title: Barriers to obstetric care at health facilities in sub-Saharan Africa--a systematic review protocol.
abstract: BACKGROUND
  Since the launch of the Millennium Development Goals (MDGs) by the United Nations in 2000, the global community has intensified efforts to reduce adverse maternal health outcomes, especially, in sub-Saharan Africa. Despite these efforts, there is an increasing concern that the decline in maternal deaths has been less than optimal, even for women who receive birthing care in health facilities. High maternal deaths have been attributed to a variety of issues such as poor quality of care, inadequate resources, poor infrastructure, and inaccessibility to healthcare services. In other words, even in settings where they are available, many women do not receive life-saving obstetric care, when needed, despite the fact that basic and comprehensive obstetric care is widely recognized as a key to meeting maternal health goals. It is important to understand the common challenges that this developing region is facing in order to ensure a more rapid decline in adverse maternal health outcomes. The aim of this review is to synthesize literature on barriers to obstetric care at health institutions which focuses on sub-Saharan Africa, the region that is most affected by severe maternal morbidity and mortality.
  
  
  METHODS
  This review follows guidelines by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. An electronic search of published literature will be conducted to identify studies which examined barriers to health facility-based obstetric care in sub-Saharan Africa. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases will be searched. Published articles in English, dated between 2000 and 2014, will be included. Combinations of search terms such as obstetric care, access, barriers, developing countries, and sub-Saharan Africa will be used to locate related articles, and eligible ones retained for data abstraction. A narrative synthesis approach will be employed to synthesize the evidence and explore relationships between included studies.
  
  
  CONCLUSIONS
  Information on the barriers to obstetric care is needed to inform policies for the improvement of maternal health. This review will contribute to providing related vital evidence to facilitate removal of barriers to maternal health services and interventions.
  
  
  BACKGROUND
  PROSPERO 2014:CRD42014015549 .
authors.affiliation: College of Health and Biomedicine, Victoria University, PO Box 14428, Melbourne, Victoria, 8001, Australia. minerva.kyeinimakoh@live.vu.edu.au.
authors.forename: Minerva
authors.initials: M
authors.lastname: Kyei-Nimakoh
authors.affiliation: College of Health and Biomedicine, Victoria University, PO Box 14428, Melbourne, Victoria, 8001, Australia. mary.carolan@vu.edu.au.
authors.forename: Mary
authors.initials: M
authors.lastname: Carolan-Olah
authors.affiliation: College of Health and Biomedicine, Victoria University, PO Box 14428, Melbourne, Victoria, 8001, Australia. Terence.McCann@vu.edu.au.
authors.forename: Terence V
authors.initials: TV
authors.lastname: McCann
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D036861:Delivery, Obstetric; D003906:Developing Countries; D005260:Female; D006268:Health Facilities; D006297:Health Services Accessibility; D006801:Humans; D008428:Maternal Mortality; D007744:Obstetric Labor Complications / Q000628:therapy*; D011247:Pregnancy; D012107:Research Design; D000078202:Systematic Reviews as Topic