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Factors influencing implementation of interventions to promote birth preparedness and complication readiness



The recent WHO report on health promotion interventions for maternal and newborn health recommends birth preparedness and complications readiness interventions to increase the use of skilled care at birth and to increase timely use of facility care for obstetric and newborn complications. However, these interventions are complex and relate strongly to the context in which they are implemented. In this article we explore factors to consider when implementing these interventions.


This paper reports a secondary analysis of 64 studies on birth preparedness and complication readiness interventions identified through a systematic review and updated searches. Analysis was performed using the Supporting the Use of Research Evidence (SURE) framework to guide thematic analysis of barriers and facilitators for implementation.


Differences in definitions, indicators and evaluation strategies of birth preparedness and complication readiness interventions complicate the analysis. Although most studies focus on women as the main target group, multi-stakeholder participation with interventions occurring simultaneously at both community and facility level facilitated the impact on seeking skilled care at birth. Increase in formal education for women most likely contributed positively to results. Women and their families adhering to traditional beliefs, (human) resource scarcities, financial constraints of women and families and mismatches between offered and desired maternity care services were identified as key barriers for implementation.


Implementation of birth preparedness and complication readiness to improve the use of skilled care at birth can be facilitated by contextualizing interventions through multi-stakeholder involvement, targeting interventions at multiple levels of the health system and ensuring interventions and program messages are consistent with local knowledge and practices and the capabilities of the health system.

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Our systematic review on the impact of birth preparedness and complication readiness (BPCR) interventions on birth with a skilled attendant revealed that BPCR is a complex intervention, highly dependent on the context in which it is implemented [1]. We also found that BPCR interventions vary in terms of approaches, actors involved, in definitions applied, in outcomes measured and in the strategies used to evaluate them.

The concept of BPCR emerged almost 20 years ago and is described as a process of planning for birth and anticipating actions in case of obstetric emergencies in order to reduce delays in seeking skilled care [2]. In 2005 BPCR was included in the World Health Organization (WHO) antenatal care package [3, 4], with emphasis on the following elements: deciding on desired place of birth; preferred birth attendant; location of the closest facility for birth and in case of complications: funds for expenses related to birth and/or complications; supplies necessary to bring to the facility; an identified labour and birth companion; an identified support to look after home and other children while the woman is away; transport to a facility for birth or when complications arise; and identification of compatible blood donors when needed. At around the same time, Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) developed a BPCR matrix acknowledging the important role of coordinated efforts of all ‘safe motherhood stakeholders’ for implementing BPCR. The matrix delineates roles and activities of policymakers, facility managers, providers, communities, families, and women in ensuring that women and newborns reach accessible, appropriate, acceptable and good quality care during pregnancy, childbirth and postpartum [2].

Despite widespread promotion and inclusion of BPCR in Safe Motherhood interventions, evidence on the effect of BPCR interventions remains limited. Our recent systematic review of the available evidence found that BPCR, as part of a package of interventions, has the potential to increase skilled care at birth and timely use of facility care for obstetric and newborn complications [1]. The results of the review have been included in recently published WHO guidelines on health promotion interventions for maternal and newborn health, where WHO recommends implementation of BPCR interventions [5].

To support those who plan to implement BPCR interventions, we conducted a secondary analysis of the papers included in our systematic review [1] and additional studies identified, in order to identify factors influencing implementation. We explore stakeholder perceptions and experiences of BPCR interventions, identify barriers and facilitators to BPCR implementation, and discuss how these relate to improvements in use of skilled care at birth.


This article reports a secondary analysis of studies identified in a systematic review conducted in 2013 [1, 6] and additional articles identified through a subsequent search. The systematic review included articles published in English between 2000–2012, identified from PubMed, Embase and CINAHL plus a manual search of the grey literature and a database that included results of systematic mapping of maternal health research in low- and middle-income countries [7]. The original review was concerned with effects on care seeking including use of a skilled attendant at birth (SBA) or facility birth, use of antenatal care (ANC) as well as effects on knowledge and preparations made for BPCR.

