Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis

Abstract

Objective: To assess the effectiveness of strategies incorporating training and support of traditional birth attendants on the outcomes of perinatal, neonatal, and maternal death in developing countries.

Design: Systematic review with meta-analysis.

Data sources: Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were "birth attend*", "traditional midwife", "lay birth attendant", "dais", and "comadronas". Review methods We selected randomised and non-randomised controlled studies with outcomes of perinatal, neonatal, and maternal mortality. Two independent reviewers undertook data extraction. We pooled relative risks separately for the randomised and non-randomised controlled studies, using a random effects model.

Results: We identified six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants. All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P<0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P<0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p<0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P<0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three randomised trials, relative risk 0.79, 0.53 to 1.05, P=0.12; three non-randomised studies, 0.80, 0.44 to 1.15, P=0.26).

Conclusion: Perinatal and neonatal deaths are significantly reduced with strategies incorporating training and support of traditional birth attendants.

Fig 1 Flowchart of study selection

Fig 2 Perinatal mortality. Midhet study did not report total births; denominator is number of live births. Perinatal mortality for Gill study comprised stillbirth and neonatal mortality within 1 week; effects of cluster design for both mortalities were estimated from standard errors, allowing estimation of cluster adjusted rate ratio for the combined outcome. Relative risk of perinatal mortality for Bhutta study was calculated with raw data for individual clusters

Fig 3 Neonatal mortality. 1000LB=per 1000 live births. Midhet study did not report total births; denominator is number of live births. Relative risk of neonatal mortality for Bhutta study was calculated with raw data for individual clusters

Fig 4 Maternal mortality. Effect of cluster design for Gill and Bhutta trials was estimated from standard errors of the other outcomes, allowing estimation of cluster adjusted rate ratio for maternal mortality

Fig 5 Support for traditional birth attendants