Table 1 Characteristics of included studies (^astudies included in the systematic review)

Ahluwalia et al., 2003; Kaharuza, 2001; Ahluwalia et al., 2010; ^a

Pre and post study with qualitative component

TANZANIA, rural, Kwimba and Missungwi districts, Mwanza region

Multiple interventions included house visits by volunteers to provide BPCR education to pregnant women and their families. A community surveillance system for pregnancies and community-based plans for transportation to health facilities were also set up. Transport methods included by canoe, oxcart, bicycle/tricycle and stretcher.

Acharya et al., 2015

Cross-sectional facility based study

INDIA, New Delhi

Study aim: To assess the status of BPCR among pregnant women attending a primary health center. Main findings: Majority of women had identified a skilled attendant at birth for delivery. Nearly half of the women had saved money for delivery and had also identified a mode of transportation for the delivery.

Agarwal 2010

Cross-sectional study

INDIA, Indore City (Slum)

Study aim: To present levels and factors associated with BPCR among slum women. Main findings: Half of all respondents were well prepared taking more than 2 steps (identified a trained birth attendant, identified a health facility, arranged for transport, and saved money for emergency). Factors associated with well prepared women were maternal literacy and availing of antenatal services. A TBA attended majority of births. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers.

August 2015

Cross-sectional study

TANZANIA, Rufiji District

Study aim: to assess men’s knowledge and their involvement in BPCR. Main findings: Half of the men were able to mention one danger sign and made birth preparations in the form of a birth kit. There was no association with age, education and marital status.

Baqui et al. 2008^a

Quasi-experimental pre and post comparative study with a control group

INDIA, rural districts of Uttar Pradesh

Interventions included house visits by auxiliary nurse midwives (ANMs) or Anganwadi workers and change agents to provide BPCR counselling to pregnant women and their families.

Brazier et al., 2009; Hounton et al., 2008;

Graham et al., 2008); Hounton et al., 2008; Newlands, 2008; Graham et al., 2008^a

Quasi-experimental pre and post study with a control group

BURKINA FASO, rural

Behaviour change and community mobilization through participatory theatre and songs. Upgrading of health facilities and improving the referral system. Control district was also provided with facility upgrades but not the behavioural change component.

Choudhury 2011

Qualitative

BANGLADESH, Rangpur and Kurigram districts

Study aim: qualitative exploration of the existing maternal care practices during pregnancy, delivery and post-partum period among women of the ultra poor households. Main findings: Traditional believes could impose restrictions in mobility (evil spirits more active in evening). Few women were birth prepared and local birth attendant (TBA) was not contacted in advance out of fear of black magic. Making too many plans for arrival such as new clothes could bring bad luck. There was fear of health workers for various reasons.

Darmstadt et al., 2010^a

Cluster-RCT

BANGLADESH, rural unions in Mirzapur

Antenatal house visits by volunteers who promoted BPCR including for newborn education. CHWs conducted additional postnatal visits to promote preventive newborn care practices and to identify and refer sick neonates. The control group received the usual care services provided by the local and national governments.

Debelew 2014

Cross-sectional study

ETHIOPIA, Jimma Zone

Study aim: to identify the factors affecting birth preparedness and complication readiness at the different levels. Main findings: The majority of respondents planned to save money and to arrange transport. One third planned to give birth in health facility and planned to be attended by skilled attendant for their current pregnancy. Being in urban residence and having health center within two hours distance as well as educational status of primary or above, husband’s occupation of employed or merchant, third or above wealth quintiles, knowledge of key danger signs during labor and attitude and frequency of antenatal care visits increased the likelihood of preparation for birth and its complications.

