| Sociocultural barriers sometimes hindered mothers from receiving care in hospitals. For instance, women preferred not to be examined by male health providers, or for cultural reasons preferred a particular position in which to deliver, or for religious reasons did not divulge information that was needed for their care. | Blum 2006; Khalaf 2009; Thorsen 2012 | Low confidence | Due to moderate concerns about adequacy; and moderate concerns about relevance |
| Health workers had conflicting views on the role of professional councils. For instance, some viewed professional councils as advocates for their members, while others viewed them as a regulatory body with punitive functions. | VSO 2012 | Very low confidence | Due to moderate concerns about methodological quality; and moderate concerns about relevance; and severe concerns about adequacy |
| Staff shortage was a widely reported problem and led to increased workloads, which in turn compromised quality of care. For instance, heavy workload limited health worker time for history taking and thorough assessment of women, and hand hygiene was sometimes compromised. Staff shortages and work overload jeopardised health workers’ ability to provide timely care, and manage routine care as well as emergency cases. In addition, shortage of staff sometimes led health workers to exceed their scope of practice, and influenced a health facility's ability to provide 24‐hour care. | Afsana 2001; Anwar 2009; Barua 2011; Bradley 2009; Conde‐Agudelo 2008; Fränngård 2006; Fujita 2012; Graner 2010; Hassan‐Bitar 2011; Ith 2012; Khalaf 2009; Lugina 2001; Maputle 2010; Mathole 2006; Mondiwa 2007; Spangler 2012; Thorsen 2012; VSO 2012 | Moderate confidence | Due to minor concerns about coherence; and minor concerns about methodological limitations |
| A lack of specialists or experienced staff, including absence of health workers with key skills such as anaesthetists, influenced the provision of care and supervision of junior staff. When no specialists were available, some tasks such as emergency obstetric care were not delivered at all, or tasks were transferred to health workers who were not properly qualified or trained to deliver them. When senior experienced health workers were not available, junior health workers lacked supervision. | Afsana 2001; Anwar 2009; Blum 2006; Bradley 2009; De Brouwere 2009; Fränngård 2006; Hassan‐Bitar 2011; Khalaf 2009; Penfold 2013; Pitchforth 2010; Spangler 2012; VSO 2012 | Moderate confidence | Due to moderate concerns about methodological limitations |
| Health workers had vague job descriptions that sometimes led them to perform tasks that were beyond their expertise or scope of practice. | Bradley 2009 | Very low confidence | Due to minor concerns about methodological limitations; and serious concerns about relevance and adequacy |
| Staff shortages and work overload could jeopardise health workers’ ability to display support, empathy, and friendliness to women in labour. | Conde‐Agudelo 2008; Maputle 2010; VSO 2012 | Very low confidence | Due to minor concerns about methodological limitations; and moderate concerns about relevance and adequacy |
| Staff shortages and increased workload, as well as living and work conditions, sometimes caused stress and frustration, affected health workers' family life, and led to concerns about personal safety. | Anwar 2009; Blum 2006; Fränngård 2006; Graner 2010; Lester 2003; VSO 2012 | Moderate confidence | Due to moderate concerns about methodological limitations; and minor concerns about relevance and adequacy |
| A wide range of interlinked reasons for staff shortages were suggested. These included limited funds to recruit health workers; bureaucratic processes of the recruitment process, e.g. absence of committees responsible for recruitment at the district level; scarcity of health workers especially in rural areas; and other factors that deterred retention of health workers (see finding on factors affecting recruitment, Table 1). In addition, institutional arrangements, e.g. when health facilities hired contract staff in order to reduce labour costs, and inefficient deployment of available staff sometimes created staff shortages. Facilities with staff shortages and work overload were viewed as unattractive places to work, and made it difficult for managers to transfer staff from well‐served to underserved areas, thus compounding/increasing the problem. | Anwar 2009; Graner 2010; Molina 2011; Pitchforth 2010; VSO 2012 | Moderate confidence | Due to moderate concerns about adequacy; and minor concerns about relevance and methodological limitations |
| Health workers' salaries and benefits were considered insufficient for the work done, the responsibility and personal risk, and the additional responsibilities assigned, e.g. through informal task‐shifting. In addition, salaries were insufficient for their personal needs, e.g. to send their children to school and for transport costs to visit their husbands.
