The Impact of Quality Improvement Processes, Interventions and Structure on Maternal and Perinatal Mortality in Low-and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Background: Maternal and perinatal mortality remain high in low and middle-income countries (LMICs) compared to high income countries. We aim to summarise obstetric quality improvement (QI) processes, interventions and structure that have a measurable impact on mortality measures. Methods: A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country obstetric systems was conducted from according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in a LMIC according to the World Bank Income Classification, occurred in an obstetric setting and measured the effect of an implementation on maternal or perinatal mortality. Results: Of 42,145 search results, 46 studies were included in a qualitative synthesis, and 14 articles included for a meta-analysis. Upgrading facilities to be capable of providing emergency obstetric care improved maternal mortality by RR 0.60 (95%CI 0.40 to 0.89). Obstetric education and training, implementing community-based programs, using QI programs and eliminating user fees improved maternal and perinatal mortality. Conclusion: There is evidence multiple QI interventions can improve maternal and perinatal mortality in an LMIC setting. These implementations should be considered by policy-makers when aiming to improve maternal outcomes.