Introduction
Methods
Community demand creation strategies
|
Emergency loan and insurance funds for emergency obstetric care |
Financial incentives for care-seeking |
Human resource development and training
|
Training of traditional birth attendants (TBAs) in clean delivery and referral |
Training of other cadres of community health workers |
Training of nurse-aides (including task-shifting) as birth attendants |
Training to improve skills of professional midwives in antenatal and intrapartum care |
Obstetric drills |
Training in neonatal resuscitation for physicians and other health workers |
Health system organizational strategies
|
Public-private partnerships to provide emergency obstetric care |
Maternity waiting homes |
Home birth with skilled attendance versus hospital birth for low-risk pregnancy |
Evaluation strategies
|
Perinatal audit |
Results
Community demand creation strategies
Emergency loan/insurance funds for emergency obstetric care
Background
Literature-based evidence
Conclusion
Financial incentives for care-seeking
Background
Literature-based evidence
Conclusion
Human resource development and training
Training TBAs in clean delivery and referral
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Reviews and meta-analyses
| |||
Sibley et al. 2007 [45] | Pakistan and rural Guatemala. Meta-analysis (Cochrane). 2 RCTs included (N = 18,699 pregnant women). | Assessed the effects of trained (intervention) vs. untrained (controls) traditional birth attendants. | SBR: adj. OR = 0.69 (95% CI: 0.57–0.83). |
Sibley and Sipe 2004* [46] | 24 countries and three regions. Meta-analysis (non-Cochrane). 60 studies included | Assessed the effects of the training of TBAs (intervention) vs. untrained TBA baseline (controls). | PMR: 8% reduction with TBA training (statistically significant) Birth asphyxia-associated PMR: 11% with TBA training (statistically significant). |
Intervention studies
| |||
Alisjahbana 1995 [54] | Indonesia (West Java). 2 districts. Longitudinal, intervention study. N = 3275 pregnant women (N = 2275 in the intervention district, and N = 1000 in the controls). | Assessed the impact of the intervention in a district where training was given at all levels of the health care system (informal and formal) and birthing homes were established in villages with special attention to referral, transportation, communication and appropriate case management. There was no intervention in the control district. | PMR: 99/2275 (43.5/1000) vs. 37/1000 (37/1000) in study and control villages respectively [NS]. There was a decrease in PMR in the intervention village with time, compared to no change in the control village. |
Greenwood et al. 1990 [53] | Gambia (Farafenni area). 41 rural villages. Before-after intervention study. | Assessed the impact of primary heatlh care (PHC) programme in villages (intervention) vs. villages without the PHC programme (controls). Survey was also done for one year before and three years after the start of the programme. | SBR: 50/1000 (61/1220) vs. 51.9/1000 (37/712) in the PHC village vs. non-PHC villages in the post intervention period. (SBR increased in both PHC and non-PHC villages during first post-intervention year, possibly due to improved surveillance). PMR: 81.1/1000(99/1220) vs. 88.4/1000 (63/712) in PHC villages vs. non-PHC villages in the post intervention period. NMR: Decreased ~50% in the PHC village from the pre-intervention to the post-intervention period. No change in NMR in non-PHC villages. In PHC villages 65% of women were assisted at childbirth by a trained TBA during the post-implementation period and the proportion of women who delivered in a hospital or health centre increased. |
Larsen et al 1983 [159] | South Africa. Rural community. Observational study. 4 traditional birth attendants caring for 22 pregnant women with no access to professional health care. | Assessed the impact of the training of TBAs over a 2 year period (intervention). | PMR: 0/1000. No statistical data given. |
Observational studies
| |||
Andersson 2000 [50] | Sweden (Sundsvall and Skelleftea). Population-based data Retrospective cohort study. Perinatal deaths (N = 4876) among N = 116211 newborns during the years 1831–1899. | Assessed the impact of the implementation of the midwifery system (43.7% of home deliveries were midwife assisted in 1871–1880 vs. 73.4% during the last decade of the century). Access to the midwives was 73.6% among more urban mothers vs. 50.8% among rural mothers. | PMR: 42/1000 births during the years 1831–1899. PMR: RR = 0.75 (95% CI: 0.66–0.84) among urban mothers comparing the decade after the midwifery system to the years before. PMR: RR = 0.79 (95% CI: 0.72–0.87) among rural mothers comparing the decade after the midwifery system to the years before. Prevented fractions of perinatal deaths: 32% vs. 15% comparing the decade after the midwifery system to the years before. respectively. |