Low salaries and incentives sometimes led to a lack of motivation and poor performance, absenteeism, and increased rates of dual practice. | Anwar 2009; Belizan 2007; De Brouwere 2009; Fränngård 2006; Graner 2010; Hassan‐Bitar 2011; Ith 2012; Molina 2011 | Moderate confidence | Due to moderate concerns about methodological limitations; and minor concerns about relevance and adequacy |
| Factors reported by health workers or their managers to influence recruitment, retention, motivation, or performance of health workers were: good‐quality accommodation for health workers provided by government, allowances for extra project‐related work, paid vacations for 1 month of the year, improved access to and funding for continued education/in‐service training, career progression, non‐biased evaluations or performance‐related rewards or promotions, e.g. for those doing better, working longer, or taking on added responsibilities, and verbal recognition by supervisors and management. 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 needed to maintain clinical skills, lack of family amenities, limited opportunities for private practice, lack of electricity, TV, or internet, coupled with poor roads and lack of transport deterred health workers from undertaking rural employment. In addition, interference in treatment decisions by local politicians and mismanagement of posting and transfer from the national level were demotivating to health workers working in rural facilities. | Anwar 2009; Bradley 2009; De Brouwere 2009; Fränngård 2006; Hassan‐Bitar 2011; Ith 2012; VSO 2012 | Moderate confidence | Due to minor concerns for methodological limitations and relevance |
| Health workers perceived managers as lacking in management capacity and skills and sometimes felt unsupported. Health workers also complained that concerns about the workplace were sometimes left unheard, and no solutions or feedback given. | Anwar 2009; Bradley 2009; Ith 2012; Lester 2003; Mondiwa 2007; VSO 2012 | Moderate confidence | Due to moderate concerns about relevance; and minor concerns about methodological limitations and adequacy |
| Helping women access financial assistance for out‐of‐pocket payments was sometimes time‐consuming for health workers. | Pitchforth 2006 | Very low confidence | Due to serious concerns about relevance and adequacy |
| Inadequate pre‐service and in‐service training sometimes limited health workers' skills and ability to provide care. For instance, some health workers lacked training to attend home births or manage complicated pregnancies or deliveries, e.g. eclampsia or HIV in pregnancy. In contrast, training allowed midwives to practice assisting women to deliver in non‐supine positions and enabled them to get accustomed to this practice. | Afsana 2001; Barua 2011; Blum 2006; DeMaria 2012; Fujita 2012; Graner 2010; Lester 2003; Mathole 2006 | High confidence | ‐ |
| Health worker competencies and opportunities for on‐the job training were sometimes limited by poor scheduling of in‐service education sessions, high cost of continuing education for health workers, inequitable selection for professional development opportunities, lack of ongoing training and follow‐up, and shortage of instructors for upgrading courses. 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. | Fränngård 2006; Ith 2012; Pettersson 2006; Spangler 2012 | Moderate confidence | Due to minor concerns about methodological limitations and relevance; and moderate concerns about adequacy |
| Learning through practical application facilitated 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. | DeMaria 2012 | Very low confidence | Due to moderate concerns about methodological limitations and relevance; and severe concerns about adequacy |
| Health workers reported several barriers to implementing recommended practice. Firstly, health workers were sometimes unaware of current recommended effective practices. Secondly, health workers' flexibility, attitudes, and beliefs about medical knowledge and skills sometimes influenced their receptivity to new practice knowledge. For example, health worker attitudes did not view medical education as dynamic; held beliefs that no significant progress had been made and clinical practice was similar to techniques learnt many years ago; or were not flexible or willing to implement alternative positions of delivery, even though these were preferred by women. | Conde‐Agudelo 2008; Pettersson 2006; Pitchforth 2010 | Low confidence | Due to moderate concerns about relevance and adequacy |
