title: Assessing emergency obstetric care provision in low- and middle-income countries: a systematic review of the application of global guidelines.
abstract: BACKGROUND
  Lack of timely and quality emergency obstetric care (EmOC) has contributed significantly to maternal morbidity and mortality, particularly in low- and middle-income countries (LMICs). Since 2009, the global guideline, referred to as the 'handbook', has been used to monitor availability, utilization, and quality of EmOC.
  
  
  OBJECTIVE
  To assess application and explore experiences of researchers in LMICs in assessing EmOC.
  
  
  METHODS
  Multiple databases of peer-reviewed literature were systematically reviewed on EmOC assessments in LMICs, since 2009. Following set criteria, we included articles, assessed for quality based on a newly developed checklist, and extracted data using a pre-designed extraction tool. We used thematic summaries to condense our findings and mapped patterns that we observed. To analyze experiences and recommendations for improved EmOC assessments, we took a deductive approach for the framework synthesis.
  
  
  RESULTS
  Twenty-seven studies met our inclusion criteria, with 17 judged as high quality. The highest publication frequency was observed in 2015. Most assessments were conducted in Nigeria and Tanzania (four studies each) and Bangladesh and Ghana (three each). Most studies (17) were done at subnational levels with 23 studies using the 'handbook' alone, whereas the others combined the 'handbook' with other frameworks. Seventeen studies conducted facility-based surveys, whereas others used mixed methods. For different reasons, intrapartum and very early neonatal death rate and proportion of deaths due to indirect causes in EmOC facilities were the least reported indicators. Key emerging themes indicate that data quality for EmOC assessments can be improved, indicators should be refined, a holistic approach is required for EmOC assessments, and assessments should be conducted as routine processes.
  
  
  CONCLUSIONS
  There is clear justification to review how EmOC assessments are being conducted. Synergy between researchers, EmOC program managers, and other key stakeholders would be critical for improved assessments, which would contribute to increased accountability and ultimately service provision.
authors: Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria; aduragbemibankethomas@gmail.com.
authors: Aduragbemi
authors: A
authors: Banke-Thomas
authors: Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.|Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
authors: Kikelomo
authors: K
authors: Wright
authors: Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
authors: Olatunji
authors: O
authors: Sonoiki
authors: Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
authors: Oluwasola
authors: O
authors: Banke-Thomas
authors: Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
authors: Babatunde
authors: B
authors: Ajayi
authors: Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
authors: Onaedo
authors: O
authors: Ilozumba
authors: Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.|Department of Obstetrics and Gynecology, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
authors: Oluwarotimi
authors: O
authors: Akinola
keywords: EmOC assessment; emergency obstetric care; low- and middle-income countries; maternal health; quality of care