Solnes Miltenburg et al.

Systematic Reviews 2013, 2:11

http://www.systematicreviewsjournal.com/content/2/1/11

PROTOCOL Open Access

A protocol for a systematic review of

birth preparedness and complication readiness
programs
Andrea Solnes Miltenburg1*, Yadira Roggeveen1, Marianne van Elteren2, Laura Shields1, Joske Bunders1,
Jos van Roosmalen2 and Jelle Stekelenburg3

Abstract
Background: One of the effective strategies for reducing the number of maternal deaths is delivery by a skilled
birth attendant. Low utilization of skilled birth attendants has been attributed to delay in seeking care, delay in
reaching a health facility and delay in receiving adequate care. Health workers could play a role in helping women
prepare for birth and anticipate complications, in order to reduce delays. There is little evidence to support these
birth preparedness and complication readiness (BP/CR) programs; however, BP/CR programs are frequently
implemented. The objective of this review is to assess the effect of BP/CR programs on increasing skilled birth
attendance in low-resource settings.
Methods: Due to the complexity of BP/CR programs and the need to understand why certain programs are more
effective than others, we will combine both quantitative and qualitative studies in this systematic review. Search
terms were selected with the assistance of a health information specialist. Three reviewers will independently select
and assess studies for quality. Data will be extracted by one reviewer and checked for accuracy and completeness
by a second reviewer. Discussion between the reviewers will resolve disagreements. If disagreements remain, a
third party will be consulted. Data analysis will be carried out in accordance with the BP/CR matrix, developed by
the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). Study data will be
grouped and analyzed by quality and study design and regrouped according to type of intervention strategy.
Discussion: This review will provide: 1) an insight into existing BP/CR programs, 2) recommendations on effective
elements of the different approaches, 3) proposals for concrete action plans for health professionals in the field of
reproductive health in resource-poor settings and 4) an overview of existing knowledge gaps requiring further
research.
Trial registration: PROSPERO registration no.: CRD42012003124
Keywords: Birth preparedness and complication readiness, Birth plan, Maternal mortality, Utilization, Skilled birth
attendant, Safe motherhood, Health education

* Correspondence: [email protected]
1
Athena Institute for Research on Innovation and Communication in Health
and Life sciences, Faculty of Earth and Life Sciences, VU University, De
Boelelaan 1105, 1081 HV, Amsterdam, the Netherlands
Full list of author information is available at the end of the article

© 2013 Solnes Miltenburg et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
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Background some promising results from a Nepalese study have been

