60million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths?

Darmstadt, Gary L.; Lee, Anne CC; Cousens, Simon; Sibley, Lynn; Bhutta, Zulfiqar A.; Donnay, France; Osrin, Dave; Bang, Abhay; Kumar, Vishwajeet; Wall, Steven N.; Baqui, Abdullah; Lawn, Joy E.

doi:10.1016/j.ijgo.2009.07.010

« Previous Next »International Journal of Gynecology & Obstetrics
Volume 107, Supplement , Pages S89-S112, October 2009

60million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths?

Gary L. Darmstadt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Current address: Integrated Health Solutions Development, Global Health Program, Bill & Melinda Gates Foundation, Seattle, WA, USA
- Corresponding author. Integrated Health Solutions Development, Global Health Program, Bill & Melinda Gates Foundation, PO Box 23350, Seattle, WA 98102, USA.
Anne CC Lee
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Simon Cousens
- London School of Hygiene and Tropical Medicine, London, UK
Lynn Sibley
- Department of Family and Community Nursing, Nell Hodgson Woodruff School of Nursing; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
Zulfiqar A. Bhutta
- Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan
France Donnay
- Current address: Integrated Health Solutions Development, Global Health Program, Bill & Melinda Gates Foundation, Seattle, WA, USA
Dave Osrin
- UCL Centre for International Health and Development, Institute for Child Health, London, UK
Abhay Bang
- Society for Education, Action and Research in Community Health, Gadchiroli, Maharashtra, India
Vishwajeet Kumar
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Steven N. Wall
- Saving Newborn Lives/Save the Children-US, Washington, DC, USA and Capetown, South Africa
Abdullah Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Joy E. Lawn
- Saving Newborn Lives/Save the Children-US, Washington, DC, USA and Capetown, South Africa

Abstract

Background

For the world's 60million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth.

Objective

We present a systematic review of evidence for the effect of community-based cadres—community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)—in improving perinatal and intrapartum-related outcomes.

Results

The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%–47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a meta-analysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR.

Conclusion

Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

Keywords: Birth asphyxia, Community health worker, Community midwife, Hypoxia, Intrapartum, Neonatal mortality, Stillbirth, Traditional birth attendant