her care and did not empower mothers to be active participants in their care. Such negative attitudes may interact with structural problems and further limit women-centred care in these settings.

Reflexivity

As recommended as part of primary qualitative research, we reflected on how our backgrounds and positions might have influenced our choice of review topic, study selection, data extraction, analysis, and interpretation of data. SMB, CG, SL, and AF are employed by the Norwegian Public Health Institute, and HN is employed by Uganda National Health Research Organisation. SMB, SL, AF, and HN are trained physicians, while CG is a social scientist. SMB, SL, AF, and HN have all previously worked as clinicians in low- and middle-income settings. In these roles, we have to varying degrees experienced working conditions characterised by poor resources and have seen how this influenced our own motivation and our ability to provide patient-centred care. We are therefore sympathetic to the challenges experienced by health workers in these kinds of settings. We are also of the opinion that discussions about the quality of intrapartum and postnatal care are sometimes characterised by strong criticisms of the behaviour of health workers and of the care they provide, and a failure to adequately reflect on and consider the conditions under which these health workers provide care and the system-level reasons for these conditions.

Authors' conclusions

Implications for practice

Below are a set of questions that may help health system or programme managers when implementing or planning for obstetric health services. These questions were drawn from the findings for which we had high or moderate confidence.

  1. At your facility, what is the staffing situation in relation to the workload, for instance for providing 24-hour care? Where task-shifting strategies or increasing health workers' scope of practice are suggested as options to improve the staffing situation, how will this impact on health workers' workload and on the overall quality of care? Would recruiting more health workers be a better option instead of moving people around?
  2. For facilities that deliver emergency obstetric care, are specialists available when needed? If no specialists are available and tasks have been transferred to non-specialist health workers, have these health workers been provided with training, supervision, and linkages to other centres, for instance for referral or support by telephone?
  3. How do health workers at your facility perceive their working and living conditions? Could these be the underlying reasons for absenteeism, decreased morale, poor retention, and recruitment of health workers?
  4. For managers at district or higher programme levels, are sufficient funds available for the recruitment of health workers? Is the recruitment process responsive to the local needs with minimal bureaucracy? Recruitment arrangements need to take into account facility arrangements, e.g. 24-hour opening.
  5. Do health workers' salaries reflect their training, experience, actual workload and responsibilities, and the need for reasonable living conditions?
  6. What are health facility managers' training needs and how can they be supported to attain this training?
  7. What are the pre- and/or in-service training needs for the health workers at your facility? Consider if the health workers can manage complicated pregnancies, alternative delivery positions (practice), among others. When planning for in-service training, consider how this training is organised, e.g. scheduling of classes, availability of tutors for upgrading courses, selection of trainees according to health facility, or individual training needs, etc.
  8. What are the reasons why women may be reluctant to accept referral to higher levels of care? When exploring how to improve the referral process, health system managers may need to consider these issues in order to make the referral system more responsive to women's needs, e.g. their need of financial support or the need to manage their fears.
  9. Does your health facility have a regular and reliable supply of electricity and water all year round? Consider how intersectoral collaboration could help resolve problems with electricity and water supply.
  10. Does your health facility have the necessary equipment such as cord clamps, complete delivery kits, as well as sterilising equipment required for good-quality maternity care? In order to deliver quality care, attention needs to be given to ensure necessary equipment is available and sufficient in number to meet the demands for maternity care.
  11. In case your health facility occasionally runs out of supplies, drugs, and blood that are necessary to provide maternity care, what are the underlying reasons for stock-outs of these items and how can these problems be addressed?
  12. Is the physical environment at your health facility optimally organised to facilitate health workers' delivery of good-quality care? For instance, what is the location of the postnatal ward in relation to the labour ward for health workers who need to monitor mothers in labour as well as mothers in postpartum and their newborns? Consider collaborating with health workers to organise the available space in view of the number of mothers served.
  13. What opportunities are available at the health facility level to foster good interprofessional relations, e.g. opportunities for collaborations, team building, and appreciating each others' competencies?

Implications for research

We drew implications for research from topics where we found no studies, or from findings for which we had low or very low confidence, and we suggest that these be explored further in future research.

Other factors in macroenvironment, professional councils, sociocultural factors

  • How other factors in the macroenvironment such as governance, policy, financing, etc. influence health workers' ability to provide maternity care
  • The roles of professional councils, and how these roles influence health workers' ability to provide maternity care
  • Sociocultural factors that influence health workers' ability to provide care

Human resources/health worker education

  • How staffing situation and workload influence health workers' ability to empathise and care for women in labour
  • Where financial assistance programs to support mothers are available, how these influence quality of care
  • How learning through practical application influences health workers' skills and confidence

Standards and protocols

  • Factors that influence implementation and adherence to standards and protocols
  • Individual health worker and institutional barriers to implementation of current recommended practice and seeking new knowledge

Referral mechanisms

  • Interprofessional relationships and how these influence referral
  • Health worker knowledge and skills in determining the need for referral
  • Health worker and mother trust relationship and how this influences referral
  • Reasons for unnecessary referral and how these impact on quality of care at receiving facilities
  • How lack of transport for referral at health facilities affects health workers, mothers, families, and communities
  • How administrative processes such as authorisation processes and feedback between referring facilities influence the referral process, health workers' practice, and patient outcomes
  • How information systems (patient and health facility) affect management and continuity of care of high-risk mothers

Commodities and health services infrastructure

  • Reasons why equipment and facilities are not regularly maintained
  • Reasons why health facilities vary in availability, functionality, and quality of signal functions and how this can be rectified
  • Experiences of health workers who conduct deliveries at home

Interaction between mother, community, and health workers; interaction between health workers

  • Ways to facilitate change in the culture of practice, including health worker norms, attitudes, and behaviours. This could include exploring ways of changing health worker communication and interaction with mothers and their families, as well as mothers' participation in decision-making.
  • What are people's expectation of the health service and how the service can be improved to meet those expectations
  • Midwife-led care and how it influences communication, interaction, and hospital culture
  • Strategies to build or encourage teamwork, co-ordination, and good interprofessional communication and how these influence health worker morale and satisfaction

Acknowledgments

The development of this synthesis was supported in part by the Research Council of Norway through the Global Health and Vaccination Program (GLOBVAC), Project number 220851. John Eyers developed and conducted the literature search for this synthesis. SL is partly funded by the South African Medical Research Council. The Norwegian Satellite of the Effective Practice and Organisation of Care (EPOC) Group receives funding from the Norwegian Agency for Development Cooperation (Norad), via the Norwegian Institute of Public Health to support review authors in the production of their reviews.