Poor maternal health, leading to maternal death and published. Components of the birth-preparedness matrix
severe acute maternal morbidity, remains a major prob- were implemented and led to a 30% reduction in neo-
lem, especially in sub-Saharan Africa, where the ma- natal mortality and 75% reduction in maternal mortality
ternal mortality ratio (MMR) is declining steadily [1]. [9]. However, another Nepalese study on the implemen-
While a number of countries have made substantial pro- tation of a birth-preparedness package did not show any
gress in reducing child mortality, the high neonatal mor- change in the utilization of skilled birth attendants. This
tality rate and its link to obstetric causes is still of great study concluded that programs that merely encourage
concern [2]. The main direct causes for maternal death pregnant women to use skilled birth attendants were
and severe acute maternal morbidity are hemorrhage, not efficient and suggested research must go beyond
eclampsia, sepsis, obstructed labor and complications the household level in order to have a significant im-
arising from an unsafe abortion [3]. It is assumed that pact [10].
most cases of maternal death and severe acute mater- Although there is a paucity of evidence measuring the
nal morbidity can be prevented when births are as- effect of BP/CR, it has nevertheless been implemented
sisted by skilled birth attendants. Safe Motherhood as an essential part of antenatal care consultations. BP/
programs were successful in reducing maternal mor- CR is included in the new World Health Organization
tality by placing skilled birth attendants within func- (WHO) model for antenatal care as part of antenatal
tioning health systems, which include the availability care education. Several countries have adopted this new
of or referral to emergency obstetric care services [4]. model to fit the local context [11-13]. A growing num-
Packages of (integrated) interventions, including ante- ber of pregnant women make use of antenatal care
natal and postnatal care services, safe abortion services, services. Roughly 80% of the women in sub-Saharan Af-
and the availability of family planning services can fur- rica use antenatal care services at least once [14]. The
ther reduce severe acute maternal morbidity and im- WHO model proposes that antenatal care attendance
prove overall maternal health. It is expected that there should result in all pregnant women being aware of the
will be a reduction in both neonatal mortality and mor- need for skilled birth attendance as well as increased
bidity rates when these services are available [4-6]. How- knowledge of how and when to access skilled birth
ever, the availability of maternal health services does not attendants [12]. Despite the growing number of ante-
mean they that are affordable and accessible, provide good natal care visits, the number of births attended by skilled
quality of care and are used. birth attendants still lags behind. In Tanzania, for ex-
The low utilization of maternal health services is fre- ample, despite the antenatal care coverage rate of
quently analyzed with the Three Delays Model around 94% (one time visit), the rate of skilled birth at-
developed by Thaddeus and Maine (1994), which identi- tendance can be as low as 30%, especially in rural areas.
fies three phases of delay: delay in seeking care, delay in The same study found that two components of BP/CR,
reaching care and delay in receiving adequate care when health education and counseling, were the least likely
reaching a health facility [5]. Better knowledge of danger components of antenatal care to be provided [15].
signs means that the predictable elements of the three Evidence for the effect of antenatal care education and
phases of delay can be anticipated and prepared for with BP/CR programs on the reduction of the three phases of
a birth plan for each pregnancy. Birth preparedness and delay, ideally resulting in a reduction of maternal mor-
complication readiness (BP/CR) is a process of planning tality and morbidity, is limited [8,12] According to
for birth and anticipating actions needed in case of an Stanton (2004), reasons for the limited evidence include
emergency [7]. In 2001 the Johns Hopkins Program for the use of study samples that are too small to capture
International Education in Gynecology and Obstetrics the complexity of birth preparedness. Also, the historical
(JHPIEGO) developed the BP/CR matrix, which ‘deli- focus on collecting data on BP/CR using women as the
neates the roles of policymakers, facility managers, pro- primary target group has hampered the gaining of
viders, communities, families, and women in ensuring insights into the success or failure of interventions [8].
that women and newborns receive appropriate, effective, In many rural contexts, women are not the decision-
and timely care’ [7]. It is hypothesized that implementa- makers in the family and are thus rarely involved in
tion of BP/CR concepts that focus on individuals, fam- pregnancy-related decisions [14]. To gain insights into the
ilies and communities could reduce at least the first two involvement of decision-makers, interventions should in-
phases of delay. An operational BP/CR matrix means clude partners and other community members. For ex-
prepared health facilities that are able to handle child- ample, a woman is only fully prepared when, in addition
births and complications, thus contributing to a reduc- to having planned where to deliver (preferably with skilled