For this secondary analysis of factors influencing implementation, we included all articles included in the systematic review [n = 33] of 20 BPCR interventions. Additional identified studies include 16 papers on BPCR consisting mainly of descriptive studies [823] and a methodological evaluation of BPCR [24] which were identified through the original search but excluded for the systematic review. A subsequent search identified 14 newly published studies of the past 3 years for inclusion in this article [2538]. In total we reviewed 64 papers for this secondary analysis.

For the findings presented in this paper, we conducted a narrative synthesis of qualitative information on implementation factors from the 64 papers. We used an adapted SURE (Supporting the Use of Research Evidence) framework to guide the extraction of relevant information from studies and to structure the synthesis [39]. The framework comprises a comprehensive list of barriers and facilitators to implementing health systems interventions including stakeholder knowledge and attitudes, health service delivery factors, and social and political considerations; the framework has been used in other systematic reviews of qualitative evidence [40, 41].


Description of included studies

Characteristics of the 64 included studies are presented in Table 1; some studies report on the same BPCR programme or intervention and are listed together. Most of the studies of BPCR interventions were conducted in South Asia (Nepal n = 7; India n = 6; Bangladesh n = 4; Pakistan n = 1; and Tibet n = 1), followed by East Africa (Tanzania n = 7; Ethiopia n = 6; Uganda n = 4; Eritrea n = 1; and Kenya n = 1), West Africa (Burkina Faso n = 3; Nigeria n = 3; and Benin n = 1), South East Asia (Cambodia n = 1; and Indonesia n = 1), and Latin America (Guatemala n = 1); one study included multiple countries, and two articles were literature reviews. BPCR implementation strategies varied and often included multiple interventions, which are summarized in Table 2. These included house visits by volunteers who provided education on BPCR, training of health workers in facilities to provide BPCR as part of ANC, provision of education materials or other visual aids with BPCR information, community mobilization activities to increase awareness on BPCR and mass media campaigns with BPCR messages.

Table 1 Characteristics of included studies (astudies included in the systematic review)
Table 2 BPCR implementation strategies employed by included studies

Studies define BPCR and its main components variously which complicates interpretation of results, context and policy advice. For example, the most commonly described components include: identifying funds for birth and emergency expenses; deciding on a preferred birth attendant; identifying transport to the health facility for birth or complications; choosing the place of birth and location of nearest facility; and knowledge and identification of danger signs in pregnancy. Other definitions include identifying compatible blood donors, preparing supplies, identifying a birth companion, and discussing plans with husband and family. In the systematic review, it was impossible to determine which strategy and which components, or which combination of strategies and components, was most effective in improving health seeking outcomes [1]. Despite these differences, this analysis of contextual and implementation factors provides an understanding of some common barriers and facilitators to implementing interventions that promote BPCR. The SURE framework is added as Additional file 1.

Stakeholder perspectives on BPCR

All studies involved women and their families; some specifically addressed communities at large [42,46,73,61,64,56,53,59,67,43,47,70,55,49,50,51,52,44,68,45]; and three studies specifically targeted health care workers [43, 46, 47]. Descriptive studies of BPCR almost exclusively evaluated preparedness of women [9, 11, 13, 16, 17, 19, 21, 27, 29, 30, 35, 48], with the exception of Iliyasu et al. (2010) and August et al. (2013) that specifically assessed BPCR among husbands [18, 26]. The JHPIEGO Maternal and Newborn Health Program and Skilled Care Initiative directed BPCR interventions at individuals, communities, facilities and policy level [49, 52].

Perspectives of women and their families

Some studies reported women’s perceptions of birth as a normal and ‘natural event’ which could be successful at home, and that this often reduced the urgency to plan for facility birth. Other studies similarly reported beliefs that pregnancy outcomes are predetermined and ‘in God’s hands’, therefore there was no perceived need to be prepared for birth [13, 14, 45, 63]. In two studies in Tanzania and Nepal ‘modern’ health services were regarded as the ‘last resort’ to be used only after complications arose [14, 55]. Improving knowledge of danger signs is an essential element of most BPCR interventions. However, promoting this knowledge without ensuring awareness of the need for planning for normal birth might unintentionally results in the perception that no actions need to be taken if all signs are ‘absent’ and promote the notion that uncomplicated births indeed are best at home [14]. Quasi-experimental studies identified strong correlations between education level and BPCR, and concluded that BPCR interventions were more successful, and facility delivery more likely, among women with higher levels of education [11, 13, 15, 17, 21, 56, 57].