The Cochrane Qualitative and Implementation Methods Group provided support to the authors and the EPOC group in general for the development of the GRADE CERQual approach, and with linking qualitative syntheses with effectiveness reviews.

The Effective Health Care Research Consortium provided funding to make this review open access. The Consortium is funded by UK aid from the UK Government for the benefit of developing countries (Grant: 5242). The views expressed in this review do not necessarily reflect UK government policy.

Data and analyses

This review has no analyses.

Additional tables

Appendices

Appendix 1. Search strategies

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present= Searched 21st November 2016

1 parturition/ (7613)

2 delivery, obstetric/ (26005)

3 labor, obstetric/ (29122)

4 Live birth/ (2375)

5 Natural childbirth/ (2399)

6 Term Birth/ (2374)

7 Maternal health services/ (12349)

8 Maternal mortality/ (9399)

9 Perinatal care/ (3766)

10 Postnatal care/ or Postpartum Period/ (27263)

11 Prenatal care/ (24446)

12 Birthing Centers/ (677)

13 (birth$ or childbirth? or child birth$ or deliver or deliveries or delivery or labor or labour or lying in or accouchement or parturition? or obstetric? or gynecolog* or gynaecolog* or perinatal or prenatal or "pre natal" or antenatal or "ante natal" or postnatal or "post natal" or "maternal health" or "maternal mortality" or post-partum or "post partum" or postpartum or eclampsia or pre-eclampsia or preeclampsia or "hellp syndrome" or intrapartum or intra-partum or "intra partum").tw. (1047837)

14 Obstetrics/ or exp Obstetric Labor Complications/ (84945)

15 hypertension, pregnancy-induced/ or eclampsia/ or hellp syndrome/ or pre-eclampsia/ (33899)

16 exp Home Childbirth/ (2477)

17 (((home* or noninstitutional or non-institutional or domicile* or village* or domestic or community) adj3 (deliver* or birth* or childbirth* or child birth*)) or "place of delivery" or "place of birth*" or "place of childbirth*").tw. (8466)

18 or/1-17 (1115197)

19 exp Physicians/ (122586)

20 exp Nurses/ (81461)

21 Midwifery/ (17650)

22 Obstetrical Nursing/ (3317)

23 Professional practice/ or Clinical competence/ (95153)

24 (doctor* or obstetrician* or nurse or nurses or midwi* or physician* or "skilled health provider*" or "skilled attend*" or "skilled birth attend*" or "skilled health" or " skilled assistan*" or "skilled care" or "skilled manpower" or " skilled delivery" or "skilled staff").tw. (667236)

25 or/19-24 (830149)

26 Developing Countries.sh,kf. (82706)

27 exp Africa/ or exp Asia/ or exp Caribbean/ or exp West Indies/ or exp South America/ or exp Latin America/ or exp Central America/ (1083654)

28 (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America).tw. (152876)

29 exp Russia/ or (Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Azerbaijan or Bangladesh or Barbados or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or India or Maldives or Indonesia or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Northern Mariana Islands or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Papua New Guinea or Portugal or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Sri Lanka or Ceylon or Solomon Islands or Somalia or Sudan or Suriname or Surinam or Swaziland or South Africa or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe).tw. (944303)

30 ((developing or less* developed or under developed or underdeveloped or middle income or low* income or underserved or under served or deprived or poor*) adj (countr* or nation? or population? or world or state*)).ti,ab. (78576)

31 ((developing or less* developed or under developed or underdeveloped or middle income or low* income) adj (economy or economies)).ti,ab. (386)

32 (low* adj (gdp or gnp or gross domestic or gross national)).tw. (207)

33 (low adj3 middle adj3 countr*).tw. (8063)

34 (lmic or lmics or third world or lami countr*).tw. (4726)

35 transitional countr*.tw. (146)

36 or/26-35 (1601296)

37 qualitative research/ (33749)

38 (qualitative or ethno$ or emic or etic or phenomenolog$ or hermeneutic$ or heidegger$ or husserl$ or colaizzi$ or giorgi$ or glaser or strauss or van kaam$ or van manen or constant compar$).ti,ab. (208581)

39 Focus groups/ or Interview/ or Interviews as Topic/ or Health services administration/ or Questionnaires/ or Self-report/ (500860)

40 (focus group$ or grounded theory or narrative analys$ or lived experience$ or life experience$ or theoretical sampl$ or purposive sampl$ or ricoeur or spiegelberg$ or merleau or metasynthes$ or meta-synthes$ or metasummar$ or meta-summar$ or metastud$ or meta-stud$ or maximum variation or snowball).ti,ab. (55506)

41 ((thematic$ adj3 analys$) or (content analy$ or field note$ or fieldnote$ or field record$ or field stud$) or (participant$ adj3 observ$) or (nonparticipant$ adj3 observ$) or (non participant$ adj3 observ$)).ti,ab. (53249)

42 (semi-structured or semistructured or structured categor$ or unstructured categor$ or action research or (audiorecord$ or taperecord$ or videorecord$ or videotap$) or ((audio or tape or video$) adj5 record$) or interview* or quasi-experiment* or (case adj stud*)).ti,ab. (401000)

43 (collaborat* or consultat* or experience or involve* or narrative* or opinion* or participat* or partner* or perspective* or story or stories or "social science*" or view* or voice*).ti,ab. (3427661)

44 37 or 38 or 39 or 40 or 41 or 42 or 43 (4069871)

45 18 and 25 and 36 and 44 (6703)

46 limit 45 to yr="2013 -Current" (2061)

