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Table 3 Implementation barriers and challenges cited in studies included in the systematic review for each research question

From: Factors affecting effective community participation in maternal and newborn health programme planning, implementation and quality of care interventions

Implementation barriers & challenges Community participation in quality improvement Community participation in MNH programme planning & implementation
Not-so-enabling environment
Need more supportive maternal health policies   1, 2
Low status of women, gender inequity 18, 19, 26 14, 28
Discrimination against indigenous people, ethnic groups, poor people 29  
Conflict, insecurity and violence against women 18, 19, 29 14
Politicians do not collaborate when they see no benefit for themselves   16
Urban environment highly politicized   16
Urban setting negatively affects time available to participate, especially for men; recruitment and retention of community health volunteers is also more challenging.   16, 21, 22
Community capacity
Community leadership
Changes in leadership   15
Community leadership doesn’t prioritize maternal health or health more generally. 19  
Community capacity to plan and work together is limited. Takes time to develop. 20 16, 20, 21, 22, 23, 24, 28
Trust issues exist among different groups. 18, 19 16, 18, 22
 • Lack of transparency in management of community funds. 18, 19 18
Ineffective structures   
 • Existing structures are dysfunctional 27 27
 • At sub-district level, organizational structures are less defined and many different local groups exist. (Dinajpur Safe Motherhood Initiative chose to develop a Community Support System structure to address this challenge.)   18, 19
Health system
Managing resources & resource constraints   
 • Human resource constraints of public health system   15
 • Health services supervision system weak, irregular 27 27
 • Services lack “modern equipment and advanced technology” 18, 19 18, 21, 22
Health facility data inconsistent and incomplete – difficult to plan effectively and difficult to assess attribution of programme outcomes; limited capacity for data management 18, 20, 29 18, 20
Service provider attitudes are resistance to change 29 21, 22
Wider health system issues such as ineffective referral system (outside of local control) 29  
Community -health system interaction
 • Limited access to facilities (distance, difficult terrain) 20 17, 20
 • Lack of funds (for transport) 20 20
 • Lack of financial and technical resources (MOH, community) 20 20, 23, 24
 • Rotation of health personnel doesn’t allow time to develop trusting relationships with community 29  
 • Expectations of community health workers are unrealistic; too many tasks   15
Poor communication 20 20
Need to improve linking/interface of communities with services 18, 19 18, 23, 24
Intercultural sensitivity/competence
Cultural traditions of women delivering and residing in other homes outside of study area for postnatal period affects birth preparedness plans and postnatal follow-up care.   15
Reluctance of families to travel long distances for neonatal care (cultural practice and security issues underlie this reluctance)   15
Increasing empowerment of youth led to conflict at times   21, 22
Reaching and including people with low literacy and numeracy skills 29 17
May not be reaching the poorest and most vulnerable with the strategies used, strategies may not be effective for these groups 18, 19 18
General programme design/implementation challenges
Proxy indicators have some limitations (e.g., utilization of EmOC for “met need”) 18, 19 18
Expansion and scaling up 20, 26, 29  
Low coverage and high complexity of the intervention   15
Volunteers taking on too many tasks   15
  1. Note: see numbered list of references at the end of this article to interpret the numbers presented in the columns below. This is a descriptive, qualitative analysis based on what the reviewed studies reported. The number of studies reporting each barrier or challenge is not intended to be an indicator of the level of importance of the factor.