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Meta-Analysis
. 2011 Apr 13;11 Suppl 3(Suppl 3):S10.
doi: 10.1186/1471-2458-11-S3-S10.

Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect

Anne C C Lee  1 , Simon Cousens, Gary L Darmstadt, Hannah Blencowe, Robert Pattinson, Neil F Moran, G Justus Hofmeyr, Rachel A Haws, Shereen Zulfiqar Bhutta, Joy E Lawn
Affiliations
Meta-Analysis

Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect

Anne C C Lee et al. BMC Public Health. .

Abstract

Background: 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).

Methods: We 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.

Results: We 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.

Conclusion: Evidence 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.

Funding: This 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.

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Figures

Figure 1
Figure 1
Search strategies and results. Skilled Birth Attendance and Emergency Obstetric Care and Intrapartum-Related Neonatal Deaths
Figure 2
Figure 2
Search strategies and results. Traditional Birth Attendants
Figure 3
Figure 3
Search strategies and results. Incidence of neonatal encephalopathy
Figure 4
Figure 4
Variation of the incidence of neonatal encephalopathy (NE) with the natural log of the proportion of institutional deliveries. Legend: Each dot represents NE incidence data reported by a single study. For some countries more than one incidence was reported. The regression line is modeled as: lnNE=2.237 – 0.311 * logit (% Institutional Delivery) R2=0.50 According to this model, when increasing from settings with very low proportion of births in facilities (10%) to settings with high proportions of facility deliveries (90%), the incidence of neonatal encephalopathy decreases by 75%. When applying case fatality rates for neonatal encephalopathy based on the respective mortality setting, mortality from neonatal encephalopathy is reduced by 85% when facility birth is increased from 10% to 90%.
Figure 5
Figure 5
Meta-analysis of effect of skilled birth attendance in the community on neonatal or perinatal outcomes (Effect on all cause Neonatal Mortality Rate)
Figure 6
Figure 6
Meta-analysis of effect of skilled birth attendance in the community on neonatal or perinatal outcomes (Effect on Early Neonatal Mortality Rate)
Figure 7
Figure 7
Meta-analysis of effect of skilled birth attendance in the community on neonatal or perinatal outcomes (Effect on Perinatal Mortality Rate)
Figure 8
Figure 8
Box plot of Delphi expert opinion effect on intrapartum-related neonatal deaths of: Skilled attendance alone, Basic Emergency Obstetric care and Comprehensive Emergency Obstetric Care (21 experts). Legend: Inter-quartile range indicated by top and bottom of shaded boxes. Median value indicated by
See this image and copyright information in PMC

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