| Lack of time, infrastructure, and skills limited health workers' ability to seek knowledge and practice new clinical skills. For instance, chronic staff shortages meant less time available for health workers to seek information. This was sometimes further compounded by lack of information sources such as internet access, and poorly resourced hospital libraries. In addition, lack of training and skills in networking, epidemiology, research appraisal, or critical thinking about clinical practice limited health workers' awareness and receptivity to clinical practice changes, and this lack of skills led some professionals to prefer old, familiar procedures. | Afsana 2001; Belizan 2007; Conde‐Agudelo 2008; Lugina 2001 | Low confidence | Due to moderate concerns about relevance and adequacy; and minor concerns about methodological limitations |
| Lack of guidelines/protocols, or where they were inconsistent or health workers were not aware or were uncertain of them, could impact patient care and outcomes and cause harm. | Barua 2011; de Carvalho 2012; Khalaf 2009; Lugina 2001; Mathole 2006 | Low confidence | Due to moderate concerns about adequacy; and minor concerns about methodological limitations |
| Health workers did not always adhere to protocols/guidelines, even when they were aware of them. Guidelines/protocols were not followed for a number of reasons. Some health workers felt that guidelines were insufficient without consensus from staff. Some studies described how health workers continued to practice ineffective procedures because they were considered routine; due to lack of time; because they lacked the autonomy to avoid using what they knew to be inappropriate care; because the resources at the institution were not aligned with the protocols for postpartum care; or when it was unclear who was professionally responsible, e.g. in using the partograph. | Belizan 2007; de Carvalho 2012; Conde‐Agudelo 2008; Molina 2011; Pettersson 2006 | Low confidence | Due to moderate concerns about methodological limitations, relevance, and adequacy |
| 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’. | Belizan 2007 | Very low confidence | Due to moderate concerns about relevance; serious concerns about adequacy; and minor concerns about methodological limitations |
| Some health workers did not use recommended interventions when delivering care because of 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. | Barua 2011 | Very low confidence | Due to moderate concerns about relevance; serious concerns about adequacy; and minor concerns about methodological limitations |
| Health workers were sometimes reluctant to admit their lack of skills in delivering care for fear of blame and criticisms from managers. This fear of criticism could undermine health worker confidence and performance. | Lugina 2001; Pettersson 2006; Thorsen 2012 | Low confidence | Due to minor concerns about relevance; and moderate concerns about adequacy |
| Insufficient stock and/or lack of drugs such as hydralazine, magnesium sulphate, oxytocin, misoprostol, antiretrovirals, and supplies such as gloves, sometimes influenced the quality of care provided to mothers and their babies. For instance, health workers had to use less effective alternative drugs, e.g. diazepam instead of magnesium sulphate. Lack of supplies sometimes limited good hygiene and practice of aseptic techniques, resulting in unsafe practices, e.g. reuse of disposable gloves could increase the risk of HIV infection. Lack of supplies sometimes led to poor outcomes and increased the length of stay in health facilities. Lack of supplies could determine if a new clinical practice was implemented and maintained over time. | Anwar 2009; Belizan 2007; Bradley 2009; de Carvalho 2012; Foster 2006; Fränngård 2006; Graner 2010; Ith 2012; Lester 2003; Mathole 2006; Penfold 2013; Pitchforth 2010; Spangler 2012; VSO 2012 | Moderate confidence | Due to moderate concerns about methodological limitations |
| Lack of drugs or supplies meant mothers or their carers had to purchase their own. This sometimes led to wasted time in procuring the drugs and supplies and the creation of informal markets and corruption at health facilities. | Barua 2011; Foster 2006; Fränngård 2006; Lester 2003; Pitchforth 2010; Spangler 2012; VSO 2012 | Low confidence | Due to moderate concerns about methodological limitations and adequacy; and minor concerns about coherence |
| Lack of equipment limits health workers' ability to deliver quality care to mothers and their babies. As a result of this lack of equipment, mothers and their babies sometimes received poor quality care. | Barua 2011; Fränngård 2006; Graner 2010; Lester 2003; Molina 2011; Penfold 2013; Pettersson 2006; Pitchforth 2010 | High confidence | ‐ |
