Systematic review on human resources for health interventions to improve maternal health outcomes: Evidence from developing countries.

Background: Reducing maternal mortality has been a key item on the global health agenda. The fifth Millennium Development Goal has set a target of a 75 per cent reduction in maternal mortality by 2015. Nevertheless progress has been slow and child birth remains the leading cause of mortality and disability for women of reproductive age in low- and middle-income countries. Human-resource shortages inequitable access poor planning and inefficient management and distribution are some of the most important factors impeding efficient use of human resources for better maternal and child health outcomes. While there is a large body of literature and experience sharing on this topic there are no studies systematically reviewing this evidence to highlight the important lessons gaps and recommendations in the literature. Research objectives: To review and synthesise existing evidence on the implementation and effects of human resources for health (HRH) interventions on maternal health outcomes focusing on skilled birth attendants (defined as health personnel with midwifery skills). The review aims to draw out lessons learned identify gaps and offer recommendations for the improvement of HRH interventions for better maternal outcomes. Methodology: The authors included randomised quasi-randomised and before-after studies which evaluated interventions in system management of human resources for health (for example policy finance education partnership and leadership) related to skilled birth attendants in home community and referral facility settings in low- and middle-income countries. They also included qualitative and observational studies to gather information about the implementation context and the interventions. The authors excluded interventions provided by Traditional Birth Attendants and Community Health Workers. The authors searched peer-reviewed English-language literature published between 2000 and 2010. They searched the electronic database PubMed and the HRH Global Resource Centre examined cross-references and searched reference lists of identified studies. The authors analysed the results using narrative synthesis and thematic analysis. Quality assessment: The review uses appropriate methods to reduce risk of bias in terms of adopting explicit criteria for study inclusion screening and data-extraction processes and information about the included studies. However the review has some major limitations. The search was not sufficiently comprehensive within the grey literature and does not cover literature in languages other than English so it is not clear that publication bias was avoided. Finally the review does not assess the quality of the included studies. As a result the review does not make clear which evidence is subject to low risk of bias in assessing causality and it does not report and analyse findings separately by risk-of-bias status. This is a particular concern because the review includes a number of study designs with potentially high risk of bias in attributing effects to the intervention. The review does not acknowledge these limitations but nevertheless draws relatively strong policy conclusions.