Dickerson 2010

Programme evaluation

TIBET, Medrogongkar and Dulung Dechen County

Intervention: PAVOT (Pregnancy and Village Outreach Tibet) is a community- and home-based maternal- newborn outreach program that serves rural pregnant Tibetan women. The program is based on a training-of- trainers model in which experienced master trainers train rural healthcare workers and laypersons to outreach the homes of rural-living women and families. During out- reach, providers relay maternal-newborn health education, hands-on skills training, and material resources directly to recipients. One of the specific PAVOT interventions was encouragement of development of a birth plan. Main findings: The majority of women attended more than 3 ANC visits but half of the women gave birth at home.

Ekabua 2011

Cross-sectional study

NIGERIA, Cross River State

Study aim: to assess the awareness and intention to use maternity services Main findings: The majority of respondents were aware of birth preparedness. Knowledge of danger signs was poor.

Family Care International Kenya, 2007; Moor et al., 2002(; Family Care International Kenya, 2003^a

Quasi-experimental pre and post study

KENYA, Homa Bay and Migori districts, Nyanza province

Behaviour change campaign making use of printed materials including birth preparedness messages through drama and meetings. Materials supplied to health care workers (HCWs) as well as facility upgrades and improving provider skills. The control district received only facility intervention.

Family Care International Tanzania, 2007^a

Quasi-experimental pre and post study with a control group

TANZANIA, Igunga and Urambo districts, Tabora region

Behaviour change communication and mobilization efforts through participatory meetings at village level and theatre and performing arts. Improvements to the availability and quality of maternity care through strengthening physical infrastructure and improving provider skills. Control district received no intervention.

Fonseca-Becker et al., 2004^a

One group before and after evaluation

GUATEMALA, north- west and south-west regions

Service delivery improvements and trained health care providers and behaviour change interventions focused on organizing communities to effectively respond to obstetric emergencies and creating demand for the improved services through the use of radio and printed materials. Includes a community action cycle: a five-step participatory cycle consisting of organizing for community action; promoting community dialogue; planning together; collective action; and participatory evaluation. The communities developed their own emergency plans.

Hailu 2011

Cross-sectional study

ETHIOPIA, Sidama Zone

Study aim: To assess the current status and factors associated with birth preparedness and complication readiness among pregnant women. Main findings: The majority prepared to give birth at home and few women were birth prepared. First time pregnancy and ANC attendance were associated with being prepared.

Hiluf 2007

Cross-sectional study

ETHIOPIA, Tigray Region

Study aim: to assess knowledge and practices with respect to BPCR and factors associated with women who gave birth in the last 12 months. Main findings: Nearly a quarter of the respondents were prepared for birth and its complications. Preparedness was higher amongst literate mother, married women, women with previous stillbirth and those who received information about BPCR.

Hodgins et al., 2009; Valley Research Group 2007^a

One group before and after evaluation

NEPAL, rural, Jhapa and Banke districts

House visits by volunteers who provide BPCR education to pregnant women and family members, making use of pictorial handouts.

Hossain et al., 2006; Barbey et al., 2001^a

Quasi-experimental study pre and post comparative study with a control group

BANGLADESH, rural, Birampur region

Interventions included facility upgrades, quality of care and BPCR and community mobilization. SBAs, fieldworkers and village doctors were trained to disseminate BPCR messages that were also incorporated into a variety of visual aids during home visits, group discussions at clinics and village meetings. Comparison district received facility upgrade but no community intervention; control district received no intervention.

Iliyasu 2010

Cross-sectional study

NIGERIA, Kano State

Study aim: to assess men’s perception of high risk pregnancy and danger signs; birth preparedness and complication readiness, and participation in maternity care. Main findings: Half of the men considered bleeding a danger sign. One third mentioned convulsion as danger sign. Les than a third of the men made arrangements for mother’s health care, transportation and delivery or made savings for obstetric emergencies. One third of the men accompanied women to maternity care. Higher participation was observed in younger educated men.