Embase Classic+Embase (Ovid) <1947 to 2016 Week 47= - Searched 28th November 2016

1 qualitative research/ (49608)

2 nursing methodology research/ (14311)

3 exp questionnaire/ (582341)

4 discourse analysis/ (1294)

5 content analysis/ (13574)

6 attitude/ or attitude to abortion/ or attitude to breast feeding/ or attitude to change/ or attitude to pregnancy/ or cultural bias/ or cultural sensitivity/ or family attitude/ or patient attitude/ (118463)

7 ethnographic research/ (906)

8 ethnonursing research/ (22)

9 constant comparative method/ (898)

10 qualitative validity/ (153)

11 purposive sample/ (1934)

12 exp observational method/ (8902)

13 field study/ (6532)

14 theoretical sample/ (176)

15 phenomenology/ (10927)

16 personal experience/ (33548)

17 cluster analysis/ (48162)

18 grounded theory/ (6521)

19 (qualitative or ethno$ or emic or etic or phenomenolog$ or hermeneutic$ or heidegger$ or husserl$ or colaizzi$ or giorgi$ or glaser or strauss or van kaam$ or van manen or constant compar$).ti,ab. (243480)

20 (focus group$ or grounded theory or narrative analys$ or lived experience$ or life experience$ or theoretical sampl$ or purposive sampl$ or ricoeur or spiegelberg$ or merleau or metasynthes$ or meta-synthes$ or metasummar$ or meta-summar$ or metastud$ or meta-stud$ or maximum variation or snowball).ti,ab. (61408)

21 exp interview/ (250594)

22 ((thematic$ adj3 analys$) or (content analy$ or field note$ or fieldnote$ or field record$ or field stud$) or (participant$ adj3 observ$) or (nonparticipant$ adj3 observ$) or (non participant$ adj3 observ$)).ti,ab. (59046)

23 (semi-structured or semistructured or structured categor$ or unstructured categor$ or action research or (audiorecord$ or taperecord$ or videorecord$ or videotap$) or ((audio or tape or video$) adj5 record$) or interview* or quasi-experiment* or (case adj stud*)).ti,ab. (467042)

24 (collaborat* or consultat* or experience or involve* or narrative* or opinion* or participat* or partner* or perspective* or story or stories or view* or voice*).ti,ab. (4198662)

25 self report/ (96730)

26 birth/ (18006)

27 delivery/ or obstetric procedure/ or home delivery/ or labor management/ or labor support/ or natural childbirth/ (45282)

28 labor/ or childbirth/ (46030)

29 term birth/ (3191)

30 maternal care/ or maternal treatment/ or maternal welfare/ or rooming in/ (29419)

31 maternal mortality/ (21969)

32 perinatal care/ (13193)

33 postnatal care/ (6038)

34 prenatal care/ (34265)

35 (birth$ or childbirth? or child birth$ or ((deliver or deliveries or delivery) adj3 (birth* or childbirth* or obstetric* or labour or labor)) or labor or labour or lying in or accouchement or parturition? or obstetric? or gynecolog* or gynaecolog* or perinatal or prenatal or "pre natal" or antenatal or "ante natal" or postnatal or "post natal" or "maternal health" or "maternal mortality" or post-partum or "post partum" or postpartum or eclampsia or pre-eclampsia or preeclampsia or "hellp syndrome" or intrapartum or intra-partum or "intra partum").tw. (887574)

36 (((home* or noninstitutional or non-institutional or domicile* or village* or domestic or community) adj3 (deliver* or birth* or childbirth* or child birth*)) or "place of delivery" or "place of birth*" or "place of childbirth*").tw. (9545)

37 obstetrics/ (43530)

38 exp labor complication/ or eclampsia/ or "eclampsia and preeclampsia"/ (191233)

39 physician/ or female physician/ or gynecologist/ or hospital physician/ or internist/ (399473)

40 head nurse/ or staff nurse/ or clinical nurse specialist/ or nurse midwifery education/ or charge nurse/ or advanced practice nurse/ or nurse midwifery/ or nurse midwife/ or acute care nurse practitioner/ or registered nurse/ or family nurse practitioner/ or doctor nurse relation/ or nurse anesthetist/ or nurse practitioner/ or nurse consultant/ or nurse manager/ or male nurse/ or emergency nurse practitioner/ or practical nurse/ or nurse patient relationship/ or nurse/ or expert nurse/ (214304)

41 midwife attitude/ or midwife/ (25667)

42 (doctor* or obstetrician* or nurse or nurses or midwi* or physician* or "skilled health provider*" or "skilled attend*" or "skilled birth attend*" or "skilled health" or " skilled assistan*" or "skilled care" or "skilled manpower" or " skilled delivery" or "skilled staff").tw. (812818)

43 obstetrical nursing/ (2689)

44 practical nursing/ or primary nursing/ or nursing outcome/ or community health nursing/ or nursing assessment/ or nursing expertise/ or perinatal nursing/ or advanced practice nursing/ or ambulatory care nursing/ or nursing practice/ or nursing evaluation research/ or nursing/ or visiting nursing service/ or nursing knowledge/ or nursing shortage/ (285840)

45 Developing Country.sh. (100060)

46 (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America).hw,ti,ab,cp. (290288)

47 (Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Aruba or Azerbaijan or Bahrain or Bangladesh or Barbados or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brasil or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Cyprus or Czechoslovakia or Czech Republic or Slovakia or Slovak Republic or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Estonia or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Greece or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or Hungary or India or Maldives or Indonesia or Iran or Iraq or Isle of Man or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Malta or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Northern Mariana Islands or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Poland or Portugal or Puerto Rico or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Kitts or St Kitts or Nevis or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Saudi Arabia or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Slovenia or Sri Lanka or Ceylon or Solomon Islands or Somalia or South Africa or Sudan or Suriname or Surinam or Swaziland or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe or Rhodesia).hw,ti,ab,cp. (3599575)

48 ((developing or less* developed or under developed or underdeveloped or middle income or low* income or underserved or under served or deprived or poor*) adj (countr* or nation? or population? or world)).ti,ab. (90272)

