title: Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change.
abstract: BACKGROUND
  The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries.
  
  
  METHODS
  A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature.
  
  
  RESULTS
  Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52%-65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71%-75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors.
  
  
  CONCLUSIONS
  This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health.
authors.affiliation: Tanzanian Training Centre for International Health, Ifakara, Tanzania. nyamtema_angelo@yahoo.co.uk
authors.forename: Angelo S
authors.initials: AS
authors.lastname: Nyamtema
authors.forename: David P
authors.initials: DP
authors.lastname: Urassa
authors.forename: Jos
authors.initials: J
authors.lastname: van Roosmalen
mesh_terms: D003906:Developing Countries; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008427:Maternal Health Services / Q000379:methods / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D008429:Maternal Welfare / Q000706:statistics & numerical data*; D011247:Pregnancy; D015397:Program Evaluation