Jennings 2010

Quasi-experimental pre and post comparative study with a control group

BENIN, Zou/Collines region

Intervention: Introduction of the job aids: a set of pictorial counseling cards designed to support communication to women about care during and after pregnancy according to national guidelines. Intervention components: training, organizational changes, and field support. All health care personnel at the intervention sites were trained for three days in the content and use of the counseling cards, interpersonal communication, and quality improvement. Main findings: The study measured three outcomes: (1) quality of counseling provided to pregnant women; (2) provider perceptions regarding use of the job aids; and (3) women’s knowledge of messages relating to maternal and newborn care. Women in the intervention arm received more recommended messages than in the control arm. Increased communication skills regarding use of visual aids and verification of understanding was seen in the intervention arm. Improvements in knowledge among pregnant women were observed in the area of birth preparedness, recognition of danger signs, and clean delivery.

Kabakyenga 2011

Cross-sectional survey

UGANDA, Mbarara district

Study aim: To explore the association between knowledge of obstetric danger signs and birth preparedness among recently delivered women: Main findings: More than half of the women knew at least one danger signs during pregnancy, childbirth than during the post-partum period. Few women had knowledge of 3 or more key danger signs during the three periods. Of the four birth preparedness practices; 91% had saved money, 71% had bought birth materials, 61% identified a health professional and 61% identified means of transport. Overall one third of the respondents were birth prepared (saved money, bought materials, identified health professional and identified transport). Young age and high levels of education had synergistic effect on the relationship between knowledge and birth preparedness.

Kabakyenga 2012

Cross-sectional survey

UGANDA, Mbarara district

Study aim: to assess the influence of birth preparedness practices and decision-making on location of birth and assistance by SBAs. Main findings: One third of the women had been prepared for childbirth and the prevalence of assistance by SBAs in the sample was two thirds. Decision making on location of birth was the husband in the majority of cases. When women made the final decision on location of birth in consultation with either the spouse or other people, the likelihood of giving birth assisted by a skilled birth attendant was very high and low when they made the decision alone.

Kakaire 2011

Cross-sectional facility based study

UGANDA, Kabale district

Study aim: to assess factors associated with birth preparedness and complication readiness as well as the level of male participation in the birth plan and healthcare seeking for emergency obstetric referrals. Main findings: Nearly half of the women had saved money in the event of complications and were joined by their men to ANC and during labour.

Karkee 2013

Prospective cohort study

NEPAL, Kaski district

Study aim: to assess birth preparedness level in expectant mothers and to evaluate its association with skilled attendance at birth. Main findings: The majority of women were birth prepared, 72% prepared the five activities (identification of delivery place, identification of transport, identification of blood donor, money saving, and antenatal care check-up). Of the cohort 85% SBA and it appeared that the more arrangements made, the more likely were the women to have skilled attendance at birth.

Kaso 2014

Cross-sectional study

ETHIOPIA, Robe Woreda, Oromia Region

Study aim: to assess knowledge and practices with respect to birth preparedness and complication readiness and factors associated in rural community among women of reproductive age. Main findings: Few respondents were prepared for birth and its complications and was higher amongst educated women.

Kumar et al., 2012; Kumar et al., 2008^a

Cluster-RCT

INDIA, rural Shivgarh, Uttar Pradesh

Intervention package including home visits, community meetings and folk-song meetings, maternal and newborn health stakeholder meetings and meetings for community volunteers. Control clusters received standard care.

Kuteyi 2011

Cross-sectional study

NIGERIA, Osun State

Study Aim: to assess knowledge and practices of pregnant women attending antenatal clinics with respect to BPCR. Main findings: The majority of pregnant women had poor knowledge of obstetric danger signs; only a third were birth prepared (if they had identified and agreed on a place of delivery, were saving money towards delivery, had begun purchasing materials/supplies for a clean delivery and newborn care, if they knew their estimated date of delivery and had undergone voluntary counseling and testing for HIV), while one third were not complication ready (if they fulfilled at least four of the following criteria: had adequate knowledge of danger signs as defined above, designated a decision maker, identified the nearest functional comprehensive emergency obstetric care facility to use in case of emergency, identified the source of emergency funds, arranged an emergency means of transport, arranged a means of communication, and identified a suitable blood donor). Women who received antenatal care from the tertiary health facility, those with higher education, were married, who had more ANC visits, booked or were at the time of study in the third trimester and those who lived close to the health facility were more likely to prepare for birth.