We found evidence in the studies that despite being able to recognise danger signs during pregnancy sometimes women remain silent and do not seek care because of cultural beliefs about the underlying causes. For example, in Tanzania obstructed labour, retained placenta and eclampsia were associated with adultery [47, 58]. In some countries BPCR actions are limited due to fear of unfavourable outcomes and the belief that ‘preparing’ could bring bad luck [20, 45]. In Tanzania and Kenya, although families reportedly discussed pregnancy and childbirth together (including husbands and wives), the studies indicate that taboos still exist and that this can restrict BPCR discussions. For example, announcing pregnancy and informing the husband when labour starts, is believed to bring misfortune [53], limiting husbands’ ability to make timely preparations [47]. Cultural beliefs and norms also hindered transport preparations in some contexts, as women refrained from crossing a river since this was believed to cause abortion/preterm birth [47], and travel at night was considered dangerous due to active evil spirits [20]. In Bangladesh and Kenya, purchasing relevant items in preparation for birth was reportedly discouraged, especially items for the baby. Financial preparations were perceived as wasteful as it is unknown if the child would survive [20, 53, 58].

Identifying a SBA beforehand was a key BPCR message in all studies, and this inevitably involved making a choice about where to give birth and with whom. Some studies emphasized the importance of providing women with clear information during ANC on who is considered a SBA [50, 55]. In some contexts, traditional birth attendants (TBAs) are the preferred attendant as the first point of care in pregnancy and when complications arise. They are considered ‘skilled’ because of their years of experience, ability to perform important rituals and willingness to attend women at home [48, 59, 60]. Similarly, women’s understanding of the expected date of birth could limit timely preparations for facility birth or birth with a SBA, as some women perceived the estimated date of birth as exact date of birth, thus awaiting this exact time to make further plans [14, 20, 45, 47].

Most interventions took place in contexts where men or other family members are the main decision makers and gatekeepers to women’s timely access to care. Despite this, men are often excluded from maternal health interventions, and this can impact on the likelihood that BPCR actions are taken. In studies in Tanzania women reported that men may cause delay in seeking transport for women in labour or with complications for several reasons: they are unavailable at the time, they may not be aware of the emergency, or they feel ashamed to be seen supporting their wives [14, 47]. A study in India reported that although men appear willing to perform certain tasks, primarily related to financial contributions, they often do not take on more proactive or supportive roles and are reluctant to get fully involved [61]. In a Nepali programme, women requested volunteers to increase awareness of husbands and mothers in-law, to help them in childbirth preparations [55]. Descriptive studies indicate that when men are involved in making plans for birth, they more often accompany their wives to the antenatal clinic and labour ward [16, 18, 45]. Some studies specifically involved men, by providing information to men (68), or training men as maternal health promoters (56, 58). In the latter intervention, implemented in Eritrea and Tanzania, men delivered BPCR messages to households and communities, which was well received and contributed to men’s understanding of the importance of timely care seeking during pregnancy and for childbirth.

Perspectives of community stakeholders

Pregnancy and childbirth are usually regarded as family events and the wider community rarely plays a major role in preparation or readiness activities [47, 50, 61]. However, other community stakeholders who were not always targeted by BPCR interventions, such as community leaders, responded positively to interventions and implementers [57, 61, 62]. Interventions that did include community BPCR components resulted in increased awareness of maternal deaths in the community [43] and increased feeling of responsibility for pregnant women in the community. The latter through interventions which were specifically applicable to communities at large [50], such as developing transport or financial support systems, or through linking interventions to existing community structures [43, 47]. In one study in Nepal, women requested more detailed information on where to go for birth and how to arrange transport [55].

In one study in India, community leadership was particularly supportive where youth groups held activities to increase awareness of maternal health problems, which subsequently increased direct interaction with government officials on problems faced by health providers and the women themselves [61]. Community transport and financial schemes for maternal emergencies were successful if supervised by transparent, trustworthy and stable leadership [57, 63] and reversely inefficient when corrupted or insufficiently managed [43, 57].