| Lack of blood or limited infrastructure to manage blood transfusion limited health workers from delivering appropriate care. | Afsana 2001; Anwar 2009; Ith 2012 | Moderate confidence | Due to moderate concerns about adequacy; and minor concerns about relevance |
| Lack of equipment, supplies, or drugs sometimes wasted health workers' time, increased their workload and risk of infection, and led to low morale. | Belizan 2007; Bradley 2009; Foster 2006; Graner 2010; Lester 2003; Mathole 2006; Penfold 2013; Pitchforth 2010; VSO 2012 | Moderate confidence | Due to moderate concerns about methodological limitations; and minor concerns about coherence |
| Poor, incomplete, and non‐systematised patient information could lead to delayed or incorrect management of high‐risk mothers, or interfered with continuity of care. | Molina 2011; Pettersson 2006 | Low confidence | Due to serious concerns about adequacy |
| Lack of or unreliable supply of electricity, including a lack of fuel to run generators, and lack of water influenced health providers' ability to deliver quality care. | Anwar 2009; Pitchforth 2010; Spangler 2012; VSO 2012 | Moderate confidence | Due to moderate concerns about methodological limitations |
| The lack of space and amenities as well as poor physical layout and organisation of wards limited the delivery of quality care. | Belizan 2007; Conde‐Agudelo 2008; DeMaria 2012; Fränngård 2006; Khalaf 2009; Lester 2003; Molina 2011; Pettersson 2006; Pitchforth 2010 | Moderate confidence | Due to minor concerns about adequacy, relevance, and methodological limitations |
| The lack of funds and material resources sometimes prevented health facility managers from adequately maintaining equipment and physical infrastructure. | Ith 2012; Pettersson 2006; VSO 2012 | Low confidence | Due to minor concerns about coherence; and moderate concerns about methodological limitations and adequacy |
| Health facilities varied in the availability, functionality, and quality of interventions assigned as signal functions for obstetric care. At the lower‐level facilities, most of these functions were not available, e.g. parenteral antibiotics or anticonvulsants or neonatal resuscitation. At the higher levels, some of these functions appeared to be available, but functionality varied, for instance when there were drug stock‐outs or unqualified providers of care. | Afsana 2001; Spangler 2012 | Very low confidence | Due to moderate concerns about methodological limitations, relevance, and adequacy |
| Health workers felt it was easier to deliver care in facilities than at home. Some of the positive aspects about delivering care at the health facility were that they were able to do other work while monitoring labour; provide care for several mothers; 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 (e.g. episiotomies) were easier to perform. In addition, health facilities provided a secure, controlled, hygienic work environment, where electricity, equipment, and medications were always available. | Blum 2006 | Very low confidence | Due to moderate concerns about relevance; and serious concerns about adequacy |
| Where primary care workers in lower‐level facilities lacked the knowledge and the skills to determine the need for referral, or were unable to provide emergency care, mothers could receive inadequate care. This lack of skills could also result in unnecessary referrals to other health facilities. | Molina 2011 | Very low confidence | Due to minor concerns about methodological limitations; moderate concerns about relevance; and serious concerns about adequacy |
| Lack of trust and professional rivalries between midwives, doctors, and obstetrician gynaecologists may delay referral of mothers and their babies. Midwives sometimes felt blamed by physicians when complications arose and hesitated to seek support from the medical teams at the receiving facilities. Some midwives did not travel with the mothers to the referring facility for fear of blame for any negative occurrence during the referral process. | Ith 2012; Tabatabaie 2012 | Low confidence | Due to moderate concerns about adequacy and relevance |
| Respondents felt that maternal perceptions of the health system could make mothers reluctant to accept referral. For instance, mothers were sceptical about the cost of care, poor management and care at the next‐level facility, the procedures used, the high levels of Caesarean sections, and fear of complications. Also mothers may have already travelled far to reach the facility they perceive as a good one, or feared unfamiliar, urbanised settings. As a result of mothers' reluctance to accept referral, midwives may feel pressured to conduct high‐risk deliveries or spend a lot of time convincing reluctant mothers or their families. | Barua 2011; Blum 2006; Graner 2010; Lester 2003; Tabatabaie 2012 | Moderate confidence | Due to minor concerns about methodological limitations, coherence, relevance, and adequacy |
