Abstract
{ "background": "Maternal mortality remains a critical public health challenge in sub-Saharan Africa. Systemic weaknesses in care delivery at health facilities are a recognised contributor to adverse outcomes, yet robust evidence on the causal impact of facility-level systems interventions is limited.", "purpose and objectives": "This study aimed to quantify the causal effect of a structured maternal care facility systems intervention on key clinical outcomes. The primary objective was to estimate its impact on the rate of postpartum haemorrhage (PPH).", "methodology": "A quasi-experimental, difference-in-differences design was employed across 42 public health facilities. The intervention comprised a bundled package of systems strengthening: standardised clinical protocols, emergency equipment provisioning, and team-based simulation training. Control facilities continued routine care. The primary outcome was the facility-level PPH rate, analysed using a generalised linear mixed model: $\\log(E[Y{it}]) = \\beta0 + \\beta1 (\\text{Intervention}i \\times \\text{Post}t) + \\gamma X{it} + \\alphai + \\deltat + \\epsilon{it}$, where $\\alphai$ and $\\delta_t$ are facility and time fixed effects. Robust standard errors were clustered at facility level.", "findings": "The intervention was associated with a statistically significant reduction in the PPH rate. The adjusted incidence rate ratio was 0.72 (95% CI: 0.58 to 0.89), corresponding to a 28% relative reduction. Secondary analyses indicated improvements in adherence to clinical guidelines and availability of essential commodities.", "conclusion": "A targeted facility systems intervention significantly improved a critical clinical outcome. This provides causal evidence that strengthening operational systems within existing health infrastructure can enhance maternal care quality.", "recommendations": "Policy should prioritise integrated, facility-level systems strengthening bundles. Programme design should incorporate rigorous embedded evaluation to quantify health impacts and inform scale-up.", "key words": "maternal health, health systems