Magoma 2010

Qualitative

TANZANIA, Ngorongoro district

Study aim: to gain an understanding of the socio-cultural and health systems factors influencing women’s decisions to seek antenatal, skilled delivery and immediate post-partum care. Main findings: The Maasai and Watemi women’s preferences for a home birth and lack of planning for delivery are reinforced by the failure of health care providers to consistently communicate the importance of skilled delivery and immediate post-partum care for all women during routine antenatal visits. Husbands typically serve as gatekeepers of women’s reproductive health in the two groups - including decisions about where they will deliver- yet they are rarely encouraged to attend antenatal sessions.

Magoma 2013

RCT

TANZANIA, Ngorongoro district

Intervention: Introduction and promotion of birth plans by care providers during ANC to prepare women and their families for birth and complication readiness. This included discussions on planned place of delivery, the importance of skilled delivery care for all women, transport arrangements to the delivery site or during an emergency, funding arrangements for delivery or emergency care services if needed, identification of possible blood donors, identification of a birth companion if desired and appropriate, and support in looking after the house- hold while the woman was at the health facility. Main findings: More women in the intervention arm discussed birth planning with their providers and more women delivered in health facility and attended post-natal care.

Markos 2014

Cross-sectional study

ETHIOPIA, Goba woreda, Bale Zone

Study aim: to assess BPCR among women of child bearing age. Main findings: Only 82 (14.6%) study subjects were knowledgeable about BPCR and 29% was prepared and complication ready.. Women with primary or secondary education as well as women who attended ANC were more likely to be birth prepared.

Mbalinda 2014

Mixed-Methods

UGANDA, Mulago hospital

Study aim: to explore the association between knowledge of obstetric danger signs and BPCR among women admitted in pregnancy with obstetric complications. Main findings: Only about 1 in 3 women were able to mention at least three of the five basic components of BPCR, and could be regarded as ‘knowledgeable on BPCR’. One in every 4 women could not mention any of the five components.

McPherson et al., 2006 ^a

One group before and after evaluation

NEPAL, Siraha rural district

Community health workers (CHWs) used a BPCR package with flip charts and distributed key chains to pregnant women containing BPCR messages through monthly discussions in women’s groups. Facility-based CHWs counselled women who used facility-based services.

McPherson 2010

Process evaluation

NEPAL, Banke and Jhapa district

Intervention: Jeevan Suraksha “provides information about recommended actions to be taken at each stage of normal pregnancy and birth, identifies the danger signs that indicate possible complications, and encourages financial planning for normal births and for possible emergencies”. Content was integrated into a set of activities includ- ing 1) health education and counseling with pregnant women and household decision-makers during the antenatal period, primarily by Female Community Health Volunteers (FCHVs); (2) strengthening existing health services; and 3) postpartum home visits by FCHVs. A key aspect of the intervention was the distribution of a pictorial booklet that promotes key MNH practices to all pregnant women who are registered with FCHVs. Main findings: FCHVs increased their workload and expanded their role and relationship with the community. The booklet is shared and discussed among household and community members through a number of channels and clearly informs and influences household practices and decision-making. ‘Too may messages’ caused by redundancies reduces the potential impact of the booklets. Inclusion of additional household members as potential decision makers would increase effectiveness.

Cluster-RCT

PAKISTAN, rural, Khuzdar district, Balochistan province

Women and their husbands received pictorial booklets and audio cassettes, training of birth attendants in early recognition of obstetric danger signs, and providing telecommunication and transportation services for women in need of emergency obstetric and neonatal care. The intervention group consisted of a woman’s only and a couples group. Additionally, TBAs were trained for clean home delivery and owners of local vehicles were trained for referral. Healthcare providers in intervention and control arms received clinical training

Moran et al., 2006; Baya et al., 2004 ^a

One group before and after evaluation

BURKINA FASO, Koupela

Community and facility-based HCWs and SBAs provided one-on-one counselling with pregnant women and families on key messages focused on BPCR using a flip chart. These messages were reinforced through district-based radio messages and theatre plays. Facilities were upgraded and HCWs were provided with additional training.