Egullion et al. 1985 [51] | Zimbabwe (Manicaland). Clinics, health centers and hospitals. An intervention study. Over 4000 TBAs were trained by December 1984. | To assess the impact on pregnancy outcomes of a culturally sensitive training of TBAs based on the risk approach and including information about clean delivery, pregnancy including ANC and birth preparedness, normal duration of labour, postnatal care, and harmful traditional practices. Training conducted by maternity nurses, and included fostering linkages between TBAs and the health system. | No statistical data provided, but "marked improvements" were noted, such as reduction in neonatal tetanus, and earlier arrival of obstructed labour cases at the hospital. |
Kwast et al. 1996 [49] | Guatemala, Indonesia, Bolivia and Nigeria. Four different community-based projects between 1989 and 1993. Different study designs. Before-and-after studies in Guatemala and Indonesia. | Bolivia (the Warmi project): formed women's groups, trained birth attendants, husbands and women on safe birth practices, and strengthened referral linkages with the hospital, including a subsidy for hospital admissions. Guatemala (the Quetzaltenango maternal and neonatal health project): enhanced the skills of 400 TBAs vs. comparison areas where no such training was initiated. Indonesia (the Tanjungsari regionalization project): improved maternity services from village to hospital, including establishment of communication and transport links vs. a comparison sub-district without this intervention. Nigeria: provided life-saving skills training for midwives and interpersonal communication skills for all providers. | PMR (Bolivia): 105/1000 vs. 38/1000 births before and after the intervention, respectively. PMR (Guatemala): decreased among referred women in both the implementation and the control areas. 22.2% vs. 11.8% among referred women before and after implementation in the intervention area (P = 0.003). PMR (Indonesia): 47.7/1000 to 35.8/1000 births over 18 months of the project. 42.1/1000 vs. 25.9/1000 among all women delivered by the TBA during the last 6 months of the project. 98.7/1000 vs. 49.6/1000 among those with complications delivered by the TBA over the last 6 months of the project. Intrapartum SBR (Nigeria): 5.5% vs. 1.8% before and after the project. 57% reduction in postpartum haemorrhage (3.7 to 1.6%) and of 70% reduction in prolonged labour (from 20.6 to 6.2%). |
Matthews et al. 1995 [52] | Nigeria (Uyo). Canadian-Nigerian safe motherhood project in the clan area within the catchment area of the government hospital. An intervention program. TBAs (N = 120) were registered for the course which took seven months. | To assess the impact of the training TBAs to use a pictorial method (a card with drawings and symbols) to identify and record risk conditions in childbirth on maternal and neonatal outcomes. | PMR: 25/1000 (20/795). Of these deaths, eight occurred in the group of mothers transferred to hospital. The remaining twelve babies had died at birth in the villages. |
Foord 1995 [160] | Gambia (West Kiang district vs. Upper Baddibu district). An intervention study with a control district. N = 1516 women (794 in intervention and 722 in control area respectively) | To assess the impact of the intervention in the West Kian district through upgrading of personnel, TBA training, improved treatment and referral schemes, and increased number of visits to rural outreach areas vs. control district (Upper Baddibu) without this intervention. | Fetal death (miscarriage + SB): 39.9/1000 vs. 24.5/1000 in intervention and control districts, respectively. Early PMR: 54.9/1000 vs. 39.6/1000 in intervention and control districts, respectively. |
Conclusion
Training of other cadres of Community Health Workers (CHWs)
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Reviews and meta-analyses
| |||
Hodnett et al. 2003 [55] | USA, South Africa, England, Rosario, Argentina; Pelotas, Brazil; Havana, Cuba; and Mexico City. Meta-analysis (Cochrane). 5 RCTs included (N = 9507 poor women) | Assessed the effects of additional antenatal support (intervention) vs. usual care (controls) during pregnancies at risk of low birth weight. | SBR/NMR: RR = 1.15 (95% CI: 0.89, 1.51) [NS]. [112/4778 vs. 96/4729 in intervention and control groups, respectively]. |
Intervention studies
| |||
Bhutta et al. 2008 [56] | Pakistan (Sindh). Rural community (8 village clusters). Pilot study. Before-after intervention data in both intervention and control villages. N = 3747 pregnant women (N = 2056 in the intervention villages, N = 1691 in the controls). | Compared the impact of an intervention where Lady Health Workers (LHWs) and TBAs (Dais) received enhanced training in newborn care and established close liaisons with each other as well as community mobilization activities (intervention) vs. control villages where the regular LHW training programme was continued, but no attempt was made to link LHWs with the Dais. | SBR: RR = 0.66 (95% CI: 0.53–0.83); P < 0.001. [65.9/1000 vs. 43.1/1000 births before and after the intervention in intervention villages, respectively]. SBR: RR = 1.04 (95% CI: 0.84–1.30); P = 0.23 [NS]. [58.1/1000 vs. 60.5/1000 births before and after the intervention period in the control villages, respectively]. PMR: 110.8/1000 vs. 72.5/1000 before and after the intervention in intervention villages, respectively. PMR: 94.64/1000 vs. 101.2/1000 before and after the intervention period in the control villages, respectively. |
