Linking families and facilities for care at birth: what works to avert intrapartum-related deaths?

Abstract

Background: Delays in receiving effective care during labor and at birth may be fatal for the mother and fetus, contributing to 2 million annual intrapartum stillbirths and intrapartum-related neonatal deaths each year.

Objective: We present a systematic review of strategies to link families and facilities, including community mobilization, financial incentives, emergency referral and transport systems, prenatal risk screening, and maternity waiting homes.

Results: There is moderate quality evidence that community mobilization with high levels of community engagement can increase institutional births and significantly reduce perinatal and early neonatal mortality. Meta-analysis showed a doubling of skilled birth attendance and a 36% reduction in early neonatal mortality. However, no data are available on intrapartum-specific outcomes. Evidence is limited, but promising, that financial incentive schemes and community referral/transport systems may increase rates of skilled birth attendance and emergency obstetric care utilization; however, impact on mortality is unknown. Current evidence for maternity waiting homes and risk screening is low quality.

Conclusions: Empowering communities is an important strategy to reduce the large burden of intrapartum complications. Innovations are needed to bring the poor closer to obstetric care, such as financial incentives and cell phone technology. New questions need to be asked of "old" strategies such as risk screening and maternity waiting homes. The effect of all of these strategies on maternal and perinatal mortality, particularly intrapartum-related outcomes, requires further evaluation.

Photograph reprinted with permission granted by Anne CC Lee. · Community Action Cycle: Figure reprinted with permission granted by Lancet. · Photograph reprinted with permission granted by Anne CC Lee.

Photograph from Shivgarh, Uttar Pradesh, India, reprinted with permission granted by Bill & Melinda Gates Foundation/Jeffrey Spector.

Photograph reprinted with permission granted by Bill & Melinda Gates Foundation/Jeffrey Spector. · Boat picture: photograph reprinted with permission granted by Indu Alhuwhalia. · Bike picture: photograph reprinted with permission granted by Save the Children/Michael Bisceglie. Mozambique. · Stretcher picture: photograph reprinted with permission granted by Luwei Pearson.

Fig. 1

Maternal perceptions of barriers to obstetric care based on analysis of large-scale household surveys (2000–2007). Source: Based on new analysis of DHS data (2000–2007) from Macro DHS Statcompilier, May 2009. Since the specific questions vary by country, the number of countries with data per question is given.

Fig. 2

Estimates of the effect of community mobilization on institutional delivery. (A) All community mobilization studies meeting inclusion criteria. (B) High-intensity community mobilization studies.

Fig. 3

Out-of-pocket expenditure as a percentage of total expenditure on health. Source: New analysis using data from National Health accounts available from WHO Statistical Information System, June 2009. The range lines demonstrate the minimum and maximum for each region. Percentages are unweighted regional averages for countries with data on out-of-pocket expenditure as a percentage of total of expenditure on health. Currently, there is no comparable national data on out-of-pocket expenditure specific to maternal, newborn and child health expenditure because National Health Accounts do not routinely split out and report this figure.