Implementers of BPCR messages, health workers or volunteers, were generally well accepted by individuals, families and communities. In one Tanzanian study, home visits by volunteers were especially appreciated for the time spent on discussions and questions [45]. BPCR messages were easily understood by women respondents in Nepal and Burkina Faso [23, 52]. Studies that used visual aids such as cards, posters or booklets were positively received and understood [32, 42, 43, 45, 50].

Perspectives of health workers and BPCR implementers

Although most studies trained facility-based health workers to implement BPCR interventions either at facility or in the community [42, 43, 49, 5153, 55, 56, 64,56,53,59,67,43,47,70,55,49,50,51,52,44,68,45,39,40,41,48,54,58,60,57,65,66], other studies worked mainly with community health workers [47, 50, 52, 55, 56, 59, 67] including TBAs [43, 50] and community volunteers [42, 44, 45, 61, 64, 65, 68, 69]. In studies in Tanzania, facility-based health workers indicated they felt appreciated by the community volunteers, which increased collaboration [45, 47]. In another Tanzanian study, TBAs changed from childbirth care providers to educators, counsellors and referral advisors, thus becoming active promoters of skilled attendance at birth [45].

Implementers generally reported they were satisfied with their activities and job aids [22, 23, 42, 45, 47] and felt supported by combinations of job aids with training, field support, and organizational change [22, 23]. Some village volunteers felt appreciated by their communities and were committed to activities [47, 55], others felt overburdened by study tasks [23]. Implementers in Nepal and Benin reported that job aids included too many or a repetition of messages or lacked concrete activities or examples for preparations to effectively help women and their families [22, 23]. Facility interventions of BPCR during ANC in Benin and Tanzania increased workload by requiring more time with pregnant women [14, 22].

Health service delivery factors

In some studies hospital staff and researchers noted that shortage of staff at facilities, in particular during nights and weekends, and high staff turnover limited intervention effectiveness. For example high turnover of facility personnel in Tanzania and Bangladesh [43, 56], limited government training or supervision of staff in Burkina Faso and India [64, 70] and limiting staff payments, causing health staff to run private business and as a consequence SBA absence in the clinics in Cambodia [42]. Giving staff additional tasks while at the same time maintaining morale and commitment was not easy, despite provision of additional training [43, 47, 49, 51, 53, 56, 64, 66]. Several BPCR interventions reported in the included studies incorporated service delivery improvements including training of facility-based [4345, 48, 49, 52, 54, 68] and community-based [46, 47, 64, 67] health workers on (emergency) obstetric care, improving facility infrastructure and supplies [43, 47, 53, 56, 64] as well as strengthening the transport and referral system [46, 51, 53, 56, 64]. A study in Tanzania made additional effort to improve the supply of drugs, provided essential obstetric equipment, and facilitated strengthening of the logistics system at facility level [56]. However, no improvements were seen as ordered supplies were frequently not available mainly due to logistics problems at higher levels in the health system [56].

Women’s and family member’s views about the accessibility of care seemed to influence their willingness to prepare for facility birth. Lack of availability of care 24 h a day [42] or lack of awareness that lower-level health facilities also provide childbirth services [53] could result in women choosing home birth. Even if women considered facility birth, large distances to nearest facilities, poor road conditions and lack of transport options [47, 52,44,68,45,39,40,41,48,54] made facility birth unrealistic. Cost for transportation, formal and informal costs for facility-based services and general out-of-pocket payments limited affordability of care [14, 47, 53, 55, 56, 61] and made TBA care often the cheaper option [42]. Perceived lack of quality of care at facilities including accounts of staff being described as inattentive and unconcerned or needing bribes before treatment was another barrier for SBA [53, 58].

Social and political factors

Three studies in Nepal show implementation was affected by political instability and civil war, hindering implementation location or intensity [50, 55, 68]. The situation in Nepal reduced accessibility to health facilities due to security concerns in some areas [68] and in one study changed the implementation location from rural to urban although the intervention was thought to be most effective in rural geographical locations [50].

BPCR interventions in the studies included in this review were primarily implemented in patriarchal societies where gender inequality pervades household decision making [54, 57, 71]. Several interventions attempted to address this specific barrier to BPCR, by involving locally influential people. For example, TBAs, traditional healers, church leaders, community or clan elders and political leaders were consulted prior to the intervention or were encouraged to become involved as active promoters [62, 63, 66]. In Indonesia, promotion material featured a popular singer which helped to give the campaign a brand name which spoke to the majority of the target population [49].