Mercer et al. 2004 [57] | Bangladesh. Rural community. Before-after study design. N = 27 partner NGOs from 1996–2002 funded by the Bangladesh Population and Health Consortium. | To assess the effectiveness of a non-governmental organization (NGO) primary health care programme utilising female Family Health Visitors (FHV) who were responsible for basic health and family planning counseling, doorstep delivery of contraceptives and oral rehydration salts, and mobilization of women to use satellite clinics and higher level facilities. | NMR: 39.0/1000 in 1996 (baseline). From 1999–2002, decreased consistently from 36.8 to 15.1/1000 live births among the poorest, and from 30.6 to 16.5/1000 among the remainder of women. |
Conclusion
Training nurse-aides (including task-shifting) as birth attendants
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Observational studies
| |||
Manungo et al. 1996 [61] | Zimbabwe. Rural hospital. Retrospective analysis of records. N = 1459 deliveries, of which N = 824 (57%) were conducted by nurse aides. | Compared the impact of the nurse-aide-conducted deliveries (exposed) vs. those by the trained medical staff (unexposed) on perinatal mortality. | SBR: 1/824 vs. 13/635 in the nurse aide vs. trained staff groups, respectively. PMR: 5/1000 vs. 57/1000 births in the exposed vs. non-exposed groups, respectively. |
Conclusion
Training to improve skills of professional midwives in antenatal and intrapartum care
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Reviews and meta-analyses
| |||
Hodnett 2000 [161] | UK (London) and Australia (New South Wales). Meta-analysis (Cochrane). 2 RCTs included (N = 1815 participants). | Assessed the effects of antenatal, intrapartum and postpartum care by midwives (intervention) vs. usual care by multiple caregivers (controls). | SBR/NMR: OR = 1.96 (95% CI:: 0.83–4.63) [NS]. [14/908 vs. 7/907 in intervention and control groups, respectively]. |
Hodnett et al. 2003 [55] | Australia, US (South Carolina), UK and France. Meta-analysis (Cochrane). 11 RCTs included (N = 9507 participants). | Assessed the effects of social support from midwives (intervention) vs. usual care (controls) antenatally for pregnancies at risk of low birth weight. | SBR/NMR: RR = 1.15 (95% CI: 0.89–1.51) [NS]. [112/4778 vs. 96/4729 in intervention and control groups, respectively]. |
Villar et al. 2001 [162] | UK and Scotland. Meta-analysis (Cochrane). 2 RCTs included (N = 2890 low-risk women). | Assessed the effects of midwife/general practitioner managed care (intervention) vs. obstetrician/gynecologist led shared care with midwives (controls) on perinatal mortality. | PMR: OR = 0.59 (95% CI: 0.28–1.26) [NS]. [10/1447 vs. 17/1443 in intervention and control groups, respectively]. |
Intervention studies
| |||
Ibrahim et al. 1992 [66] | Sudan. Community-based (48 rural villages). Prospective before-after study spanning three years (March 1985–April 1988). N = 6275 deliveries monitored by 40 village midwives, of which 150 were stillbirths and 167 neonatal deaths. | Assessed the impact of training and upgrading of the skills of village midwives (licensed, with 1 year of midwifery training) starting from the middle of the second year of the study. | SBR: 43/1845 (2.3%) vs. 55/2132 (2.6%) vs. 48/2298 (2.1%) in 1985–86, 1986–87 and 1987–88 respectively. SBR+NMR: RR = 0.75 in the third year in comparison with the first two (P < 0.05). |
Theron et al. 2000 [64] | South Africa (Eastern Cape Province). Prospective, controlled trial. N = 73 midwives (N = 34 in the study town, N = 39 in the controls). | The practical skills of midwives caring for pregnant women were determined before and after the introduction of training via Maternal Care Manual in the study town. No training was given in the control towns. | Distribution of marks: a significant (P < 0.001) improvement occurred in the study town between pre- and postintervention periods, whereas the control towns showed no change. The mean improvement in the study town was 3.5 marks (36.6% improvement) vs. 0.1 marks (1.1% improvement) in the control towns. |
Observational studies
| |||
Montero-Mendoza et al. 2000 [163] | Mexico (Chiapas). Rural and urban area. Cross-sectional study. N = 670 women between 15 to 49 years old with N = 1,382 pregnancies from 1987 to 1996. | Compared the impact of birth assistance by a midwife (study group) vs. a relative of the pregnant woman, her husband or herself (controls). | PMR: OR = 0.30 in study vs. control groups, P < 0.01. (36.2/1000 live births) |
Conclusion
Obstetric drills
Background
Literature-based evidence
Conclusion
Training in neonatal resuscitation for physicians and other health care workers
