Levels of care for maternal and neonatal healthcare: a scoping review.

Background: To meet the 2030 aims of the Global Strategy for Women's, Children's and Adolescents' Health and Sustainable Development Goals, annual rates of maternal and newborn mortality and stillbirth must decrease. The organisation of maternal and newborn health (MNH) services influences access to and quality of care. We designed this scoping review to understand how levels of MNH care are organised in different country contexts. Methods: We conducted a scoping review of peer-reviewed literature published after 2009. Based on the World Health Organization (WHO) quality-of-care framework, we conducted descriptive and deductive textual narrative analysis to identify the reported number of levels of MNH care stratified by country and mortality rates; describe how levels are conceptualised; and explore alignment of levels for the maternal-newborn dyad. Results: We included 162 of 3591 reports. The number of MNH facility levels of care across 56 countries ranged from two to seven. Types of identified MNH care facilities were described at varying levels. Two levels of care were reported in 5% of cases, three levels in 55%, four levels in 30%, five levels in 8%, and six and seven levels in <1% of cases. Home and community-based MNH care (non-facility) was reported in 8% of country descriptions. Countries with the lowest stillbirth, maternal, and newborn mortality rates mostly reported three or four facility levels. The criteria used to distinguish MNH levels of care as low, intermediate, and high were aligned with domains of the WHO quality-of-care framework, mostly human and physical resources. Conclusions: Levels of MNH care described in the literature were distinguished by characteristics, including provision and experience of routine and emergency care. Three or four levels of MNH facility care were most commonly reported. Linking maternal and newborn facility care to community connections is an important consideration to ensure equitable access to routine and emergency care.