Abstract
BackgroundOur objective was to estimate the effect of various childbirth care packages on neonatal mortality due to intrapartum-related events (“birth asphyxia”) in term babies for use in the Lives Saved Tool (LiST).MethodsWe conducted a systematic literature review to identify studies or reviews of childbirth care packages as defined by United Nations norms (basic and comprehensive emergency obstetric care, skilled care at birth). We also reviewed Traditional Birth Attendant (TBA) training. Data were abstracted into standard tables and quality assessed by adapted GRADE criteria. For interventions with low quality evidence, but strong GRADE recommendation for implementation, an expert Delphi consensus process was conducted to estimate cause-specific mortality effects.ResultsWe identified evidence for the effect on perinatal/neonatal mortality of emergency obstetric care packages: 9 studies (8 observational, 1 quasi-experimental), and for skilled childbirth care: 10 studies (8 observational, 2 quasi-experimental). Studies were of low quality, but the GRADE recommendation for implementation is strong. Our Delphi process included 21 experts representing all WHO regions and achieved consensus on the reduction of intrapartum-related neonatal deaths by comprehensive emergency obstetric care (85%), basic emergency obstetric care (40%), and skilled birth care (25%). For TBA training we identified 2 meta-analyses and 9 studies reporting mortality effects (3 cRCT, 1 quasi-experimental, 5 observational). There was substantial between-study heterogeneity and the overall quality of evidence was low. Because the GRADE recommendation for TBA training is conditional on the context and region, the effect was not estimated through a Delphi or included in the LiST tool.ConclusionEvidence quality is rated low, partly because of challenges in undertaking RCTs for obstetric interventions, which are considered standard of care. Additional challenges for evidence interpretation include varying definitions of obstetric packages and inconsistent measurement of mortality outcomes. Thus, the LiST effect estimates for skilled birth and emergency obstetric care were based on expert opinion. Using LiST modelling, universal coverage of comprehensive obstetric care could avert 591,000 intrapartum-related neonatal deaths each year. Investment in childbirth care packages should be a priority and accompanied by implementation research and further evaluation of intervention impact and cost.FundingThis work was supported by the Bill and Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.
Highlights
Our objective was to estimate the effect of various childbirth care packages on neonatal mortality due to intrapartum-related events (“birth asphyxia”) in term babies for use in the Lives Saved Tool (LiST)
They found that women receiving Basic emergency obstetric care (BEmOC) and Comprehensive emergency obstetric care (CEmOC) had a higher risk of DATABASES PubMed, POPLI Neonatal encephalopathy (NE), WHODa ta ba s es (LI LACS,Afri c a nI ndex Medi c us,a ndEMRO), Cochrane
This observational study is prone to selection bias, as skilled care/emergency obstetric care was likely sought for higher-risk, complicated deliveries, and the observed association is unlikely to reflect the population effect of the intervention [37]
Summary
Our objective was to estimate the effect of various childbirth care packages on neonatal mortality due to intrapartum-related events (“birth asphyxia”) in term babies for use in the Lives Saved Tool (LiST). In low income countries, where skilled professionals attend fewer than half of deliveries, and each year 60 million births occur outside facilities [2], the burden of neonatal morbidity and mortality related to childbirth remains very high [3]. While skilled attendance at delivery and emergency obstetric care are the basis of modern obstetrics, there is remarkably limited impact evaluation. This gap is related both to methodological challenges such as the large sample sizes required for meaningful statistical comparisons, and because many obstetric interventions were in routine practice before the advent of randomized controlled trials (RCTs), making it unethical, for example, to undertake a RCT of the impact of Caesarean section [10]. Estimates of the effectiveness of intrapartum care in reducing maternal and neonatal mortality and stillbirths are needed to inform healthcare planning and prioritization in low resource countries
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