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Intervention studies
| |||
Cowles 2007 [89] | Northern India. Rural hospitals. An intervention study. | Assessed the impact of the Basic Neonatal Resuscitation Program (BNRP) for the birth attendants (nurses and ward aides) in providing more effective neonatal resuscitation at birth. | SBR: decreased in the hospitals where the course had been taught on site. Doctors stated that, when called for resuscitation, they would find the nurses giving the Ambu Bag, and a living baby, when before the babies had died. |
Deorari et al. 2001 [90] | India. 14 teaching hospitals. Before-after study. N = 28 faculty members from each hospital, who in turn trained staff at their own hospital. Each institution provided 3 months pre-intervention and 12 months post-intervention data. | Compared the impact for 12 months after (intervention) vs. for 3 months before (control) use of Neonatal Resuscitation Programme (NRP) in teaching hospitals to doctors and nurses. | Total cause-specific NMR: 901/25,713 (3.5%) vs. 264/7,070 (3.7%) after and before the intervention, respectively. (P > 0.05). Asphyxia-related cause-specific mortality: Significant reduction (P < 0.01). |
Jeffery et al. 2004 [164] | Macedonia. 16 participating hospitals. National perinatal strategy programme. | Assessed the impact of a train-the-teachers education intervention to develop the capacity of health professionals to introduce evidence-based perinatal practice originally developed in Australia. | PMR: RR = 0.79 (95% CI: 0.73–0.85). [21.5/1000 vs. 27.4/1000 after vs. before, respectively]. Early NMR: 36% reduction (infants > 1000 g birth weight) A total of 115 doctors and nurses graduated from this programme. |
India. Rural setting. Prospective cohort study. N = 58 cases of asphyxia; 38 delivered by conventionally trained TBAs [N = 968] and 20 by TBAs with advanced training [N = 911]. | Simplified methods of resuscitation were taught to TBAs. An additional group received advanced training on use of the mucous extractor and bag-and-mask ventilation. | PMR: 19% reduction comparing advanced vs. conventionally trained TBAs, respectively. Asphyxia-associated perinatal mortality: 70% reduction comparing advanced vs. conventionally trained TBAs, respectively. | |
Raina et al. 1989 [96] | India (Haryana). Villages of Ambala District. Exploratory study. TBAs (N = 100) where 90% of deliveries occur at home, and are performed by TBAs. | To assess the training needs of traditional birth attendants with reference to their knowledge of the causes of birth asphyxia, their capacity to recognise it and the methods they were using to manage the condition. | TBAs mentioned 6 resuscitation measures they used in birth asphyxia. 4 or more of these were only used by 20 of the TBAs. 70% of the participants used resuscitation procedures for 1/2 hour before giving up due to such prognostic features as a blue or pale color, the absence of cord pulsations, no breathing, limpness and the absence of pulsations in the anterior fontanelle. Knowledge of modern resuscitation equipment and procedures was poor and referrals were made based on the proximity of the institution and not on the quality of care available. |
Zhu et al. 1997 [91] | China (Zhuhai). Maternal and Child Health Hospital. Perspective, before-and-after intervention study. N = 4,751 newborns with 366 asphyxiated babies in a period of 2 years and historical controls of 1,722 live births. | Compared the impact on neonatal mortality of the Neonatal Resuscitation Program (NRPG) (intervention) vs. historical controls when the traditional resuscitation program was in place. | PMR: 3-fold decrease with NRPG compared to historical controls (chi(2) = 10.54, P < 0.01). |
Observational studies
| |||
Blond et al. 1994 [93] | France. 31 maternity hospitals. Before-after study. N = 156 medical personnel (doctors, mid-wives) and paramedics [53% of all available personnel]. | To assess the impact of special training to medical personnel (intervention) vs. personnel without any special training (control) in 1990. | Improved neonatal resuscitation rates compared with untrained personnel. Severe meconium aspirations: 0 vs. 3 in 1990 vs. 1989, respectively. |
Conclusion
Health system organizational strategies
Public-private partnerships to provide emergency obstetric care
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Observational studies
| |||
Shantharam Baliga et al. 2007 [101] | India. Government District Headquarters Maternity Hospital. Before-after intervention study. | Tracked the impact of scale-up of neonatal services from 1998–2001, and compared outcomes in 2004 (post-upgrade) to 1998 (pre-upgrade) | Hospital SBR: 44.79 vs. 35.52/1000 live births in 1998 and 2004, respectively; P = 0.04. Hospital PMR: 65.81 vs. 50.15/1000 live births in 1998 and 2004, respectively; P = 0.003. Hospital early NMR: 21.02 vs. 14.63/1000 live births in 1998 and 2004, respectively; P = 0.03. |
Conclusion
Maternity waiting homes