tion of the third phase of delay [7,8]. Although there is birth attendants), funds are allocated for transport and
little evidence that BP/CR interventions are effective, family members are identified to accompany her when
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labor starts or complications arise [7,14,16]. How to link inform important factors influencing BP/CR effectiveness
individuals, families and communities to health systems [21]. Recent literature shows that, although challenging,
that are capable of supporting birth preparedness, re- there are ways to include qualitative studies in systematic
quires further study. Examples of links include adequate reviews [20,22].
transportation services and health-care workers capable
of responding according to guidelines if there is an ob- Study inclusion criteria
stetric emergency while simultaneously attending to the The studies included are randomized controlled trials,
woman’s needs [10,14,16]. Representative samples of quasi-experimental studies, cohort studies, case control
involved actors are needed to evaluate BP/CR interven- studies, cross-sectional surveys and qualitative studies.
tions. The BP/CR matrix provides an overview of the Table 1 displays the PICOTS elements: participants, in-
different roles and responsibilities for the variety of tervention, control, outcome, timeframe and setting.
actors implementing BP/CR. So far, the main effect
measurements have mostly focused on health outcome Participants
indicators, such as mortality and morbidity rates; however, We have included women of reproductive age who are
the evaluation of the knowledge, intentions and behaviors pregnant at any given gestational stage or women who
of the various actors around childbirth might provide have recently given birth. We have restricted inclusion
insights into why BP/CR programs are effective or not. to women who have had births in the past two years to
Qualitative evaluation of BP/CR programs can assist this avoid recall problems, since we assume that recollections
process [8]. of pregnancy and birth experience more than two years
ago will be prone to bias. Husbands of pregnant women
Study design or husbands of women who recently gave birth are also
Aim and objectives included in the target population. The targeted popula-
The objective of this study is to assess the effect of BP/ tion also includes health workers who deliver pregnancy
CR programs on increasing skilled birth attendance in a care. This includes skilled birth attendants, health pro-
low-resource environment. We have chosen to focus on motion officers and community health workers, and
the effects of skilled birth attendance since it is expected others working in community, government or private
that this will give us an indication of the effects of BP/ (including faith-based) health institutions. We also in-
CR before any impact on mortality and morbidity is no- clude (trained) traditional birth attendants, because of
ticeable, especially since health outcome indicators such their important role in childbirth in many communities.
as MMR are difficult to obtain with sufficient accuracy
to measure progress [17]. Intervention and control
As there are several ways to implement and evaluate Interventions include single interventions that address
BP/CR interventions, the following key research one component of the BP/CR matrix, such as training of
questions need to be answered. health workers to deliver BP/CR education. Also inclu-
ded are combined interventions such as overall antenatal
1. To what extent do BP/CR programs result in care interventions and community health interventions
increasing skilled birth attendance. that include multiple BP/CR elements. Public health
2. What strategies are used to implement BP/CR? interventions usually consist of a package of components
3. What methodologies are used to measure the and can be seen as complex since the different compo-
effectiveness of BP/CR? nents can have independent and inter-dependent effects
4. Which factors influence the effectiveness of BP/CR? [20]. In the analysis and presentation of our results, we
will mention if BP/CR was part of a sole intervention or
Methods part of a combined approach. We expect that many in-
This systematic review follows the guidelines for a sys- terventions are not defined or described as relating to
tematic review as given in the Cochrane Handbook for birth preparedness but in fact do contribute to the pro-
Systematic Reviews of Interventions [18], the PRISMA cess of planning for birth. Since BP/CR comprises ele-
statement [19] and the guidelines published by the NHS ments of antenatal, intrapartum and postpartum care,
Center for Reviews and Dissemination [20]. As rando- interventions can take place in all or one of these phases
mized trials may be scarce in this area, excluding other of pregnancy and childbirth. Also interventions can take
quantitative data (for example, quasi-experimental stud- place at different levels of care (household, community,
ies) and qualitative data would substantially narrow the provider, facility and policy level). Interventions made on
evidence base and exclude valuable data. Furthermore, one level and those that cover all levels will be included.
quantitative evidence is needed to assess the effective- We anticipate difficulties in defining a control group,
ness of BP/CR, whereas qualitative data is needed to since elements of the BP/CR matrix have already been
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Table 1 Inclusion criteria (PICOTS elements)