49 ((developing or less* developed or under developed or underdeveloped or middle income or low* income) adj (economy or economies)).ti,ab. (486)

50 (low* adj (gdp or gnp or gross domestic or gross national)).ti,ab. (271)

51 (low adj3 middle adj3 countr*).ti,ab. (8121)

52 (lmic or lmics or third world or lami countr*).ti,ab. (5213)

53 transitional countr*.ti,ab. (181)

54 or/45-53 (3784180)

55 or/1-25 (5166727)

56 or/26-38 (1028044)

57 or/39-44 (1150472)

58 54 and 55 and 56 and 57 (7356)

59 limit 58 to yr="2013 -Current" (2635)

60 limit 59 to exclude medline journals (530)

PsycINFO (Ovid) <1806 to November Week 3 2016= - Searched 30th November 2016

1 exp Qualitative Research/ (7191)

2 phenomenology/ (11580)

3 exp Hermeneutics/ (1867)

4 exp Constructivism/ (4726)

5 interviews/ (7742)

6 social sciences/ or theoretical orientation/ (14468)

7 task switching/ (1000)

8 questioning/ or information seeking/ or interviewing/ (9247)

9 measurement/ or needs assessment/ or surveys/ (55739)

10 exp questionnaires/ (16412)

11 data mining/ (1698)

12 observation methods/ (4984)

13 grounded theory/ (3135)

14 program evaluation/ (11420)

15 risk assessment/ (11578)

16 Verbal Communication/ (13293)

17 narratives/ (16466)

18 discourse analysis/ or content analysis/ (11995)

19 sociocultural factors/ (39283)

20 exp decision making/ (88049)

21 cluster analysis/ (3459)

22 exp Community Attitudes/ or exp Health Attitudes/ or exp Childrearing Attitudes/ or exp Client Attitudes/ or exp Consumer Attitudes/ or exp Female Attitudes/ (51496)

23 cultural sensitivity/ (5812)

24 (qualitative or ethno$ or emic or etic or phenomenolog$ or hermeneutic$ or heidegger$ or husserl$ or colaizzi$ or giorgi$ or glaser or strauss or van kaam$ or van manen or constant compar$).ti,ab. (176357)

25 (focus group$ or grounded theory or narrative analys$ or lived experience$ or life experience$ or theoretical sampl$ or purposive sampl$ or ricoeur or spiegelberg$ or merleau or metasynthes$ or meta-synthes$ or metasummar$ or meta-summar$ or metastud$ or meta-stud$ or maximum variation or snowball).ti,ab. (59634)

26 ((thematic$ adj3 analys$) or (content analy$ or field note$ or fieldnote$ or field record$ or field stud$) or (participant$ adj3 observ$) or (nonparticipant$ adj3 observ$) or (non participant$ adj3 observ$)).ti,ab. (47701)

27 (semi-structured or semistructured or structured categor$ or unstructured categor$ or action research or (audiorecord$ or taperecord$ or videorecord$ or videotap$) or ((audio or tape or video$) adj5 record$) or interview* or quasi-experiment* or (case adj stud*)).ti,ab. (362094)

28 (collaborat* or consultat* or experience or involve* or narrative* or opinion* or participat* or partner* or perspective* or story or stories or view* or voice*).ti,ab. (1286446)

29 self report/ (14552)

30 or/1-29 (1723640)

31 birth/ or "labor (childbirth)"/ or midwifery/ or obstetrical complications/ or preeclampsia/ (9330)

32 expectant mothers/ (573)

33 childbirth training/ or obstetrical complications/ or perinatal period/ or postnatal period/ or prenatal care/ (8805)

34 (birth$ or childbirth? or child birth$ or ((deliver or deliveries or delivery) adj3 (birth* or childbirth* or obstetric* or labour or labor)) or labor or labour or lying in or accouchement or parturition? or obstetric? or gynecolog* or gynaecolog* or perinatal or prenatal or "pre natal" or antenatal or "ante natal" or postnatal or "post natal" or "maternal health" or "maternal mortality" or post-partum or "post partum" or postpartum or eclampsia or pre-eclampsia or preeclampsia or "hellp syndrome" or intrapartum or intra-partum or "intra partum").tw. (123609)

35 (((home* or noninstitutional or non-institutional or domicile* or village* or domestic or community) adj3 (deliver* or birth* or childbirth* or child birth*)) or "place of delivery" or "place of birth*" or "place of childbirth*").tw. (2534)

36 obstetrics/ (1027)

37 or/31-36 (126638)

38 physicians/ or gynecologists/ or internists/ or obstetricians/ (19652)

39 nurses/ or public health service nurses/ (22876)

40 midwifery/ (1085)

41 (doctor* or obstetrician* or nurse or nurses or midwi* or physician* or "skilled health provider*" or "skilled attend*" or "skilled birth attend*" or "skilled health" or " skilled assistan*" or "skilled care" or "skilled manpower" or " skilled delivery" or "skilled staff").tw. (131933)

42 or/38-41 (134044)

43 developing countries/ (4756)

44 (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America).ti,ab,hw. (27857)

45 (Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Azerbaijan or Bangladesh or Barbados or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or India or Maldives or Indonesia or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Northern Mariana Islands or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Papua New Guinea or Portugal or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Sri Lanka or Ceylon or Solomon Islands or Somalia or Sudan or Suriname or Surinam or Swaziland or South Africa or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe).tw. (177013)

46 ((developing or less* developed or under developed or underdeveloped or middle income or low* income or underserved or under served or deprived or poor*) adj (countr* or nation? or population? or world or state*)).ti,ab. (13844)

47 ((developing or less* developed or under developed or underdeveloped or middle income or low* income) adj (economy or economies)).ti,ab. (278)

48 (low* adj (gdp or gnp or gross domestic or gross national)).ti,ab. (32)

49 (low adj3 middle adj3 countr*).ti,ab. (1814)

50 (lmic or lmics or third world or lami countr*).ti,ab. (1288)

51 transitional countr*.ti,ab. (53)

52 or/43-51 (196277)