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Intervention studies
| |||
Guruvare et al. 2007 [109] | India. Six satellite maternity homes attached to the tertiary care hospital. Descriptive intervention study. | To assess the perinatal mortality rate among pregnant women taken care of at the hospital, along with the attached satellite maternity homes. This rate was compared with the national average. | PMR: 21/1000 vs. 70/1000 live births in the study group vs. the national average. (63% of perinatal deaths were stillbirths). |
Observational studies
| |||
Chandramohan et al. 1995 [106] | Zimbabwe. Rural hospital-based. Cohort study. N = 4488 high risk pregnant women (N = 1573 in the intervention group, N = 2915 in the controls) during the period 1989–1991. Information on antenatal risk factors, use of ANC, access to the hospital and stage of labour on arrival was collected for each woman. | Compared the effect of staying in a maternity waiting home from 36 wks to delivery (intervention) vs. going straight from home to hospital at the time of delivery (controls). | SBR: 19.2/1000 vs. 10.8/1000 in the control and intervention groups, respectively. PMR: RR = 1.7 (95% CI: 1.1–2.6); P < 0.05. [32.2 vs. 19.1/1000 in the control vs. intervention groups, respectively]. PMR: adj. RR = 1.5 (95% CI: 0.95–2.5); P = 0.07 in the control vs. intervention group. However, when the analysis was restricted to women with antenatal risk factors there was a significant 50% reduction in the risk of perinatal death for the women in the intervention vs. controls (adj. RR = 1.9; 95% CI: 1.1–3.4; P < 0.05). |
Poovan et al. 1990 [108] | Ethiopia. Hospital based. Prospective cohort study. N = 777 pregnant women at high risk of complications or those living in remote areas (N = 142 intervention group, N = 635 controls). | Compared the impact of either coming via a maternity waiting home (intervention) vs. coming directly to the hospital (controls). | SBR: 28.2/1000 (4/142) vs. 253.5/1000 (161/635) births in intervention and control groups, respectively. Statistical significance data not given. MMR: 0/1000 vs. 21.2/1000 live births in intervention and control groups, respectively. Statistical significance data not given. |
Tumwine 1996 [107] | Zimbabwe. Rural district. Prospective cohort study. N = 1,053 pregnant women (N = 280 intervention group, N = 773 controls). | Compared the impact on pregnancy outcomes of women using a maternity waiting shelter (exposed group) vs. those coming directly to the hospital i.e. non-waiting mothers (unexposed). | PMR: 25.0/1000 vs. 29.8/1000 in intervention and control groups, respectively; P > 0.05 [NS]. |
van Lonkhuijzen et al. 2003 [105] | Zambia. Rural setting. Prospective cohort study. N = 510 pregnant women (N = 218 exposed group, N = 292 non-exposed). | Compared the impact on risk status and pregnancy outcome in women staying at maternity waiting homes (exposed) with those women who gave birth in hospital after direct admission (unexposed). | PMR/MMR/Birth weight: No significant differences between the two groups. Spontaneous vaginal vertex delivery: 86% vs. 95% in the exposed and non-exposed groups, respectively. |
Conclusion
Home birth with skilled attendance versus hospital birth for low-risk pregnancy
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirths/Perinatal Outcomes |
---|---|---|---|
Reviews and meta-analyses
| |||
Hodnett et al. 2005 [111] | Australia, Scotland, UK, Sweden and Canada. Meta-analysis (Cochrane). 5 RCTs included (N = 8529 participants). | To assess the effects of care in a home-like birth environment (intervention) vs. care in a conventional labour ward (controls). | PMR: RR = 1.83 (95% CI: 0.99–3.38) [NS]. [41/5288 vs. 13/3241 in intervention and control groups, respectively]. |
Olsen 1997 [113] | Switzerland, USA, Essex, Australia. Meta-analysis (non-Cochrane). 6 controlled observational studies included (N = 24,092 low-risk pregnant women). | Assessed the safety of planned home birth backed up by a modern hospital system (study group) compared with planned hospital birth (controls). | PMR: OR = 0.87 (95% CI: 0.54–1.41) [NS]. |
Intervention studies
| |||
Janssen et al. 2003 [115] | Canada. University of British Columbia (Home Birth Demonstration Project). Intervention study. N = 2,178 pregnant women (N = 864 Home Birth Project clients, N = 571 midwife-attended hospital, N = 743 physician-attended hospital deliveries). | Compared the effect on the outcomes of women remaining eligible for home birth at the onset of labour (intervention) vs. those women meeting eligibility requirements for home birth but planning instead to deliver in hospital with either a midwife or physician in attendance (controls). | PMR: adj. OR = 2.50 (95% CI: 0.27–24.5) [NS] [0.3% vs. 0.1% in intervention vs. physician-attended hospital birth, respectively]. PMR: 0.3% vs. 0% in home birth vs. midwife-attended hospital birth respectively. |
Observational studies
| |||