Mukhopadhyay 2013

Cross-sectional survey

INDIA, West Bengal, Uttar Dinajpur district

Study aim: to find out the perceptions and practices regarding BPCR at individual level and the related factors among pregnant and recently delivered women. Main findings: Half of the respondents planned for first ANC within 12 weeks, four or more ANCs and FB. Awareness of danger signs was poor with half of the women knowing at least one. Overall BPCR index of the study population was 34.5. Less than half of the women saved money and identified transport, the majority was aware of the government finance scheme.

Mullany et al., 2007 ^a

RCT;

NEPAL, Kathmandu

Intervention group consisted of couples and women alone who received health education (two sessions) provided by health educators. The control group received no education, only a brief flyer designed to resemble and standardize the health education of normal care provided.

Mushi et al., 2010 ^a

One group before and after evaluation

TANZANIA, rural, Mtwara region

Training of safe motherhood promoters to educate and raise awareness on maternal health aspects for pregnant women, husbands and community members through home visits. Training of safe motherhood promoters and education interventions at home and in community for pregnant women, their husbands and key community members.

Nawal 2013

DHS survey

NEPAL

Study aim: to assess the birth preparedness and its association with institutional delivery and postnatal check-up. Main findings: Only 10% of the population was well prepared for delivery. If prepared there was a greater likelihood of FB. The level of BP/CR is greater among women with pregnancy complications, lower age group, and higher education and economic status and with greater women autonomy. Note: The MOHP implemented the birth preparedness package. The guidelines recommend that families should save money for emergencies, arrange transportation in advance based on local conditions, identify persons who can and are eligible to donate blood if required, identify and contact health facilities and health workers who can provide services, and have a clean delivery kit

Pasha 2013

Cluster-RCT

MULTI-COUNTRY

Intervention: Cluster teams of trainers were formed who facilitated a multi-faceted intervention including: 1) Community mobilization to establish village-level core groups and to strengthen community capacity to identify and address barriers to obstetric and neonatal care, 2) Home-Based Life Saving Skills (HBLSS) for birth attendants and families, 3) Improvement of quality of care in existing health facilities through a combination of facility staff Emergency Obstetric and Newborn Care (EMONC) training and health facility audits. Community mobilization and birth attendant training focused on birth planning and transportation to a hospital;

Main findings: No differences were seen between control and intervention group on primary and secondary outcomes.

Sinha et al., 2008 ^a

One group before after

INDIA, rural, Andhra Pradesh, Rangareddy district

The intervention involved awareness raising and community support for pregnant women through local government and youth committees; involvement of their families (particularly husbands) in pregnancy-related care through monthly meetings; and bi-monthly home visits by a community organizer who worked with families to create a birth preparedness plan and support access to care

Skinner et al., 2009 ^a

Qualitative

CAMBODIA, Kampong Chhnang

Dissemination and discussion of visual aids on danger signs and BPCR with families and communities.

Stanton 2004

Literature review

N/A

Study aim: To provide a detailed discussion of the issues involved in measuring birth preparedness in support of safe motherhood with the aim of improving the design and conduct of future research. Main findings: For effective BPCR evaluations there is a greater demand for data from or about women who are currently pregnant and conventional sampling approaches will not generate a sufficient sample of current pregnant women and recently delivered women. Additionally documenting birth preparedness requires data on knowledge, intentions, and behaviors associated with live and stillbirths.

Sood et al., 2004 ^a

One group before and after evaluation

NEPAL, rural, districts of Bagalung and Lalitpur

Social mobilization campaigns. The Suami SIAGA (alert husband) campaign delivered through the following mass media campaigns: The Warga SIAGA encouraged community members to be alert and prepared for births within the community. The Bidan SIAGA promoted the midwife as preferred maternal healthcare provider. The Desa SIAGA campaign encouraged villages to establish lifesaving systems for women with obstetric emergencies.