53 30 and 37 and 42 and 52 (651)

54 limit 53 to yr="2013 -Current" (217)

CINAHL (Ebsco) – Searched 30th November 2016

S43 S16 AND S20 AND S30 AND S42 Limiters - Published Date: 20130101-20171231

Database - CINAHL Plus with Full Text 871

S42 S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 Database - CINAHL Plus with Full Text 1,122,552

S41 (MH "Formative Evaluation Research")

Database - CINAHL Plus with Full Text 300

S40 (MH "Triangulation")

Database - CINAHL Plus with Full Text 3,617

S39 (MH "Multimethod Studies")

Database - CINAHL Plus with Full Text 9,091

S38 MH ("Qualitative Studies" OR "Research Nursing" OR Questionnaires+ OR Attitude+ OR "Focus Groups" OR "Discourse Analysis" OR "Content Analysis" OR "Ethnographic Research" OR "Ethnological Research" OR "Ethnonursing Research" OR "Constant Comparative Method" OR "Qualitative Validity+" OR "Purposive Sample" OR "Observational Methods+" OR "Field Studies" OR "Theoretical Sample" OR Phenomenology OR "Phenomenological Research" OR "Life Experiences+" OR "Cluster Sample+")

Database - CINAHL Plus with Full Text 599,720

S37 TI ("grounded stud*" OR "grounded research" or semiotics or heuristic or "discourse N1 analysis") OR AB ("grounded stud*" OR "grounded research" or semiotics or heuristic or "discourse N1 analysis")

Database - CINAHL Plus with Full Text 1,308

S36 TI (collaborat* or consultat* or experience* or involve* or narrative* or opinion* or participat* or partner* or perspective* or story or stories or "social science*" or view* or voice*) OR AB (collaborat* or consultat* or experience* or involve* or narrative* or opinion* or participat* or partner* or perspective* or story or stories or "social science*" or view* or voice*)

Database - CINAHL Plus with Full Text 634,184

S35 TI ("semi-structured" or semistructured or "structured categor*" or "unstructured categor*" or "action research" or (audiorecord* or taperecord* or videorecord* or videotap* OR "social science*") or ((audio or tape or video*) N5 record*) or interview* or quasi-experiment* or (case N1 stud*)) OR AB ("semi-structured" or semistructured or "structured categor*" or "unstructured categor*" or "action research" or (audiorecord* or taperecord* or videorecord* or videotap* OR "social science*") or ((audio or tape or video*) N5 record*) or interview* or quasi-experiment* or (case N1 stud*))

Database - CINAHL Plus with Full Text 178,398

S34 TI ((thematic* N3 analys*) or ("content analy*" or "field note*" or fieldnote* or "field record" or "field stud*") or (participant* N3 observ*) or (nonparticipant* N3 observ*) or ("non participant*" N3 observ*)) OR AB ((thematic* N3 analys*) or ("content analy*" or "field note*" or fieldnote* or "field record" or "field stud*") or (participant* N3 observ*) or (nonparticipant* N3 observ*) or ("non participant*" N3 observ*))

Database - CINAHL Plus with Full Text 25,194

S33 AB ("focus group*" or "grounded theory" or "narrative analys*" or "lived experience" or "life experience*" or "theoretical sampl*" or "purposive sampl*" or ricoeur or spiegelberg* or merleau or metasynthes* or "meta-synthes*" or metasummar* or "meta-summar*" or metastud* or "meta-stud*" or "maximum variation" or snowball)

Database - CINAHL Plus with Full Text 31,044

S32 TI ("focus group*" or "grounded theory" or "narrative analys*" or "lived experience" or "life experience*" or "theoretical sampl*" or "purposive sampl*" or ricoeur or spiegelberg* or merleau or metasynthes* or "meta-synthes*" or metasummar* or "meta-summar*" or metastud* or "meta-stud*" or "maximum variation" or snowball)

Database - CINAHL Plus with Full Text 5,325

S31 TI (qualitative or ethno* or emic or etic or phenomenolog* or hermeneutic* or heidegger* or husserl* or colaizzi* or giorgi* or glaser or strauss or "van kaam*" or "van manen" or "constant compar*") OR AB (qualitative or ethno* or emic or etic or phenomenolog* or hermeneutic* or heidegger* or husserl* or colaizzi* or giorgi* or glaser or strauss or "van kaam*" or "van manen" or "constant compar*")

Database - CINAHL Plus with Full Text 82,896

S30 S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29

Database - CINAHL Plus with Full Text 346,360

S29 TI ("transitional countr*") OR AB ("transitional countr*") OR SU ("transitional countr*")

Database - CINAHL Plus with Full Text 46

S28 TI (lmic or lmics or "third world" or "lami countr*") OR AB (lmic or lmics or "third world" or "lami countr*") OR SU (lmic or lmics or "third world" or "lami countr*")

Database - CINAHL Plus with Full Text 900

S27 TI (low N3 middle N3 countr*) OR AB (low N3 middle N3 countr*) OR SU (low N3 middle N3 countr*)

Database - CINAHL Plus with Full Text 2,746

S26 TI (low* N1 (gdp or gnp or "gross domestic" or "gross national" or GNI)) OR AB (low* N1 (gdp or gnp or "gross domestic" or "gross national" or GNI)) OR SU (low* N1 (gdp or gnp or "gross domestic" or "gross national" or GNI))

Database - CINAHL Plus with Full Text 41

S25 TI ((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income") N1 (economy or economies)) OR AB ((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income") N1 (economy or economies)) OR SU ((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income") N1 (economy or economies))

Database - CINAHL Plus with Full Text 79

S24 TI ((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income" or underserved or "under served" or deprived or poor*) N1 (countr* or nation* or population* or world)) OR AB ((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income" or underserved or "under served" or deprived or poor*) N1 (countr* or nation* or population* or world)) OR SU ((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income" or underserved or "under served" or deprived or poor*) N1 (countr* or nation* or population* or world))

Database - CINAHL Plus with Full Text 26,201

S23 TI (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America) OR AB (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America) OR SU (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America)