Janssen 2002 [165] | Canada. Prospective cohort study. N = 2,176 pregnant women (N = 862 home birth, N = 571 midwife-attended hospital, N = 743 physician-attended hospital births. | Compared the impact on pregnancy outcomes of planned home births (exposed group) vs. planned hospital births either attended by midwife (unexposed # 1) or the physician (unexposed # 2). | SBR: 2 vs. 0 vs. 1 in the exposed, unexposed # 1 and unexposed # 2 groups, respectively. PMR: 3 cases in the home birth group (2 stillbirths and one neonatal death). PMR: RR = 2.5 (95% CI: 0.27–24.5) in exposed vs. unexposed # 2. |
Tracy et al. 2007 [116] | Australia. Population-based study. Retrospective cohort. Women (N = 1,001,249) who gave birth in Australia during 1999 to 2002. Of these women, 21,800 (2.18%) gave birth in a birth center. | Compared the impact on perinatal mortality of giving birth in "alongside hospital" birth centers (exposed group) vs. birth in the hospitals (unexposed group). | PMR: 1.51/1000 vs. 10.03/1000 in exposed vs. unexposed groups, respectively (statistically significant). PMR: 1.4/1000 vs. 1.9/1000 among term births to primiparas in exposed vs. unexposed groups, respectively. PMR: 0.6/1000 vs. 1.6/1000 among term births to multiparas in birth centers vs. hospitals, respectively. |
Wiegers et al. 1996 [117] | Netherlands. Prospective study. Women (N = 1836) and midwives (N = 97). | Compared the impact of planned home birth (study group) vs. planned hospital birth (controls). | PMR: 0/471 (0%) vs. 2/369 (0.5%) among primiparous women in the study vs. control groups, respectively. PMR: 4/669 (0.6%) vs. 0/327 (0%) among multiparae in the study vs. control groups, respectively. Multiparae had significantly better perinatal outcome for planned homebirths than planned hospital births (t = 4.75, p < 0.001). |
Conclusion
Perinatal audit
Background
Literature-based evidence
Source | Location and Type of Study | Intervention | Stillbirth/Perinatal Outcomes |
---|---|---|---|
Reviews and meta-analyses
| |||
Mancey-Jones and Brugha 1997[124] | Zimbabwe, Guadeloupe, South Africa, Mozambique. Systematic review. Before-and-after time series analyses. 7 studies included from low-/middle income countries. | Assessed the impact on perinatal mortality rates before and during a perinatal audit. | No pooled analysis done. PMR (Guadeloupe): fell by 25% during audit. PMR (Lebowa, South Africa): significant reduction. PMR (Mozambique): no change (increase in high risk patients). PMR (Port Elizabeth, South Africa): significant reduction. |
Intervention studies
| |||
Biswas et al. 1995 [166] | Singapore. National University Hospital. Comparison of perinatal mortality rates between two time periods. N = 26,173 mothers with N = 26,423 births during 1986–1992. N = 235 perinatal deaths, of which 145 (61.7%) were stillbirths and 90 (38.3%) were neonatal deaths. | Compared the perinatal mortality rate during a 7-year period (1986–1992) vs. baseline assessed in 1982 using perinatal audit. Compared to 1982, 1986–1992 were marked by improvements in antenatal and intrapartum fetal surveillance and improved neonatal care. | PMR: 8.9/1000 vs. 14.6/1000 in during perinatal audit period vs. baseline. PMR (excluding lethal malformations): 5.7/1000 vs. 14.6/1000 in 1986–1992 vs. 1982 |
Cameron et al. 2001 [167] | Australia (Far North Queensland). Atherton Hospital. Before-and-after study design. N = 5,879 births (N = 2996 during 1991–00, N = 2883 during 1981–90). | Analysed obstetric audit data collected from 1991–2000, comparing PMR during this period with the previous decade (1981–90). Was associated with increased public sector utilization and caesarean section rate (13% to 17.4%) | SBR: 12/2996 (4/1000) vs. 7/2883 (2.4/1000) after vs. before, respectively. PMR: 16 (5.3/1000) vs. 15 (5.2/1000) after vs. before, respectively. NMR: 4/2996 (1.3/1000 live births) vs. 8/2883 (2.8/1000) after vs. before, respectively. No statistical significance data given. |
Cameron 1998[168] | Australia (Far North Queensland). Atherton Hospital. Descriptive study. N = 2883 deliveries during 1981–1990 (N = 1974 public confinements, N = 909 private confinements). | Analysed obstetric audit data collected from private vs. public facilities over the decade 1981–1990. | PMR: 5.2/1000. PMR: 5.1/1000 vs. 5.5/1000 in public and private confinements, respectively. PMR (corrected): 9.6/1000 vs. 13.5/1000 vs. 16.9/1000 in public patients, Queensland (1987) and the Far North Statistical Division (1987). |
Dahl et al. 2000 [169] | Norway (Troms County). Medical Birth Registry of Norway and medical records. Retrospective + prospective study design. N = 472 antenatal, neonatal and post neonatal deaths = 20 weeks of gestation from 1976– 1997. | Evaluation of deaths, including assessment of risk factors, mortality rates, cause of death, sub-optimal care and avoidable deaths, by medical audit to improve antenatal and neonatal care over a 22-year period. | Fetal death (miscarriage + SB) + NMR + IMR: 13.8/1000 in 1976–80 9.5/1000 in 1981–85 10.4/1000 in 1986–91 7.7/1000 in 1992–97 (P < 0.001) Reduction attributable to reduced rate of pre-term birth (P < 0.001) and low birth weight (500–1995 g) (P < 0.001). |