PICOTS Inclusion criteria
Participants Pregnant women, women who have recently delivered, husbands of pregnant women, husbands of women who have recently
delivered, health-care providers, traditional birth attendants, all adults in the community (in low- and middle-income countries)
Intervention Antenatal care education containing BP/CR components, community programs including BP/CR, single BP/CR interventions, training
of health workers (skilled birth attendant, community health worker, health promotion officer), training of community volunteers
Control Standard practice
Outcome Preparedness: Knowledge of danger signs, creation of and applying a birth plan, funds allocated, transportation arrangements
Pregnancy: Antenatal care with skilled health worker
Delivery: Delivery by a skilled birth attendant, maternal and neonatal mortality and morbidity
Timeframe Duration of follow-up and possible exposure to the intervention
Setting Low- and middle-income countries. Interventions can use facility-based, community-based or home-based services
BP/CR, birth preparedness and complication readiness; PICOTS, participant, intervention, control, outcome, timeframe and setting.

incorporated into standard care. Control groups could re- period, and in the identification, management and refer-
ceive standard care or interventions that are not BP/CR ral of complications in women and newborns [23]).
interventions. Furthermore, control groups are generally
highly heterogeneous and depend on the available resour-
ces in low- and middle-income countries. In this study, we Secondary outcomes
define standard care as the care that is provided in clinics Maternal mortality: The death of a woman while preg-
according to local or national guidelines. However, we ac- nant or within 42 days of termination of pregnancy, irre-
knowledge that due to limited (human) resources these spective of the duration and site of the pregnancy, from
guidelines are not always adhered to [15]. Due to difficul- any cause related to or aggravated by the pregnancy or
ties in performing controlled interventions in rural set- its management, but not from accidental or incidental
tings, uncontrolled studies will also be included. causes [24].
Severe acute maternal morbidity or near miss: A
woman who nearly died but survived a complication that
Outcomes
occurred during pregnancy, childbirth or within 42 days
Studies will be included if they assess any of the primary
of termination of pregnancy [25].
or secondary outcomes mentioned below. Lower mater-
Neonatal mortality: The death of a neonate divided
nal and neonatal mortality might not necessarily be seen
between early neonatal mortality (death in the first week
as a result of the BP/CR elements alone and are, there-
of life) or late neonatal mortality (death after 7 to 28
fore, chosen as secondary outcomes. Since skilled birth
days of life) [2].
attendance sometimes is presented as a complementary
Neonatal morbidity or near miss: A neonate that
outcome rather than a main outcome measure we also
survived a life-threatening condition at birth or during
include studies that do not primarily promote the use of
the neonatal period as a result of adverse influences or
skilled birth attendance but contribute to reaching this
treatments (or non-treatments) during the neonatal
goal. For example, some facility-based studies focus more
period [26].
on service delivery and quality improvement, which in-
Knowledge/awareness: Knowledge of the importance
fluences health-care utilization indirectly. Although such
of pregnancy care and delivery care by a skilled birth at-
interventions might not directly result in increased skilled
tendant, the danger signs of pregnancy, the location of
birth attendance, it is assumed that they will contribute to
health institutions and/or emergency obstetric care and
the promotion of the use of skilled birth attendants in the
existing community services for emergencies (funds and
long run. Studies will also be included when the primary
transport) [8].
outcome is related to the use of (trained) traditional birth
Intention: The intention to save money for childbirth,
attendants.
to use a skilled birth attendant, to arrange for transport,
to contact health facilities when complications arise and
Primary outcome to use postpartum care [8].
Delivery by a skilled birth attendant (defined as an Practice/behavior: Women who had more than one
accredited health professional such as a midwife, doctor antenatal care visit, a birth plan was made, money
or nurse who has been educated and trained to profi- was saved, arrangements were made for emergency
ciency in the skills needed to manage uncomplicated transport, the birth was attended by a skilled birth
pregnancies, childbirth and the immediate postnatal attendant [8].
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Timeframe to see if they meet the inclusion criteria. Discussion