| The presence of trust between mothers and midwives may influence a mother's willingness to be referred. Referral may be delayed when facilities lack midwives or other primary care workers whom the mothers trust and who can convince mothers of the need for referral. | Tabatabaie 2012 | Very low confidence | Due to minor concerns about coherence and methodological limitations; moderate concerns about relevance; and serious concerns about adequacy |
| Lack of transport hinders referral of women and their babies to higher levels of care. For instance, this occurred when health facilities lacked ambulances, or when facility budgets were insufficient to purchase fuel for vehicles. | Fränngård 2006; Graner 2010; Molina 2011; VSO 2012 | Moderate confidence | Due to minor concerns about relevance and adequacy |
| Lack of fuel for vehicles when the need for referral arises is frustrating to nurses and midwives and leaves them feeling helpless when mothers' and babies' lives are at risk. | VSO 2012 | Very low confidence | Due to minor concerns about methodological limitations; moderate concerns about relevance; and serious concerns about adequacy |
| When health facilities lack fuel for vehicles, mothers and their families are sometimes asked to pay their own transport costs. Many families could not afford this. | Fränngård 2006; VSO 2012 | Low confidence | Due to moderate concerns about relevance and adequacy |
| 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 were working in isolation; when they were concerned about the facility's reputation when poor patient outcomes arose; or when they lacked supplies, drugs, or equipment to provide care. Some of these referrals were unnecessary and resulted in increased workloads at higher levels of care. | Anwar 2009; Barua 2011; Blum 2006; Ith 2012 | Low confidence | Due to moderate concerns about adequacy and relevance |
| When secondary‐level care was non‐existent, mothers were sometimes referred to tertiary‐level care, which resulted in congestion at the tertiary level. | Molina 2011 | Very low confidence | Due to minor concerns about methodological limitations; moderate concerns about relevance; and serious concerns about adequacy |
| Administrative processes and paperwork and poor communication between referring and receiving levels of care could influence the efficient transfer of mothers and their babies to receiving units. | Molina 2011 | Very low confidence | Due to minor concerns about methodological limitations; moderate concerns about coherence and relevance; and serious concerns about adequacy |
| Lack of feedback between the referring and receiving facilities could influence midwives' practice and patient outcomes. Midwives perceived this feedback as useful for improving their practice and patient outcomes. | Fränngård 2006 | Very low confidence | Due to moderate concerns about relevance; and serious concerns about adequacy |
| Poor attitude and unethical behaviour among health workers could influence the quality of care. For instance, when health workers are harsh, rude, or impatient with mothers; or display poor cultural sensitivity, e.g. by not maintaining women's privacy; or when health workers are absent from their duty stations or involved in the illegal sale of drugs and supplies or expect 'back door' payments for services. Some of the suggested underlying reasons for these attitudes and behaviours were wrong intrinsic reasons for joining the profession and physical exhaustion from long, solitary hours of work. | Afsana 2001; Hassan‐Bitar 2011; Spangler 2012; VSO 2012 | Low confidence | Due to moderate concerns about methodological limitations and adequacy; and minor concerns about relevance |
| Mothers' participation in decision‐making during labour could be limited by health worker attitudes and authoritarian behaviour, for instance when health workers conducted procedures without asking mothers for their opinion, or when physicians did not seek feedback from mothers about practices or outcomes and expected women to co‐operate. Lack of patient participation in decision‐making can threaten quality of care. Some of the reasons for this behaviour were related to health workers’ attitudes about the woman’s preferences and role during delivery of her baby. | Belizan 2007; de Carvalho 2012; Conde‐Agudelo 2008; DeMaria 2012; Maputle 2010 | Low confidence | Due to minor concerns about coherence and adequacy; and moderate concerns about methodological limitations and relevance |