Database - CINAHL Plus with Full Text 42,956

S22 TI (Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Aruba or Azerbaijan or Bangladesh or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or India or Maldives or Indonesia or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Sri Lanka or Ceylon or Solomon Islands or Somalia or Sudan or Suriname or Surinam or Swaziland or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Tuvalu or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe) OR AB (Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Aruba or Azerbaijan or Bangladesh or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or India or Maldives or Indonesia or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Sri Lanka or Ceylon or Solomon Islands or Somalia or Sudan or Suriname or Surinam or Swaziland or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Tuvalu or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe) OR SU (Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Aruba or Azerbaijan or Bangladesh or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or India or Maldives or Indonesia or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Sri Lanka or Ceylon or Solomon Islands or Somalia or Sudan or Suriname or Surinam or Swaziland or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Tuvalu or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe)

Database - CINAHL Plus with Full Text 243,657

S21 MH (Africa+ OR Asia+ OR "South America+" OR "Central America+" OR Mexico OR "West Indies+" OR "Atlantic Islands+" OR Armenia OR Azerbaijan OR "Georgia (Republic)" OR "Indian Ocean Islands" OR "Pacific Islands")

Database - CINAHL Plus with Full Text 272,698

S20 S17 OR S18 OR S19

Database - CINAHL Plus with Full Text 511,438

S19 TI (doctor* OR obstetrician* OR physician* OR nurse* OR midwi* OR "skilled health provider*" OR "skilled attend*" OR "skilled birth attend*" OR "skilled health" OR "skilled assistan*" OR "skilled care" OR "skilled manpower" OR "skilled deliver*" OR "skilled staff*") OR AB (doctor* OR obstetrician* OR physician* OR nurse* OR midwi* OR "skilled health provider*" OR "skilled attend*" OR "skilled birth attend*" OR "skilled health" OR "skilled assistan*" OR "skilled care" OR "skilled manpower" OR "skilled deliver*" OR "skilled staff*")

Database - CINAHL Plus with Full Text 368,978

S18 (MH "Nurses+")

Database - CINAHL Plus with Full Text 178,244

S17 (MH "Physicians+")

Database - CINAHL Plus with Full Text 76,376

S16 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15

Database - CINAHL Plus with Full Text 209,077

S15 TI (birth* OR childbirth* OR deliver OR deliveries OR delivery OR labor OR labour OR "lying in" OR accouchement OR parturition OR obstetric* OR gynecolog* OR gynaecolog* OR perinatal* OR postnatal* OR "post natal*" OR prenatal* OR "pre natal*" OR antenatal OR "ante natal" OR "maternal mortality" OR "maternal death*" OR "maternal welfare" OR "maternal care" OR "maternal health" OR intrapartum OR "intra partum") OR AB (birth* OR childbirth* OR deliver OR deliveries OR delivery OR labor OR labour OR "lying in" OR accouchement OR parturition OR obstetric* OR gynecolog* OR gynaecolog* OR perinatal* OR postnatal* OR "post natal*" OR prenatal* OR "pre natal*" OR antenatal OR "ante natal" OR "maternal mortality" OR "maternal death*" OR "maternal welfare" OR "maternal care" OR "maternal health" OR post-partum OR "post partum" OR postpartum OR eclampsia OR pre-eclampsia OR preeclampsia OR "hellp syndrome" OR intrapartum OR intra-partum OR "intra partum" )

Database - CINAHL Plus with Full Text 181,776

S14 (MH "Obstetric Emergencies")

Database - CINAHL Plus with Full Text 534

S13 (MH "Labor Complications+")

Database - CINAHL Plus with Full Text 7,271

S12 (MH "Obstetrics")

Database - CINAHL Plus with Full Text 3,537

S11 (MH "Maternal Welfare")

Database - CINAHL Plus with Full Text 1,127

S10 (MH "Maternal Health Services+")

Database - CINAHL Plus with Full Text 20,312

S9 (MH "Obstetric Service")

Database - CINAHL Plus with Full Text 965

S8 (MH "Perinatal Care") OR (MH "Prenatal Care") OR (MH "Prepregnancy Care")

Database - CINAHL Plus with Full Text 14,731

S7 (MH "Maternal Mortality")

Database - CINAHL Plus with Full Text 3,849

S6 (MH "Childbirth+")

Database - CINAHL Plus with Full Text 19,591

S5 MH (Midwifery Service OR Nurse-Midwifery Service)

Database - CINAHL Plus with Full Text 1,282

S4 (MH "Obstetric Patients")

Database - CINAHL Plus with Full Text 310

S3 MH ("Maternal-Child Care" OR "Obstetric Care" OR Delivery+ OR "Intrapartum Care" OR "Postnatal Care")

Database - CINAHL Plus with Full Text 10,513

S2 (MH "Pregnancy-Induced Hypertension") OR (MH "Eclampsia") OR (MH "Pre-Eclampsia")

Database - CINAHL Plus with Full Text 5,644

S1 (MH "Postpartum Hemorrhage") OR (MH "Postpartum Risk (Saba CCC)") OR (MH "Postpartum Care (Saba CCC)")