Hawthorne et al. 1997 [170] | United Kingdom. District general and teaching hospitals (Population data). Prospective audit. N = 111 diabetic pregnant women booking in 1994. | To compare perinatal mortality associated with diabetic pregnancies with the background population (controls) to determine progress toward a specified target of diabetic pregnancy outcome approximating non-diabetic pregnancy outcome. | PMR: OR = 5.38 (95% CI: 2.27–12.70). [48/1000 vs. 8.9/1000 in diabetic pregnancy and controls, respectively]. NMR: OR = 15.0 (95% CI: 6.77–33.10). [59/1000 vs. 3.9/1000 in the diabetic pregnancies vs. controls, respectively]. |
Jansone and Lazdane 2006 [171] | Latvia (Riga). Tertiary referral perinatal care center. Retrospective audit. N = 26,783 births, of which N = 494 were stillbirths and neonatal deaths during 1995–1999. | To analyze all perinatal deaths using the Nordic-Baltic classification system, and assess trends in perinatal mortality over the study period. | PMR: No decline during the study period. Proportion of preventable perinatal deaths: 36.4% vs.14.7% in 1999 vs. 1995, respectively (P = 0.01). |
Korejo et al. 2007 [172] | Pakistan (Karachi). Government teaching hospital. Prospective review. N = 7743 deliveries in 2001, of which N = 753 were perinatal deaths (N = 569 stillbirths and N = 184 early neonatal deaths). | To review the extent and determinants of perinatal mortality using the Aberdeen classification system, which analyses cause of death as well as preventive factors, comparing the PMR in 2001 with previous data. | SBR: 73.4/1000 total births. PMR: 97.2/1000 total births. No change in PMR over 40 years due to higher patient influx and incoming referrals. Perinatal deaths associated with poor care and education and low socio-economic status. |
Krebs et al. 2002 [136] | Denmark (Copenhagen). University hospital. Blinded controlled perinatal audit). N = 12 non-malformed, breech infants with intrapartum/early neonatal death in the period 1982–92. N = 23 controls matched by presentation and planned mode of delivery. | 11 obstetricians reviewed the data (derived from maternity records) and narratives of cases and controls, subsequently completing questionnaires in which they guessed whether the baby had died based on the data (for both cases and controls), and whether suboptimal care had been provided during pregnancy and delivery, indicating a potentially avoidable death. | Suboptimal ANC: 17% vs. 4% in cases and controls, respectively. Suboptimal intrapartum care: 25% vs. 26% in cases and controls, respectively. When death was assumed, obstetricians asserted it was potentially avoidable in 7/12 (58%) of cases and 4/23 (17%) of controls (P = 0.02). |
Krue et al. 1999 [173] | Denmark (Viborg County). Perinatal audit (county-wide). | Compared perinatal mortality over a three-year perinatal audit period from 1994–1996. The mortality rate in 1995 was also compared to data from the Danish National Birth Register (1995). | PMR: 6.5/1000 vs. 9.4/1000 in 1996 vs. 1994, respectively [NS]. NMR: 2.4/1000 vs. 3.2/1000 in 1996 vs. 1994, respectively [NS]. PMR: No difference between county and national rates in 1995. |
Papiernik et al. 2005 [174] | France (Paris). Perinatal audit. All deaths from 1989 to 1992 in the Perinatal Enquiry. | Assessed the impact of audit of obstetrical practices and the analysis of perinatal deaths on perinatal mortality. | PMR: Major reduction after a 10-year period. |
Tay et al. 1992 [137] | Singapore. Tertiary referral hospital. Caesarean audit. N = 16, 875 deliveries during the 4 year period. | Assessed the impact on perinatal mortality of an intradepartmental audit (critical review of indications for cesarean delivery). | PMR: 8.25, 7.05, 9.39 and 5.38 in 1987, 1988, 1989 and 1990, respectively for infants weighing ≥ 500 g Caesarean section rate: 12.3%, 11.1%, 11.2% and 11.4% for 1987, 1988, 1989 and 1990, respectively. |
Wilkinson et al. 1997 [135] | South Africa (rural). Hlabisa Maternity Service, comprising Hlabisa Hospital, 8 village clinics, and 20 mobile clinic points. Perinatal audit with subsequent interventions. N = 21,112 consecutive births between May 1991 and December 1995. | To assess the impact of the perinatal audit on the quality of care, along with the design of interventions informed by the audit results. The interventions employed consisted of structural and functional rearrangement of the maternity service district-wide, writing and implementing protocols of care for local use, and regular in-service education. | PMR: 27/1000, 42/1000 and 26/1000 in 1991, 1992 and 1995, respectively (40% reduction from the peak in 1992; P = 0.002). PMR: 653/21,112 (31/1000) from 1991 to 1995. Proportion of perinatal deaths occurring in clinics (vs. at home/outside of clinics): 6.3% vs. 17% in 1995 vs. 1991, respectively. |
Observational studies
