EMBRACE COMPASS: protocol for a multi-country cross-sectional comparative analysis of pregnancy and postnatal care...

Maternal morbidity and mortality remain major global health challenges, with substantial variation in maternity care delivery across health systems. Although clinical guidelines are widely available, there is limited systematic, multi-country mapping of maternity care systems as integrated architectures. Evidence linking system design and implementation to population outcomes is also limited. This study aims to compare maternity care systems across countries for gestational diabetes, hypertensive disorders of pregnancy, perinatal depression, and uncomplicated pregnancy using a structured, multi-layered care architecture framework.

This is a multi-country, cross-sectional, mixed-methods comparative study including twenty countries across all World Health Organization regions and income groups, selected using purposive sampling. Data will be collected using a standardised instrument with more than 140 items mapped to a nine-layer care architecture framework, covering policy, clinical standards, guidelines, models of care, care pathways, clinical protocols, digital systems, patient experience, and financing. Data sources will include structured country submissions, systematic document review, and validation interviews with clinicians and policymakers. Each domain will be independently scored by two reviewers using a four-point ordinal scale, with assessment of inter-rater reliability. Country profiles will be validated through member checking and triangulation of documentary and interview data. Comparative analyses will include descriptive profiling, cross-country comparisons, clustering to identify system typologies, and gap analysis against international benchmarks. Implementation and equity dimensions will be assessed using established frameworks, and physical activity guidance will be examined as a cross-cutting domain. Exploratory ecological analyses will assess associations between system characteristics and publicly available outcomes, including maternal mortality, preterm birth, stillbirth, and caesarean section rates, using regression models. A structured consensus process will be used to develop minimum care architecture standards and harmonisation recommendations.

This study will provide a structured and reproducible approach to characterising and comparing maternity care systems globally. By identifying variation in system design, implementation, and equity considerations, the findings will inform policy, support harmonisation of care, and guide improvements in maternal and perinatal outcomes across diverse settings.

Open Science Framework.