Database - CINAHL Plus with Full Text 1,827

Popline – Searched 30th November 2016

( ( qualitative OR ethno* OR emic OR etic OR phenomenolog* OR hermeneutic* OR heidegger* OR husserl* OR colaizzi* OR giorgi* OR glaser OR strauss OR "van kaam*" OR "van manen" OR "constant compar*" OR "focus group*" OR "grounded theory" OR "narrative analys*" OR "lived experience" OR "life experience*" OR "theoretical sampl*" OR "purposive sampl*" OR ricoeur OR spiegelberg* OR merleau OR metasynthes* OR "meta synthes*" OR metasummar* OR "meta summar*" OR metastud* OR "meta stud*" OR "maximum variation" OR snowball OR "thematic* analys*" OR "content analy*" OR "field note*" OR fieldnote* OR "field record" OR "field stud*" OR "participant* observ*" OR "nonparticipant* observ*" ) OR ( "non participant* observ*" OR "semi structured" OR semistructured OR "structured categor*" OR "unstructured categor*" OR "action research" OR audiorecord* OR taperecord* OR videorecord* OR videotap* OR ((audio OR tape OR video*) and record*) OR interview* OR "quasi experiment*" OR "case stud*" OR collaborat* OR consultat* OR experience* OR involve* OR narrative* OR opinion* OR participat* OR partner* OR perspective* OR story OR stories OR "social science*" OR view* OR voice* OR "grounded stud*" OR "grounded research" OR semiotics OR heuristic OR "discourse analysis" ) AND ( (doctor* OR obstetrician* OR physician* OR nurse* OR midwi* OR "skilled health provider*" OR "skilled attend*" OR "skilled birth attend*" OR "skilled health" OR "skilled assistan*" OR "skilled care" OR "skilled manpower" OR "skilled deliver*" OR "skilled staff*" ) ) ) AND ( ( ((birth* OR childbirth* OR deliver OR deliveries OR delivery OR labor OR labour OR "lying in" OR accouchement OR parturition OR obstetric* OR gynecolog* OR gynaecolog* OR perinatal* OR postnatal* OR "post natal*" OR prenatal* OR "pre natal*" OR antenatal OR "ante natal" OR "maternal mortality" OR "maternal death*" OR "maternal welfare" OR "maternal care" OR "maternal health" OR intrapartum OR "intra partum" OR intra-partum OR post-partum OR "post partum" OR postpartum OR eclampsia OR pre-eclampsia OR preeclampsia OR "hellp syndrome")) ) ) – 854 (2013-2016)

WHO Global Health Library – Searched 1st December 2016

tw:((birth* OR childbirth* OR deliver OR deliveries OR delivery OR labor OR labour OR "lying in" OR accouchement OR parturition OR obstetric* OR gynecolog* OR gynaecolog* OR perinatal* OR postnatal* OR "post natal*" OR prenatal* OR "pre natal*" OR antenatal OR "ante natal" OR "maternal mortality" OR "maternal death*" OR "maternal welfare" OR "maternal care" OR "maternal health" OR intrapartum OR "intra partum" OR post-partum OR "post partum" OR postpartum OR eclampsia OR pre-eclampsia OR preeclampsia OR "hellp syndrome") AND (doctor* OR obstetrician* OR physician* OR nurse* OR midwi* OR "skilled health provider*" OR "skilled attend*" OR "skilled birth attend*" OR "skilled health" OR "skilled assistan*" OR "skilled care" OR "skilled manpower" OR "skilled deliver*" OR "skilled staff*") OR (doctor* OR obstetrician* OR physician* OR nurse* OR midwi* OR "skilled health provider*" OR "skilled attend*" OR "skilled birth attend*" OR "skilled health" OR "skilled assistan*" OR "skilled care" OR "skilled manpower" OR "skilled deliver*" OR "skilled staff*") AND (qualitative OR ethno* OR emic OR etic OR phenomenolog* OR hermeneutic* OR heidegger* OR husserl* OR colaizzi* OR giorgi* OR glaser OR strauss OR "van kaam*" OR "van manen" OR "constant compar*" OR "focus group*" OR "grounded theory" OR "narrative analys*" OR "lived experience" OR "life experience*" OR "theoretical sampl*" OR "purposive sampl*" OR ricoeur OR spiegelberg* OR merleau OR metasynthes* OR "meta-synthes*" OR metasummar* OR "meta-summar*" OR metastud* OR "meta-stud*" OR "maximum variation" OR snowball OR (thematic* AND analys*) OR ("content analy*" OR "field note*" OR fieldnote* OR "field record" OR "field stud*") OR (participant* AND observ*) OR (nonparticipant* AND observ*) OR ("non participant*" AND observ*) OR "semi-structured" OR semistructured OR "structured categor*" OR "unstructured categor*" OR "action research" OR audiorecord* OR taperecord* OR videorecord* OR videotap* OR ((audio OR tape OR video*) AND record*) OR interview* OR quasi-experiment* OR (case AND stud*) OR collaborat* OR consultat* OR experience* OR involve* OR narrative* OR opinion* OR participat* OR partner* OR perspective* OR story OR stories OR "social science*" OR view* OR voice* OR "grounded stud*" OR "grounded research" OR semiotics OR heuristic OR (discourse AND analysis))) AND (instance:"ghl") AND ( db:("LILACS" OR "WPRIM" OR "IMEMR" OR "IMSEAR" OR "WHOLIS" OR "AIM") AND year_cluster:("2014" OR "2015" OR "2013" OR "2016")) – 701 hits

Web of Science (SCI, SSCI & AHCI) – Searched 1st Dec 2016

#16 438

#15 AND #8

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 15 1,333,681

#14 OR #13 OR #12 OR #11 OR #10 OR #9

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 14 18,287

TS=("grounded stud*" OR "grounded research" or semiotics or heuristic or "discourse NEAR/1 analysis")

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 13 1,131,458

TS=(collaborat* or consultat* or experience* or involve* or narrative* or opinion* or participat* or partner* or perspective* or story or stories or "social science*" or view* or voice*)

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 12 210,221

TS= ("semi-structured" or semistructured or "structured categor*" or "unstructured categor*" or "action research" or (audiorecord* or taperecord* or videorecord* or videotap*) or ((audio or tape or video*) NEAR/5 record*) or interview* or quasi-experiment* or (case NEAR/1 stud*))

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 11 30,288

TS=((thematic* NEAR/3 analys*) or ("content analy*" or "field note*" or fieldnote* or "field record" or "field stud*") or (participant* NEAR/3 observ*) or (nonparticipant* NEAR/3 observ*) or ("non participant*" NEAR/3 observ*))

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 10 24,398

TS=("focus group*" or "grounded theory" or "narrative analys*" or "lived experience" or "life experience*" or "theoretical sampl*" or "purposive sampl*" or ricoeur or spiegelberg* or merleau or metasynthes* or "meta-synthes*" or metasummar* or "meta-summar*" or metastud* or "meta-stud*" or "maximum variation" or snowball)