Sood et al., 2004 ^a

Pre and post comparative study with a control group

INDONESIA, West Java

Encourage and promote birth preparedness on each level directly targeting husbands, villages and communities through several (media) campaigns. In addition midwives received skills training both clinically as in communicating the basics of BPCR to their clients during ANC.

Soubeiga, 2013

Retrospective cohort study

BURKINA FASO, Koupela and Dori district

Study aim: to examine whether BPCR counseling provided to during routine prenatal visits increased the probability of delivering in a health facility. Main findings: Exposure to information varied and not all BPCR messages were received equally. The four messages together (information on danger signs; promotion of facility-based delivery; information on the cost of delivery and advice on transportation during labour and in cases of obstetric emergencies) did not significantly influence the use of SBA.

Soubeiga, 2014

Systematic Review

N/A

Study aim: to evaluate the impact BPCR interventions in reducing maternal and neonatal mortality in low-income countries. Main findings: Meta-analysis showed no significant reduction on maternal mortality but identified an 18% reduction in neonatal mortality risk. There was a slight increase in the probability of facility-delivery. Note: seven out of the twelve included studies implemented action-learning cycles with women’s groups.

Taleb 2015

Qualitative program evaluation

BANGLADESH, Netrokona district

Intervention: Implementation of Individuals, Families and Communities (IFC) program which focused on BPCR and working with TBAs to serve a new role in MNH which prioritized education, referral and social support of women rather than birth attendance with the aim to influence the social and cultural norms and practices surrounding care seeking in order to increase the utilization of skilled care. In order to promote BPCR, community- and facility-based health workers were trained to assist pregnant women and their families in creating a plan and to build community awareness of the importance of BPCR. A Birth and Emergency Preparedness Plan (BEPP) card was produced illustrating the following preparations: selecting a birth attendant; choosing a birth place and transportation to reach the birthplace; organizing with a birth companion; identifying a potential blood donor; developing a strategy to save money for costs related to pregnancy; and identifying where to seek care in the case of complications. Women receive the card either from health care providers in facilities during ANC visits or from CHWs through home visits. Main findings: Qualitative assessment revealed a more general trend towards planning for birth and complications and increase in knowledge of danger signs. Additionally a shift was identified in choosing for skilled care, although this was primarily for choosing community-based skilled birth attendant (CBSBA) at home.

Turan et al., 2011^a

Quasi-experimental pre and post study with non-equivalent control group

ERITREA, one district in the Red zone and another in the Anseba zone

Training of community members (women and men) to become maternal health volunteers and lead participatory education sessions making use of materials developed. Skills training for health care providers was also conducted.

Turan 2014

Prospective cohort study

ETHIOPIA, Jimma Zone

Study aim: to determine the effect of BPCR on skilled care. One third of the respondents gave birth with skilled care. Main findings: Two thirds of women who planned SBA actual used it. Reasons for non-use of SBA despite planning were: labor was not associated with problems, lack of transport, lack of money for transport and services. Women who had knowledge of key danger signs and were well prepared (performing three or more BPCR actions: planed to save money, planed to arrange transport, planed to give birth in health facility, planed to be attended by skilled attendant and planed to arrange blood donor) were more likely to use SBA.

Urassa 2012

Cross-sectional survey

TANZANIA, Mpwapwa District

Study aim: To assess knowledge and practices with respect to BPCR amongst women who recently delivered in Mpwapa District. Main findings: The majority of the women had decisions made on place of delivery, a person to make final decision, a person to assist during delivery, someone to take care of the family, a person to escort her to health facility and planned to be delivered by a SBA. Age of the woman, education level, marital status, number of ANC visits and knowing ≥3 obstetric danger signs were associated with birth preparedness and complication readiness.