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Background Maternal mortality remains unacceptably high in many parts of the world today, even though the majority of these deaths are preventable. Between 1990 and 2015, the fifth Millennium Development Goal aspires to reach the goal of reducing maternal mortality by 75%, and in many low-income countries, this ambitious target appears to be beyond reach. Objectives To systematically review the strategies that have reduced maternal mortality within four countries: Cambodia, Malaysia, Thailand and Sri Lanka. Inclusion criteria Textual and opinion papers that explored strategies to reduce maternal mortality in Cambodia, Malaysia, Thailand and Sri Lanka were included. Participants included pregnant and birthing women who received care from a skilled birth attendant. Types of participants Pregnant and birthing women who received care from a skilled birth attendant within Cambodia, Malaysia, Thailand and Sri Lanka. Phenomena of interest The review considered publications that described: The health system/service delivery structures and underlying policy; The maternity care provided by a skilled birth attendant. Types of publications This review considered government reports, expert opinion, discussion papers, position papers, and other forms of text published in the English language. Technical reports, statistical reports and epidemiological reports were excluded. Types of outcomes The primary outcome of interest in this review was: Impact on maternal mortality rates. Secondary outcomes of interest to this review included: a) Changes to health system structures related to pregnancy and childbirth (including resources/finances) b) Change in cultural practices related to pregnancy and birth c) Empowerment of women and their position in society (and what impact this has had with respect to their choice of pregnancy and birth care). Search strategy Published and unpublished English language articles from 2000 through to 2010 were identified with electronic searches of medical and social science databases. In addition, bibliographies of articles were examined for eligible studies. Methodological quality Textual papers were assessed by two independent reviewers for authenticity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument. Data collection Textual data was extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument. Data synthesis Textual papers were, where possible, pooled using the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument. The process of meta-synthesis involved the extraction of conclusions, which were grouped into categories, then analyzed to generate synthesized findings. Results Thirty-three text and opinion papers met the inclusion criteria. Nine syntheses were derived with key themes related to decreasing maternal mortality, including professionalization of midwifery, free and equitable healthcare, strengthening of health systems, appropriate task-shifting, access issues for women, empowerment of women, improved data collection methods and global assistance from neighboring countries when required. Conclusions A combination of these nine essential factors, when empowered by an enabling environment, will lead to provision of skilled attendance for all birthing women. All governments, health professionals who work to provide skilled attendance, and women and their communities must work together with a shared commitment to tackle these issues of maternal mortality. Implications for practice The implications for practice are derived directly from the results of the meta-synthesis, and each of the nine synthesized findings. Implications for research The challenge for future research is to increase collaboration with and amongst researchers from developing countries into maternal health issues. Researchers in developing countries must lead these research initiatives, with collaboration and support if requested.
McArthur et al. (Mon,) studied this question.