Interventions to enhance healthcare utilisation among pregnant women to reduce maternal mortality in low- and middle-income countries: a review of systematic reviews
Authors: Mzembe Themba , Chikwapulo Victor , Kamninga Tony Mwenda , Vellemu Ruth , Mohamed Sahra , Nthakomwa Lomuthando , Chifungo Chimwemwe , Wazny Kerri , Musau Kelvin , Abdullahi Leyla , Peterson Maame , Madise Nyovani , Chipeta Michael G 
Published: March 2023

Abstract
Background

Maternal mortality in low- and middle-income countries (LMIC) has reduced considerably over the past three decades, but it remains high. Effective interventions are available, but uptake and coverage remain low. We reviewed and synthesised evidence from systematic reviews on interventions to increase healthcare services utilisation to reduce maternal mortality among pregnant women in LMICs.

Methods and findings

We searched PubMed Medline and Cochrane Library databases for systematic reviews published between January 2014 and December 2021, investigating interventions to increase healthcare services uptake among pregnant women in LMICs. We used the AMSTAR tool (A Measurement Tool to Assess Systematic Reviews) to assess the methodological quality of the included reviews. We extracted data on the interventions and their effects and grouped them into broad groups based on the outcomes reported in each systematic review.
We retrieved 4,022 articles. After removing duplicates, and performing title, abstract and full-text screening, we included 14 systematic reviews. The methodology quality of the included systematic reviews was from moderate to high.
Male partner involvement interventions
Interventions involving male partners were effective in increasing institutional delivery (one review, six studies); skilled attendance at delivery (one review, five studies); postnatal visits (one review, four studies); and maternal antiretroviral (ART) uptake for HIV-positive pregnant women (one review, three studies). However, there was no evidence of their effectiveness on increased early ANC initiation (less than 12 weeks gestation) or adequate ANC visits (at least four visits) (one review, four studies).
Mobile health interventions
Mobile health interventions were effective in increasing adequate ANC visits (three reviews, six studies), skilled attendance at delivery (two reviews with four studies), facility-based service utilisation (one review with three studies), early ANC initiation (one review with one study), and adherence to nutritional supplements (one review with five studies).
Interventions involving giving incentives
Only one systematic review reported interventions involving financial incentives and showed that incentives were effective in increasing the number of ANC visits but were ineffective in increasing postnatal visits.
Health systems: facility-based interventions
Facility-based health systems interventions were effective in increasing postnatal visits (one review with fourteen studies), maternal ART initiation and uptake (four interventions in one review with nine studies), immunisation uptake and follow-up ANC visits (one study each in one review). None of the reviews assessed the effect of facility-based interventions on increased facility delivery, adequate ANC visits or skilled attendance at delivery.
Health systems: community-based interventions
Community-based health-systems interventions were effective in increasing skilled attendance at delivery (one review with two interventions), ANC service utilisation (one review with two interventions), institutional delivery (one review with sixteen studies), ART initiation and uptake (two interventions in one review), and nutritional supplements and immunisation uptake (one review, seven and ten studies respectively).

Conclusion

Different interventions effectively improved healthcare service utilisation on the maternal healthcare continuum. Implementing these interventions in combination has the potential to enhance healthcare service uptake further.