One study in Tanzania showed benefits of collaboration with key-stakeholders and government leadership [47], in other countries government policies or changes in for example payment regulations could preclude BPCR implementation [42]. Although national policy changes in favour of MNHC priorities assisted the implementation process in Guatemala [51], BPCR implementation was limited by other national policy changes, such as ending cost-sharing policy in Kenya, increasing overall costs of care [53], and consequently reports of corruption [53, 56].

Good rapport between the donor agency and government workers together with communities facilitated BPCR implementation, especially when engaging communities in problem solving in relation to BPCR [57, 68, 71]. Translating Non Governmental Organization (NGO) concepts into locally meaningful capacities or strategies, not only required time, but also adaptive skills from NGO workers from headquarter to local NGO level in Kenya and Tanzania [48, 58]. Ability of national and local policy makers to continuously connect with communities and hospitals, through newly established village health worker committees or supportive supervision of health services, seem important factors for sustainability of interventions and finances [51, 63]. Scale-up of the BPCR intervention was facilitated in Burkina Faso by connecting to existing health system structures [71]. In Cambodia, short-term BPCR interventions implemented independently of the health system structure, led to fear among programme planners and implementers, that project staff would become unemployed or move to the private sector once the intervention ended [42].


Linking implementation factors with improvements in care seeking outcomes

For studies included in the original systematic review that reported improvements in use of SBA or birth in a facility, the important factors that seemed to make a difference were positive perceptions of the intervention among women, families and community members and readily understood BPCR messages which motivated behaviour change [43, 45, 52]. Positive behaviour change, which could be making more preparations for childbirth or choosing to give birth with a skilled attendant, seemed to be more likely in women with higher levels of formal education [11, 13, 15, 17, 21, 56, 57], when husbands (as well as women) were targeted with BPCR messages on the need for SBA [43, 45, 52, 61], or when the intervention helped to lessen the influence of traditional or cultural barriers [51]. In studies where BPCR interventions led to no or marginal improvements in number of women giving birth with a skilled attendant or at a facility, preference for home birth and underlying cultural beliefs mitigated the need for facility birth [47, 53, 55].

Political instability [50, 55, 68] and short duration of interventions [42, 50] were reported to be among factors which prevented BPCR interventions impacting on care seeking outcomes. On the contrary, in studies reporting improvements in SBA or facility birth, BPCR was generally implemented within a package of interventions designed to address both demand and supply strengthening [43, 46, 49, 51, 56, 64]. It is well recognized that community sensitization to BPCR without concurrent improvements in access to facilities and the quality of care provided will have little impact on care seeking or other health outcomes [43, 55]. When interventions were integrated into existing government health service delivery systems [51, 70], or were delivered in partnership with relevant safe motherhood stakeholders to ensure close links between the community and facilities [43, 45], this seemed to increase impact on care-seeking outcomes. According to study evaluations the inclusion of perceptions of hospital management and sub-district policy makers on BPCR should be part of and could facilitate NGO implementation strategies [65]. These stakeholders could be offered support to make quality improvements in health policy making [72].


Firstly, the variety of definitions and topics used to describe BPCR complicate interpretation of results, context and policy advice. Seven authors did not specify any BPCR definition [42, 46, 53, 56, 61, 64, 73]. Six interventions were focused on complication readiness only [43, 46, 47, 59, 67, 70]. Five authors did explain that BPCR should also include preparedness for routine birth, [48, 5154] although in one study this was not part of the intervention [43]. In areas with extremely low SBA use, ensuring improved conditions at home [preparing birth kits, a clean confinement room] were considered improvements in BPCR [43, 46, 47, 59, 67]. Secondly, skilled birth attendants are variously described in the included studies, making extrapolation of results from one context to another difficult. Ten studies defined skilled birth attendants as [47, 5153, 55, 56, 59, 64, 67, 70] doctors, midwives or nurses. In some studies - as per WHO definition - unqualified staff including nurse aides were considered SBAs [47, 53, 56, 64]. Other studies reported on health facility births [43, 44, 46, 49, 51, 61, 64, 67, 68] which does not necessarily mean the presence of a SBA. Two interventions included promotion of skilled care irrespective of location which consequently resulted in inclusion of home birth with SBAs [45, 50]. As study contexts varied vastly, comparing studies on intervention and outcomes remains difficult. In our view defining interventions and outcome measures properly is crucial in BPCR, as improper definitions complicate interpretation of outcomes.