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King et al. 2006 [120] | Australia (Victoria). Maternity hospitals. Perinatal death audit. A cohort of N = 3485 perinatal deaths over a 5-year period, 2000–2004. Live births: N = 312651; stillbirths: N = 242; neonatal deaths: N = 1057 | To assess the impact of a systematic audit of stillbirths and neonatal deaths via application of the classification systems developed by the Perinatal Society of Australia and New Zealand (PSANZ). | Causes of perinatal deaths: congenital abnormality (24.5%), followed by spontaneous preterm birth (17.0%), unexplained antepartum death (15.9%), and maternal conditions (14.8%). Causes of stillbirths: unexplained antepartum death was the main cause of death (22.9%), followed by congenital abnormality (20.3%) and maternal conditions (20.4%). |
Conclusion
Discussion
Summary of evidence to improve service supply and community demand for interventions to prevent stillbirth
Evidence of no or negative impact (leave out of programs) | Uncertain evidence (need for additional research before including in programs) | Some evidence (may include in programs, but further evaluation is warranted) | Clear evidence (merits inclusion in programs) | |
---|---|---|---|---|
Emergency loan/insurance funds for obstetric emergencies | X | |||
Financial incentives to improve access to emergency obstetric care | X | |||
Training traditional birth attendants in clean delivery and referral | X | |||
Training of other cadres of community health workers | X | |||
Training nurse-aides as birth attendants (including Caesarean section) | X | |||
Training professional midwives in antenatal and intrapartum care | X | |||
Obstetric drills | X | |||
Training in neonatal resuscitation for physicians and other health workers | X | |||
Public-private partnerships | X | |||
Maternity waiting homes | X | |||
Home birth with skilled attendance versus hospital birth | X (high-income country studies only; no disadvantage to home birth) | |||
Perinatal audit | X |
Delivering effective interventions to prevent stillbirths: summary of recommendations for programmes (Table 12)
1. Community demand creation strategies and training of appropriate human resources for health promotion and preventive interventions. |
2. Antenatal care to deliver quality interventions and to screen for high risk pregnancies |
3. Recognition and management of maternal infections during pregnancy, such as syphilis and malaria |
4. Skilled attendance at birth and emergency obstetric care availability (including Caesarean section) |
Mass media (including social marketing strategies, health days, etc) | Facilitated community and advocacy groups | TBAs | Trained CHWs (outreach workers) | Community-based professional midwives | Other cadres of facility-based health workers | Medical/nursing staff in first-level facilities | |
---|---|---|---|---|---|---|---|
Multiple micronutrient supplementation | + | + | ✓ | ✓ | ✓ | ✓ | |
Balanced protein-energy supplementation | + | + | ✓ | ✓ | ✓ | ✓ | |
Anti-malarials in pregnancy | + | + | ✓ | ✓ | ✓ | ✓ | |
Insecticide-treated bed nets in pregnancy | + | ✓ | ✓ | ✓ | ✓ | ✓ | |
Heparin in pregnancy for clotting disorders and antiphospholipid syndrome | ✓ | ||||||
Anti-helminthic treatment in pregnancy | ✓ | ✓ | ✓ | ✓ | |||
Syphilis screening and treatment in pregnancy | + | ✓ | ✓ | ||||
Management of intrahepatic cholestasis in pregnancy | ✓ | ||||||
Fetal movement counting (in high-risk pregnancy) | + | + | ✓ | ✓ | ✓ | ||
Doppler monitoring (in high-risk pregnancy) | ✓ | ||||||
Intrapartum cardiotocography (with access to Caesarean section) | ✓ | ||||||
Amniotic fluid volume assessment in pregnancy | ✓ | ||||||
Emergency obstetric care packages, including Caesarean section | + | + | + | + | ✓ | ✓ | |
Elective induction of labour in post-term pregnancies | + | + | ✓ | ||||
Planned Caesarean section for term breech presentation* | + | ✓ | |||||
Perinatal audit | ✓ | ✓ | ✓ |
Delivering effective interventions to prevent stillbirths: recommendations for policy and research
Evidence of stillbirth reduction | Maternal benefit | Neonatal/infant benefit | |
---|---|---|---|
Antenatal multiple micronutrient supplementation | * | Reduced anemia (iron-containing supplements) | Improved micronutrient status and survival |
Balanced protein-energy supplementation | * | Improved nutritional status | Reductions in low birth weight |
Maternal deworming | * | Reduced anemia, improved nutritional status | |
Syphilis screening and treatment | ** | Eradication of syphilis infection | Reductions in congenital syphilis (neonatal morbidity and mortality) |
Malaria chemoprophylaxis | * | Reduced burden of malaria and anemia, reduced maternal mortality | |
Insecticide-treated bed net use in pregnancy | ** | Reduced burden of malaria and anemia, reduced maternal mortality | |
Intrapartum cardiotocography with or without pulse oximetry | * | - | Reduced birth asphyxia, neonatal mortality |
Emergency obstetric care packages | **1 | Reduced maternal morbidity and mortality | Reduced neonatal morbidity and mortality |