We will assess the duration of follow-up and possible ex- between the reviewers will resolve disagreements. If
posure to the intervention. It is expected that the length disagreements remain, a third party (JB, JR or JS) will
of time required for interventions to show any effect be consulted. A flow chart showing the number of
from the use of skilled birth attendants could easily ex- studies remaining at each stage will be used according to
ceed 3 to 5 years. We anticipate that improvements in the PRISMA statement [19]. The flow chart is given in
knowledge, intentions and behavior with regard to birth Additional file 2.
preparedness could be measured earlier, but will ultim-
ately result in improvements in the use of skilled birth Quality criteria
attendants [7]. The quality of the included studies will be assessed by
the three reviewers independently. Two instruments will
Setting be used in the quality assessment of quantitative and
We decided to review evidence from populations in low- qualitative studies. The risk of bias of quantitative stu-
and middle-income countries as classified by the World dies will be assessed using the criteria outlined in the
Bank [27]. Study settings for interventions can be facility Cochrane Handbook for Systematic Reviews of Interven-
based, community based or home based. tions [18]. Although there has been considerable debate
on how the quality of qualitative research should be as-
Search methods sessed, several studies have successfully included qualita-
To identify relevant studies, the following three biblio- tive studies along with quantitative studies in systematic
graphic databases will be searched: PubMed, Embase reviews [28,29]. Several appraisal tools have been develo-
and CINAHL (Cumulative Index to Nursing and Allied ped. For this research, we will make use of the criteria
Health Literature). We will hand search potentially rele- developed by Walsh and Downe (2006). After reviewing
vant internet sources such as African Index Medicus, all the existing frameworks and checklists, they deve-
African Journals Online and the World Health Orga- loped a workable list of essential criteria classified into
nization (WHO) library to increase the likelihood of eight key areas: scope and purpose, design, sampling
including studies from low-resource environments. In strategy, analysis, interpretation, reflexivity, ethical di-
addition we will check relevant web pages from the mensions, and relevance and transferability [30]. All
WHO, the Population Council and Google Scholar for articles based on qualitative data will be assessed ac-
additional grey literature. All reference lists in retrieved cording to these eight criteria and will be rated as
articles will be checked to see if they contain additional strong, moderate or weak. See Additional file 3 for a
relevant studies. The searches will be limited to detailed overview of the assessment tool for qualita-
publications that have been published between 1 January tive studies.
1987 and 1 October 2012, that are in English and are for
low- and middle-income countries. A health information Data extraction
specialist assisted in the selection of search terms. The Study data will be extracted using a standard format and
literature search will use the following keywords in rela- entered into Microsoft Excel spreadsheets. Data will be
tion to pregnancy: health, knowledge, attitudes, practi- extracted by one reviewer and checked for accuracy and
ces; birth preparedness or birth plan; safe motherhood; completeness by a second reviewer. Data to be extracted
empowerment; women’s (or maternal) autonomy. Based include identification features of the study (setting, study
on a pilot search we excluded ‘complication readiness’, design, outcomes and funding sources), stakeholder
‘education’ and ‘counseling’ from our search because group(s) involved in the intervention (policymakers, fa-
relevant articles also appeared with the selected key- cility managers, providers, communities, families and
words and these additional terms were judged to be un- women), whether the intervention is focused on ante-
necessary. The preliminary search strategy is given in natal, intrapartum and/or postpartum care, type of inter-
Additional file 1. vention strategy (single or combined interventions) and
level of evidence (according to the Oxford levels of evi-
Study selection dence [31]).
Three reviewers (ASM, YR and ME) will independently
search and screen abstracts and titles in duplicate. The Data analysis and synthesis
titles and abstracts for articles found will be matched First, the analysis will use the BP/CR indicators
against the BP/CR matrix. The full articles will retrieved developed by JHPIEGO [32]. The matrix provides an
for all included articles or those that remain unclear and overview of all stakeholders with a shared responsibility
which will be assessed to see if they match the inclusion for BP/CR such as policymakers, health-care providers
criteria. Reviewers will independently review the articles and communities. It includes all elements for which
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individual stakeholders are responsible in either preg- assess an element of antenatal care that has gained at-
nancy, childbirth or the postpartum period. The format tention in recent years, namely the development of a
of this matrix can be seen in Additional file 4. Study data birth plan. Recent interventions have aimed to raise
for each stakeholder will be grouped and analyzed by awareness and the knowledge of mothers, families and
quality and study design (quantitative or qualitative communities, stressing that they are responsible for
studies). After this, the study data will be collected and developing a birth plan and demanding skilled birth at-
regrouped according to the type of intervention strategy. tendance. The effectiveness of this intervention is prom-
From this, a descriptive analysis of the included studies ising, although to what extent and why needs to be
will be formulated, identifying those types of interven- determined. The knowledge gained from this review
tion that have an effect on primary and secondary should therefore be of interest to those involved in re-
outcomes. productive health matters in low- and middle-income
We anticipate that there will be substantial heterogen- countries, ranging from midwives and clinical officers on