| Some health workers did not value communication, communicated poorly, or said they had problems with communication. Poor communication and interaction could threaten the trust between health workers and mothers, for instance when health workers considered communication with mothers as a waste of time, and there was insufficient communication between staff and families, or when skilled birth attendants were abrasive and demeaning in their interactions with women and showed no concern for women's families. Language barriers could interfere with effective communication between mothers and health workers. As a result, mothers sometimes appeared not to listen to health workers while health workers mechanically worked through the process of providing care. Health workers acknowledged the need to respect and involve men, women's families, and the community in maternal health, e.g. in understanding cultural beliefs related to postpartum care. | Blum 2006; de Carvalho 2012; Hassan‐Bitar 2011; Lugina 2001; Maputle 2010 | Very low confidence | Due to moderate concerns about relevance and adequacy; and serious concerns about methodological limitations |
| Mismatch between people's 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, e.g. to give injections to speed up delivery as opposed to waiting for labour to progress normally. 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. In addition, misconceptions that midwives were not working when they took a break from their work, or that health workers sold drugs, threatened the trust between health workers and the community. | Barua 2011; Blum 2006; Hassan‐Bitar 2011; VSO 2012 | Low confidence | Due to moderate concerns about methodological limitations, relevance, and adequacy |
| Health workers valued the appreciation, respect, trust, and praise from mothers, or when they made friends among mothers or worked with the community. Midwives in particular were delighted when a baby was given their name and seeing the baby grow. | Bradley 2009; Fränngård 2006; VSO 2012 | Low confidence | Due to moderate concerns about methodological limitations, relevance, and adequacy |
| 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. For instance, midwife‐led shared care increased communication between midwives, women, and their families; enabled the presence and participation of family members; and together increased satisfaction in the care provided. As a result, the need for medication during delivery was minimised, which 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 | Very low confidence | Due to moderate concerns about relevance; and severe concerns about adequacy |
| Disrespectful communication, lack of trust, inadequate opportunities to review clinical practice, and poor teamwork and co‐ordination sometimes led to poor interprofessional relations. Also, tensions arose when health providers did not recognise each others' capabilities, and when they acted in a way that reinforced clinical hierarchy, e.g. disrespectful interprofessional communication between physicians and midwives. Midwives with lower‐level training could manage normal birth, but they felt marginalised and less motivated to provide care because midwives with higher levels of training and doctors used qualification, status, and their roles to dominate clinical practice. Tensions were reported between doctors and clinical officers due to salary differentials, benefits, workload, and status. There was sometimes a lack of understanding of competencies and alternative models of care. | Belizan 2007; Bradley 2009; DeMaria 2012; Hassan‐Bitar 2011; Ith 2012; Pettersson 2006 | Low confidence | Due to moderate concerns about relevance and adequacy |
| 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. For instance, midwives valued good interprofessional collaboration that made them feel accepted as part of the professional team and provided an opportunity to improve their competence through on‐spot education provided by obstetricians. When midwives worked together in a team led by midwives, this increased their ability to share experiences and new practices and their decision‐making responsibility; improved their self esteem; and provided quality assurance and improved the quality of care provided. This teamwork was especially useful when emergencies arose. In another study, researchers observed that nurses had a strong teamwork ethic and functioned well together to complete work. | Bradley 2009; Foster 2006; Fränngård 2006; Lester 2003; Pettersson 2006 | Low confidence | Due to moderate concerns about relevance and adequacy |