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 9 114,511

TS=(qualitative or ethno* or emic or etic or phenomenolog* or hermeneutic* or heidegger* or husserl* or colaizzi* or giorgi* or glaser or strauss or "van kaam*" or "van manen" or "constant compar*")

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 8 617

#7 AND #6 AND #5

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 7 37,404

TI= (doctor* or obstetrician* or nurse or nurses or midwi* or physician* or "skilled health provider*" or "skilled attend*" or "skilled birth attend*" or "skilled health" or " skilled assistan*" or "skilled care" or "skilled manpower" or " skilled delivery" or "skilled staff")

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 6 373,103

TS=(birth$ or childbirth? or child birth$ or deliver or deliveries or delivery or labor or labour or lying in or accouchement or parturition? or obstetric? or gynecolog* or gynaecolog* or perinatal or prenatal or "pre natal" or antenatal or "ante natal" or postnatal or "post natal" or "maternal health" or "maternal mortality" or post-partum or "post partum" or postpartum or eclampsia or pre-eclampsia or preeclampsia or "hellp syndrome" or intrapartum or intra-partum or "intra partum")

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 5 614,946

#4 OR #3 OR #2 OR #1

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 4 1,987

TOPIC: ((lmic or lmics or "third world" or "lami countr*")) OR TOPIC: (transitional countr*)

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 3 6,005

TOPIC: (((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income") NEAR/1 (economy or economies))) OR TOPIC: ((low* NEAR/1 (gdp or gnp or "gross domestic" or "gross national"))) OR TOPIC: ((low NEAR/3 middle NEAR/3 countr*))

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 2 164,270

TOPIC: (Developing Countries) OR TOPIC: (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America) OR TOPIC: (((developing or "less* developed" or "under developed" or underdeveloped or "middle income" or "low* income" or underserved or "under served" or deprived or poor*) NEAR/1 (countr* or nation* or population* or world)))

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

# 1 545,156

TOPIC: (Russia or Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Azerbaijan or Bangladesh or Barbados or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or India or Maldives or Indonesia or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Northern Mariana Islands or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Papua New Guinea or Portugal or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Sri Lanka or Ceylon or Solomon Islands or Somalia or Sudan or Suriname or Surinam or Swaziland or South Africa or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe)

Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan=2013-2016

Dissertation Abstracts and Theses - searched 15 August 2013

ALL("skilled birth attendant" or "skilled birth attendants")

WHO Reproductive Health Library - searched 16 August 2013

midwife OR doctor OR doctors OR midwives OR midwifery OR physician OR physicians OR obstetrician OR obstetricians OR nurse OR nurses OR skilled

Appendix 2. Modified version of the Critical Appraisal Skills Programme qualitative appraisal checklist (Atkins 2008)

We used the following questions to assess methodological quality.

  1. Are the research questions clearly stated?
  2. Have ethical issues been taken into consideration?
  3. Is the qualitative approach clearly justified?
  4. Is the approach appropriate for the research question?
  5. Is the study context clearly described?
  6. Is the role of the researcher clearly described?
  7. Is the sampling method clearly described?
  8. Is the sampling strategy appropriate for the research question?
  9. Is the method of data collection clearly described?
  10. Is the data collection method appropriate to the research question?
  11. Is the method of analysis clearly described?
  12. Is the chosen analytical approach suitable for addressing the research question?
  13. Are the claims made supported by sufficient evidence?

Appendix 3. Steps used for data synthesis

  • Familiarisation: We read and reread the studies to familiarise ourselves with the objectives and findings from each study.
  • Identification of a thematic framework: We selected the theoretical framework developed by Graham 2001 ((1)1) a priori to guide this synthesis.
  • Indexing: We discussed the themes extracted from the studies in relation to the Graham framework. New themes emerging from the data were synthesised to suggest additions or changes to the Graham framework.
  • Charting: We transferred emerging themes and categories to analysis charts that reflected the elements of the framework.
  • Mapping and interpretation: We used the charts to map the various phenomena, and explore associations between themes.

Contributions of authors

SMB, CG, and SL devised this synthesis. SMB led the development of this synthesis with input from CG, SL, AF, and HN.

Declarations of interest

Susan Munabi-Babigumira, Claire Glenton, and Atle Fretheim are Editors with the Cochrane Effective Practice and Organisation of Care (EPOC) Group. Simon Lewin is Co-ordinating Editor with the EPOC Group. Harriet Nabudere has no interests to report.

Sources of support

Internal sources

  • The Norwegian Public Health Institute, Norway.
    SMB, CG, SL, AF are employed by the Institute
  • Uganda National Health Research Organisation, Uganda.
    HN is employed by UNRO

External sources

  • Norwegian Agency for Development Cooperation (Norad), Norway.
    The Norwegian Satellite of the Effective Practice and Organisation of Care (EPOC) Group receives funding from the Norwegian Agency for Development Cooperation (Norad), via the Norwegian Institute of Public Health to support review authors in the production of their reviews.
  • Research Council of Norway, Norway.
    This work was supported in part by the Research Council of Norway through the Global Health and Vaccination Programme (GLOBVAC), project number 220851.
  • The Cochrane Qualitative and Implementation Methods Group (QIMG), Other.
    The QIMG provided support to the authors and EPOC group in general for the development of the GRADE CERQual approach, and with linking qualitative syntheses with effectiveness reviews.
  • The Effective Health Care Research Consortium, which is funded by UK aid from the UK Government for the benefit of developing countries, UK.
    Provided funding to make this review open access

Differences between protocol and review

Large numbers of studies can threaten the quality of the analysis in qualitative evidence syntheses. In addition, syntheses of qualitative studies aim for greater variation in concepts as opposed to an exhaustive sample that aims to avoid bias. We stated a priori that we would consider between 30 to 40 eligible studies to be sufficient, and a manageable number for this synthesis. We proposed to select a purposive sample from the eligible studies in case over 40 eligible articles were included (Silverman 2000). In this synthesis, we did not need to sample from the included studies, given that we only had 31 eligible studies. We may consider sampling of included studies in future updates of this review.

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