eity between studies regarding both interventions and the ground, to academic researchers and decision-
outcomes. If it is possible to cluster studies and compute makers at the policy level. Also communities, families
an effect size for a number of outcomes for at least three and women will be targeted. We will make use of dis-
studies, we will conduct a meta-analysis of randomized semination strategies such as publishing in relevant
controlled trials. The meta-analysis will be performed peer-reviewed journals and presenting at conferences.
using the Cochrane Review Manager (the Cochrane Col- To reach midwives and clinical officers on the ground,
laboration, Copenhagen, Denmark) [33]. If a meta- we will channel the results through those non-
analysis is conducted, we will consider heterogeneity governmental organizations interested in our results and
using the chi-square test for homogeneity with statistical through decision-makers. They will be encouraged to
significance P < 0.05 and where I2 is the percentage of forward the message to communities, families and
variation between studies due to heterogeneity rather women. Decision-makers will be reached through repro-
than chance. Inclusion of cluster-randomized controlled ductive health seminars and conferences and through
trials in the meta-analysis will be analyzed and reported face-to-face discussions of our findings.
separately from randomized controlled trials. For dichot-
omous outcomes, we will compute the odds ratio with a Discussion
confidence interval of 95% to estimate the effect size, Expected significance of the study
and the standardized mean difference for continuous With the growing demand for evidence based
outcome variables. interventions of Safe Motherhood programs, this review
The aim of this review is to assess the effects of BP/ will add to the evidence base of effective promotion and
CR programs. However, the effects are not merely implementation of BP/CR programs. This review will
outcomes. We are also interested to know why certain provide 1) an insight into existing BP/CR programs, 2)
programs seem to be more effective than others. There- recommendations on effective elements within the dif-
fore, we also propose to conduct a narrative synthesis, ferent approaches, 3) proposals for concrete action plans
making use of the available qualitative studies. Narrative for health professionals in the field of reproductive
synthesis can be used in systematic reviews to tell the health in resource poor settings and 4) an overview of
story behind the numbers and provide a new body of existing knowledge gaps that require further research.
knowledge to explain the effect. To avoid any chance of
bias and remain systematic in our approach, we will
make use of the narrative syntheses framework described Additional files
in the guidance report developed by the UK Economic
Additional file 1: Search strategy on 12 November 2012. PubMed
and Social Research Council. A flow chart summarizing (12 November 2012).
the synthesis process is given in Additional file 5 [34]. Additional file 2: PRISMA 2009 flow chart (Moher et al. [19]).
When the qualitative studies support the outcomes of Additional file 3: Quality assessment tool for qualitative studies –
the quantitative studies, we will use triangulation methods. based on criteria developed by Walsh and Downe [30].
If, however, there is a disconnect we will analyze it and Additional file 4: Birth-preparedness and complication-readiness
provide advice for future research. (BP/CR) matrix (adapted from the Maternal and Neonatal Health
Program).
Additional file 5: Flow chart for synthesis process (adapted from
Dissemination guidance developed by Popay et al., [34]).
Skilled birth attendance is an essential element through
which maternal and neonatal health problems can be
Abbreviations
reduced. Several interventions aim to increase the BP/CR: birth preparedness and complication readiness; JHPIEGO: John
utilization of skilled birth attendance. This review will Hopkins Program for International Education in Gynecology and Obstetrics;
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MMR: Maternal mortality ratio; PICOTS: Participant, intervention, control, Fox-Rushby J, Hutton G, Bergsjø P, Bakketeig L, Berendes H, Garcia J, WHO
outcome, timeframe and setting; WHO: World Health Organization. Antenatal Care Trial Research Group: WHO antenatal care randomized
controlled trial for the evaluation of a new model of routine antenatal
Competing interests care. Lancet 2002, 357(9268):1551–1564. http://www.ncbi.nlm.nih.gov/
The authors declare that they have no competing interests. pubmed/11377642.
12. Di Mario S, Basevi V, Gori G, Spettoli D: What is the Effectiveness of Antenatal
Authors’ contributions Care? (Supplement). Copenhagen: WHO Regional Office for Europe Health
ASM, YR and ME formed the review team and designed the study. LS was Evidence Network; 2005. http://www.euro.who.int/__data/assets/pdf_file/
consulted on the methodology. JB, JR and JS provided expert advice and 0005/74660/E87997.pdf.
assisted with the study design. All authors read and approved the final 13. von Both C, Flessa S, Makuwani A, Mpembeni R, Jahn A: How much time
manuscript. do health services spend on antenatal care? Implications for the
introduction of the focused antenatal care model in Tanzania.
BMC Pregnancy Childbirth 2006, 6:22. http://www.biomedcentral.com/
Acknowledgments
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1
Athena Institute for Research on Innovation and Communication in Health 15. Magoma M, Requejo J, Merialdi M, Campbell OM, Cousens S, Filippi V: How
and Life sciences, Faculty of Earth and Life Sciences, VU University, De much time is available for antenatal care consultations? Assessment of
Boelelaan 1105, 1081 HV, Amsterdam, the Netherlands. 2Department of the quality of care in rural Tanzania. BMC Pregnancy Childbirth 2011, 11:64.
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University Medical Center (VUmc), Van der Boechorststraat 7, 1081, BT 16. Pembe AB, Carlstedt A, Urassa DP, Lindmark G, Nystrom L, Darj E:
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doi:10.1186/2046-4053-2-11
Cite this article as: Solnes Miltenburg et al.: A protocol for a systematic
review of birth-preparedness and complication-readiness programs.
Systematic Reviews 2013 2:11.

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