Abstract
BackgroundFacility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa.MethodsWe conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals.ResultsWe found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction.ConclusionEvaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these problems and provide better estimates of relative effectiveness of place of delivery in the region.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2458-14-1014) contains supplementary material, which is available to authorized users.
Highlights
Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries
The aim of this paper is to estimate from secondary data how maternal and perinatal mortality in SSA is affected by place of delivery
Of the 9 studies that met the inclusion criteria for the analysis: 6 studies [43,44,45,46,47,48] reported on perinatal mortality and the other 3 studies [36,49,50] reported on maternal mortality
Summary
Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. Robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa. Key factors constraining service delivery include lack of political commitment, insufficient financial and skilled human resources and weak health care system infrastructures [10,11,12]. In sub-Saharan Africa, the region with the highest maternal mortality ratio (500 deaths per 100,000 live births) and perinatal mortality rate (56 per 1,000 births) [17,18], coverage of facility deliveries are low. A recent estimate indicated that across 28 sub-Saharan countries, only 47% of births take place in a facility [19]
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