Further research of robust design is needed to: agree on key definitions and priority BPCR actions; assess the effect of including men and other key-stakeholders on care-seeking outcomes; and to understand how cultural factors influence BPCR implementation [5]. Although we aimed to include additional qualitative studies, only few were identified. Few studies reported on barriers or facilitators related to the intervention or program itself, such as resource implications, intervention integrity, leadership, and only some reported on donor policies or legislations. Often studies did not elaborate how and why such factors lead to successful or non-successful outcomes. These aspects also require further consideration in future research on BPCR interventions or packages.

The SURE framework proved useful in assessment of factors influencing implementation although we would argue that especially in low-resource settings ‘cultural factors’ should be added as a separate category. Cultural factors are generally under researched in maternal health studies [74] and such adaptation of existing models could form a way to swiftly create insight into complexities of implementing health interventions locally [75].


Implementation of BPCR interventions to improve the use of skilled care at birth requires careful consideration of contextual factors influencing implementation. When developing programmes and interventions, BPCR messages and strategies should match and respect the target audience and the different decision makers in maternal health and their values, as well as the organisation and capacities of the local health system. When mismatch occurs, such as when increased demand for facility births meets unprepared facilities in contexts where essential and comprehensive emergency obstetric care services are not available, this could cause considerable damage to the often already fragile trust the community has in the formal health system and increase complications or mistreatment of women giving birth at facilities. For this reason, it is important that BPCR is implemented alongside other interventions and activities to strengthen the supply and improve the quality of maternity care services. Implementation of BPCR should always include preparedness for both routine childbirth care and for complications, ensuring women and families have discussed the plans. Local socio-economic realities and determinants however remain a heavy burden for effective implementation of BPCR, and therefore require actions with the community and other stakeholders. BPCR messages should therefore be adapted to the local context in terms of availability, accessibility and affordability of health facilities and services. Inclusive and active involvement of all levels of stakeholders, including health officials and policymakers, appears to be a crucial step for securing linkages between the actions of all respective stakeholders that optimizes chances for women and newborns to reach needed care and contributes to the success of BPCR.



Antenatal care


Birth Preparedness and Complication Readiness


Johns Hopkins Program for International Education in Gynecology and Obstetrics NGO

Non Governmental Organization


Skilled Birth Attendant


Supporting the Use of Research Evidence


Traditional Birth Attendant


World Health Organization


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We thank Laura Shields, Allisyn Moran, Anayda Portela and participants of the WHO Technical Consultation on Health Promotion Interventions for Maternal and Newborn Health that took place between 15 and 17 of July 2014 at WHO headquarters in Geneva, for discussing the preliminary outcomes of the systematic review and for their contributions to the first version of the Context and Conditions report. We thank the co-authors of our Systematic Review for their contributions, which formed the start of this paper (Marianne van Elteren, Jelle Stekelenburg, Laura Shields, Anayda Portela).


ASM received a financial contribution from WHO for development of the context and conditions report on which this paper is based. YR acknowledges financial support from the Netherlands Society for Tropical Medicine and International Health for writing her PhD thesis of which this study will be part.

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The dataset supporting the conclusions of this article is included within the article and its additional file.

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ASM and YR wrote the initial report and drafted the article. JvR and HS contributed to extraction and analysis of data, critically reviewed drafts of the article and provided edits. All authors read and approved the final manuscript.

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Correspondence to Andrea Solnes Miltenburg.

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Checklist for identifying factors affecting the implementation of a policy option (DOCX 99 kb)

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Solnes Miltenburg, A., Roggeveen, Y., van Roosmalen, J. et al. Factors influencing implementation of interventions to promote birth preparedness and complication readiness. BMC Pregnancy Childbirth 17, 270 (2017).

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