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Background: Maternal mortality is a major challenge to health systems in Low and Middle-Income Countries (LMICs) where almost 99% of maternal deaths occurred in 2015. Primary-care facilities providing Basic Emergency Obstetric and Neonatal Care (BEmONC) facilities, and facilities that are midwife-led are appropriate for normal birth in LMICs and have been proposed as the best approach to reduce maternal deaths. However, the poor quality of maternal services that leads to decreased utilisation of these facilities is among the major causes of maternal deaths worldwide. This systematic review studied factors affecting the quality of care in BEmONC and midwife-led facilities in LMICs.
Methods: A number of public health and social science databases were searched using the following search terms: birth centre, skilled birth attendant, low-income/developing countries and quality of care. Articles in English discussing components of quality of care of BEmONC and midwife led facilities published since 1990 were included. Of the 67 full-text articles reviewed, 28 were included in the study based on inclusion and exclusion criteria. Data were extracted on a standard form and analysed thematically.
Results: Most articles were from Africa (n=20) and were quantitative surveys or cohort studies (n=14). Thematic analysis of the main ideas revealed various factors affecting quality of care including facility level determinants and other determinants influencing access to care. Facility-level determinants included these barriers: lack of equipment and drugs at the facility, lack of trained staff, poor attitudes and behaviour of service providers, and poor communication with women. Facility level positive determinants were: satisfaction with services, emotional support during delivery and trust in health providers. The access-to-care determinants were: socio-economic factors, physical access to the facility, maintaining privacy and confidentiality, and cultural values.
Improving quality of care of birthing facilities requires addressing both facility level and access-to-care determinants in order to increase utilization of the services available at the BEmONC and midwife-led facilities in LMICs.